QRS 4-2

QUICK REVIEW SERIES for
BDS 4th Year

Vol 2
SECOND EDITION
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QUICK REVIEW SERIES for
BDS 4th Year

Vol 2
SECOND EDITION
J Jyotsna Rao
bds, mds, pgcoi (mahe), f isoi
Director, SRS Dental Exams Academy, Bengaluru
Ex-Professor, Department of Oral and Maxillofacial Surgery
The Oxford Dental College, Hospital and Research Centre,
Bengaluru, INDIA
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Quick Review Series for BDS 4th Year, Volume 2, Rao J Jyotsna
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Printed in India by
Dedicated
to
SRI GURU RAGHAVENDRA SWAMI
(The eternal power who has showered his blessings on me to successfully complete the entire range
of Quick Review Series for BDS)
Foreword
Conservative Dentistry and Endodontics

I am extremely happy to pen a few words about this conscientiously written book. It is a common knowledge that books
play a major complementary and contributing role in any educational process, where they are envisioned to facilitate self-
learning beyond classroom exercises.
This book of Quick Review Series for BDS 4th Year, Vol 2, Conservative Dentistry and Endodontics, authored by Dr J
Jyotsna Rao, is presented with such a systemic approach that it demonstrates her consummate skill in preparing students
for examinations. It is good to see that she has shared her vast experience in academics with the students through this book.
While going through the pages of this book I found that the author has made a sincere attempt to present the subject of
conservative dentistry and endodontics as per the syllabus of Dental Council of India to fulfil the long-term need of a
concise quick review book with best standards, simple language and required depth of explanation of the subject through
questions and answers of various university examinations.
Designing such a book is a challenging task, especially if it has to be concise and comprehensive in scope. Such a version
demands wise sifting, prudent pruning and meaningful condensing of the enormous and variegated knowledge base of the subject.
This outstanding resource is perfect for those studying in BDS IV year. The easy-to-understand text material serves as
both preparatory tool at the start of study course providing road map of the subject to be learnt and at the course end helping
rapid review and recapitulation of what has been learnt.
I am confident that this book is undeniably appropriate for exam-going undergraduate students craving for a thorough
review of subjects in a short period of time.
Regards
Dr Murali Mohan
Principal, Professor and Head of the Department
Department of Conservative Dentistry and Endodontics
Government Dental College and Hospital
Vijayawada, Andhra Pradesh
Oral Medicine and Radiology

It gives me immense pleasure to write the foreword for the book titled Quick Review Series for BDS 4th Year, Vol 2: Oral
Medicine and Oral Radiology and to introduce the author Dr Jyotsna Rao. This special effort made by the author is com-
mendable for making the examination of the undergraduates simple and easy.
I compliment the author for maintaining the standard and depth of the subject of oral medicine and oral radiology
without compromising. The text is simple and concise covering all the topics which makes the students review the subject
and provides the potential to train the students and prepare for the challenge to face the examinations. I sincerely hope the
text caters the needs of the UG students, and I wish the book maintains the acceptability by the BDS students.
I sincerely recommend this book for the final BDS students preparing for the examinations and also for those preparing
for MDS entrance examination.
I congratulate the author Dr Jyotsna Rao and wish her all success.
Dr M Manjula, MDS
Professor and Head
Dept of Dental Surgery
Gandhi Medical College
Secunderabad
Ex-Professor and Head
Dept of Oral Medicine and Radiology
Govt Dental College and Hospital
Afzalgunz, Hyderabad
vii
viii Foreword
Oral and Maxillofacial Surgery

It gives me immense pleasure to write the Foreword for the book titled Quick Review Series for BDS 4th Year, Vol 2 : Oral
and Maxillofacial Surgery and to introduce the author Dr Jyotsna Rao. This special effort made by the author is commend-
able for making the examination of the undergraduates simple and easy.
I compliment the author for maintaining the standard and depth of the subject of Oral and Maxillofacial surgery with-
out compromising. The text is simple and concise covering all the topics which makes the students review the subject and
provides the potential to train the students and prepare for the challenge to face the examinations. I sincerely hope the text
caters the needs of the UG students, and I wish the book maintains the acceptability by the BDS students.
I sincerely recommend this book for the final BDS students preparing for the examinations and also for those preparing
for MDS entrance examination.
I congratulate the author Dr Jyotsna Rao and wish her all success.
Dr P Bal Reddy, MDS
Principal, Professor and Head
Dept of Oral and Maxillofacial surgery
Government Dental College and Hospital
Hyderabad, Telangana
Prosthodontics
I am extremely happy to pen a few words about this conscientiously written book. It is common knowledge that books
play a major complementary and contributing role in any educational process, where they are envisioned to facilitate
self-learning beyond classroom exercises.
This book of Quick Review Series for BDS 4th Year, Vol 2: Prosthodontics authored by Dr J Jyotsna Rao is presented
with such a systemic approach that it demonstrates her consummate skill in preparing students for examinations. It is good
to see that she has shared her vast experience in academics with the students through this book.
When going through the pages of this book, I found that the author has made sincere attempt to present the subject of
Prosthodontics as per the syllabus of DCI to fulfill the long-term need of a concise quick review book with best standards,
simple language and required depth of explanation of the subject, through questions and answers of various university
examinations.
Designing such a book is a challenging task, especially if it is to be concise and comprehensive in scope. Such a version
demands wise sifting, prudent pruning and meaningful condensing of the enormous and variegated knowledge base of BDS
4th year subjects.
This outstanding resource is perfect for those studying in final BDS. The easy to understand text material, serves as
both preparatory tool at the start of study course providing roadmap of the subject to be learnt, and at the end of the course
it helps in rapid review and recapitulation of what is learnt.
I am confident that this book is undeniably appropriate for exam-going UG students who are craving for thorough
review of subjects in a short period.
Regards
Dr M S Gowd
MDS (Bom), FICD, FACD, FPFA, MICP (USA)
Hon’ Dental Surgeon, Governor of Telangana
Past President, Indian Prosthodontic Society
Former Principal, Prof and Head, Dept of Prosthodontics
Army College of Dental Sciences, Secunderabad, Telangana
Preface
I am overwhelmed by the positive response received from the students all over the country to the first edition of this book.
When the first edition of this book was published, it was released as eight subject wise individual books. In order to further
make it more convenient and comfortable for the students to prepare for exams, this edition is made with tremendous
change combining all eight final BDS subjects in to two volumes with four subjects in each volume.
This volume of the book contains four subjects, i.e. Conservative dentistry and Endodontics ,Oral Medicine & Radiology,
Oral and Maxillofacial Surgery and Prosthodontics. All along with upgraded change, i have taken care so that the basic format
is maintained which is previously so well received.
I have restructured the contents of this book in such a manner that students will be benefitted by using comprehensive
and relevant information given in the book.
It is planned in a meticulous manner and I have endeavoured comprehensively to refer and include relevant information
from the standard textbooks. Though written in a question-and-answer format, this book is arranged in a logical sequence
for the purpose of better recapitulation.
Unlike previous edition here Short Essay and Short Note question answers are marked within Long Essays wherever it
was possible, so that students will have double advantage in preparing for exams by conserving time and energy.
This makes it easy for the students to quickly review the entire subject and also recollect whatever they had studied
during the academic year of final BDS.
This book is primarily intended for undergraduate students, but can also be used as a quick reference book by postgraduate
students to recollect the subject.
I hope this book will make an important contribution to the students in understanding the subject and excelling in their
examinations.
J Jyotsna Rao
drjjrao@gmail.com
ix
Acknowledgements
First of all I thank almighty for his blessings without which this work would not have been possible.
I would like to first thank my father Mr J Sudharshan Rao who is the key person behind all my successful endeavours.
I am thankful to my mother Mrs S Sujatha Laxmi for her unforgettable sacrifices and choicest blessings. My warmest
regards to my husband Mr K Vinayak Rao for his constant support to enhance my software skills.
My thanks and love to my son Master K Raghasai without whose co-operation this work would not have been pos-
sible. I am thankful to my brother Mr J Jayakrishna for his valuable constructive suggestions.
My sincere thanks is to Dr P Balreddy Principal, Professor and Head, Department of Oral and Maxillofacial Surgery,
Government Dental College and Hospital, Hyderabad, for his blessings. I wish to thank Dr BK Reddy, Ex-Principal,
Government Dental College , Hyderabad and Meghana Dental College, Nizamabad for his blessings and advice.
My sincere thanks to Dr Bhaskar Y, Dr P Chidambar, Dr Laxmikanth, and Mr Kiran (Librarian, Oxford Dental College,
Bangalore) and Narayana Swami for their invaluable support in collecting previous years’ question papers from various
universities.
I would like to specially thank Dr Parmar Adithi Kiritikumar and Dr Priyanka Das, Dr Saniyara Khanam and Dr Mardidiam
Lanong for their valuable contribution in preparing manuscript. I would like to extend my regards to Dr Rajini and P Nethravathi
for their help in correction of manuscripts.
Thanks to Elsevier India, especially Dr Lalit Singh, Mrs Nimisha Goswami, Mr Anand K Jha and all other team members
for their active contribution in publishing this book.
I would like to take this opportunity to thank all those people who, directly or indirectly were instrumental in successfully
bringing out this book. Last but not the least, I acknowledge all my friends and colleagues for their best wishes to boost my
morale.
xi
Contents
Foreword vii Topic 8 Tooth Morphology and Access Cavities 174

Preface ix
Topic 9 Endodontic and Biomechanical
Acknowledgements xi
Preparation and Working Length
CONSERVATIVE DENTISTRY AND ENDODONTICS Determination 179
Topic 10 Materials in Endodontics 187
Part I Conservative Dentistry
Topic 11 Obturation of Root Canal 199
Topic 1 Introduction to Operative Dentistry 3
Topic 12 Postendodontic Restorations 205
Topic 2 Preliminary Considerations for Operative
Topic 13 Mishaps and Failures of Endodontic
Dentistry 12
Treatments 209
Topic 3 Cariology 23
Topic 14 Treatments of Traumatized Teeth 215
Topic 4 Instruments and Separation 38
Topic 15 Endodontic Surgery and Replantation
Topic 5 Fundamentals In Tooth Preparation 60
and Transplantation 221
Topic 6 Basic Concepts in Aesthetic Dentistry
Topic 16 Endodontic Periodontal
and Adhesion to Tooth Structure 70
Inter-relationships 230
Topic 7 Composite Resin Restorations 78
Topic 17 Lasers and Endodontic Implants 233
Topic 8 Glass Ionomer Restorations 90
Topic 18 Single Visit Endodontics 237
Topic 9 Dental Ceramic Restorations 97
Topic 19 Bleaching of Discoloured Tooth 237
Topic 10 Amalgam Restorations 103
Topic 11 Pin-retained Restorations 116 ORAL MEDICINE AND ORAL RADIOLOGY
Topic 12 Cast Metal Restorations 120 Part I Oral Medicine
Topic 13 Dental Casting Procedures 129 Topic 1 Ulcerative, Vesicular and Bullous
Topic 14 Direct Filling Gold Restorations 134 Lesions 247
Topic 15 Lasers in Operative Dentistry 138 Topic 2 Red and White Lesions 259
Topic 16 Miscellaneous 139 Topic 3 Pigmentation of the Oral Tissues 274
Part II Endodontics Topic 4 Benign Tumours of the Oral
Topic 1 Clinical Diagnostic Aids in Endodontics143 Cavity Including Gingival
Topic 2 Endodontic Emergencies 150 Enlargements 281
Topic 3 Dental Pulp and Periradicular Tissues: Topic 5 Oral Cancer 296
Embryology and Anatomy 153 Topic 6 Diseases of the Tongue and Lips 305
Topic 4 Diseases of Dental Pulp and Topic 7 Salivary Glands Diseases 316
Periradicular Tissues 154 Topic 8 Disorders of TMJ and MPDS 327
Topic 5 Principles and Rationale of Endodontic Topic 9 Ionizing Radiation and Regressive
Treatment 161 Alterations of the Oral Cavity 345
Topic 6 Endodontic Instruments and Sterilization162 Topic 10 Odontologic Diseases 348
Topic 7 Endodontic Microbiology 171 Topic 11 Orofacial Pain 357
xiii
xiv Contents
Topic 12 Bacterial, Viral and Infectious Diseases Topic 17 Premalignant and Malignant Lesions 723
of the Oral Cavity including AIDS 369 Topic 18 Management of Medically
Topic 13 Diseases of the Endocrine and Compromised Patients and Medical
Respiratory System, CVS and GIT 383 Emergencies 733
Topic 14 Metabolic Disorders 391 Topic 19 Minor Oral Surgical Procedures
Topic 15 Haematologic Diseases 396 and Orthognathic Surgery 749
Topic 16 Diagnostic Laboratory Procedures 406 Topic 20 Implantology and Miscellaneous 756
Topic 17 Miscellaneous 415 PROSTHODONTICS
Part II Oral Radiology Part I Complete Dentures
Topic 1 Radiation Physics 429 Topic 1 Introduction to Complete Dentures 771
Topic 2 Radiation Biology, Hazards of Topic 2 Diagnosis and Treatment Planning 781
Radiation and Radiation Protection 441 Topic 3 Diagnostic Impressions in CD,
Topic 3 X-Ray Films and Accessories 455 Mouth Preparation for CD
Topic 4 Processing of X-Rays Films 463 and Objective of Impression Making 798
Topic 5 Image Principles: X-Rays Quality Topic 4 Primary Impression in Complete
Control 472 Dentures & Lab Procedures Prior to
Topic 6 Intraoral Radiographic Techniques 483 Master Impression Making 808
Topic 7 Extraoral Radiographic Techniques 492 Topic 5 Secondary Impression in Complete
Topic 8 Specialized Imaging Techniques 507 Dentures and Lab Procedures Prior
Topic 9 Radiographic Interpretations 516 to Jaw Relation 816
ORAL AND MAXILLOFACIAL SURGERY Topic 6 Maxillomandibular Relations 821
Part I Oral and Maxillofacial Surgery Topic 7 Lab Procedures Prior to Try-in 836
Topic 1 Introduction to Oral and Topic 8 Lab Procedures Prior to Insertion
Maxillofacial Surgery 545 and Complete Denture Insertion 856
Topic 2 General Principles of Surgery 554 Topic 9 Relining and Rebasing in Complete
Topic 3 Local Anaesthesia 563 Dentures 873
Topic 4 Conscious Sedation and General Topic 10 Special Complete Dentures
Anaesthesia 580 and Miscellaneous 878
Topic 5 Principles of Exodontia and Part II Fixed Partial Dentures
Instrumentation 583 Topic 1 Introduction to Fixed Partial
Topic 6 Impactions 594 Dentures 893
Topic 7 Maxillofacial Trauma 606 Topic 2 Parts and Design of Fixed Partial
Topic 8 Mandibular Fractures 621 Dentures 899
Topic 9 Cysts of Orofacial Region 636 Topic 3 Occlusion in Fixed Partial Dentures 912
Topic 10 Benign Tumours of the Jaw 648 Topic 4 Types of Abutments 921
Topic 11 Diseases of TMJ 658 Topic 5 Tooth Preparation 927
Topic 12 Diseases of Salivary Gland 668 Topic 6 Types of Fixed Partial Dentures 943
Topic 13 Diseases of Maxillary Sinus 679 Topic 7 Impression Making in Fixed
Topic 14 Inflammatory Lesions of Jaw and Partial Dentures 945
Orofacial Infections 689 Topic 8 Temporization or Provisional
Topic 15 Facial Neuropathology 706 Restorations and Lab Procedures
Topic 16 Preprosthetic Surgery 714 Involved in Fabrication of FPD 952
Contents xv
Topic 9 Cementation of Fixed Partial Topic 7 Principles of RPD Design 1019

Dentures and Miscellaneous 958 Topic 8 Surveying and Preparation of
Topic 10 Maxillofacial Prosthetics and Implant Mouth for RPD 1024
Dentistry 971 Topic 9 Impression Materials and Procedures
Part III Removable Partial Dentures for RPD 1031
Topic 1 Introduction, Treatment Planning, Topic 10 Support for the Distal Extension
and Mouth Preparation 981 Denture Base, Occlusal Relationship
Topic 2 Diagnosis Planning and Mouth for RPD, and Laboratory Procedures
Preparation 986 and Work Authorization for RPD 1035
Topic 3 Major and Minor Connectors 991 Topic 11 Correction of RPDs, Repairs &
Topic 4 Rests and Rest Seats 1002 Additions to RPD, Relining and
Topic 5 Direct and Indirect Retainers 1005 Rebasing the RPD and Miscellaneous 1038
Topic 6 Denture Base Considerations 1018
Section I
Topic-Wise Solved Questions

of Previous Years
PART I CONSERVATIVE DENTISTRY

Topic 1 Introduction to Operative Dentistry 3
Topic 2 Preliminary Considerations for Operative Dentistry 12
Topic 3 Cariology 23
Topic 4 Instruments and Separation 38
Topic 5 Fundamentals In Tooth Preparation 60
Topic 6 Basic Concepts in Aesthetic Dentistry
and Adhesion to Tooth Structure 70
Topic 7 Composite Resin Restorations 78
Topic 8 Glass Ionomer Restorations 90
Topic 9 Dental Ceramic Restorations 97
Topic 10 Amalgam Restorations 103
Topic 11 Pin-retained Restorations 116
Topic 12 Cast Metal Restorations 120
Topic 13 Dental Casting Procedures 129
Topic 14 Direct Filling Gold Restorations 134
Topic 15 Lasers in Operative Dentistry 138
Topic 16 Miscellaneous 139
Section I

of Previous Years
Part I
Conservative Dentistry
Topic 1
Introduction to Operative Dentistry
COMMONLY ASKED QUESTIONS
LONG ESSAYS:
1 . Discuss the importance of history taking, patient’s assessment and treatment planning in conservative dentistry.
2. Enumerate the various diagnostic aids in the field of operative dentistry. Discuss in detail the importance of
radiographic examination and its limitation.
3. Discuss different types of contact points and their importance in restorative dentistry.
SHORT ESSAYS:
1 . Discuss different types of contact points and their importance in restorative dentistry. [Ref LE Q.3]
2. Discuss the methods of diagnosis of proximal caries lesion. [Ref LE Q.2]
3. Classify hand instruments and add a note on nomenclature.
4. Diagnostic aids to detect caries. [same as SEQ.2]
SHORT NOTES:
1 . Diagnosis of dental caries.
2. Secondary dentine.
3. FDA tooth numbering system. [Ref SE Q.3]
4. Common diagnostic aids of caries detection. [Ref LE Q.2]
3
4 Quick Review Series for BDS 4th Year, Vol 2
5. Uses of radiographs.
6. Tetracycline stains.
7. Test cavity.
8. Tertiary dentine.
9. Col.
10. Percussion.
11. Embrasures.
12. Mention two diagnostic aids used for the diagnosis of caries. [Ref SN Q.1]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Discuss the importance of history taking, patient’s 4. History of past illness – past diseases are recorded to
assessment and treatment planning in conservative note if they are in any way related to the present disease.
dentistry. 5. Treatment history – history of medications, adverse
drug reactions, allergies and hospitalization is recorded.
Ans. 6. Personal history – patient is asked about their personal
habits such as smoking and alcohol consumption. Fe-
Pretreatment considerations consisting of patient’s his- male patients are enquired about their menstrual cycle
tory, assessment, examination and diagnosis and treat- and pregnancies.
ment planning are the basis of sound dental care. 7. Family history – history of any genetic disorders is en-
History quired about to rule out common diseases such as hy-
Proper history is important to conclude a correct diag- pertension and diabetes.
nosis. The standard format used for collecting a patient’s The treatment plan depends on thorough assessment and
history is as follows: examination of the patient.
1. Patient’s details (name, age, sex and occupation
address) Steps in patient examination
2. Presenting complaints I. Patient assessment considerations
3. History of present illnesses II. Examination and diagnosis
4. History of past illnesses III. Treatment planning
5. Treatment history I. Patient assessment considerations
6. Personal history A. Infection control
7. Family history B. Chief complaint
1. Patient’s details C. Medical review
l Name – the patient feels comfortable when they are l Communicable diseases
called by their names. l Allergies or medications
l Age – age is an important factor as certain diseases, l Systemic diseases and cardiac abnormalities
conditions and growth occur at certain age groups. l Physiologic changes associated with ageing
l Sex – some disorders are particular to the male or D. Sociologic and psychological review
female gender. E. Dental history
l Occupation – this information helps to rule out any F. Risk assessment
work-related conditions in the patient. II. Examination and diagnosis
l Address – address of the patient is important for General considerations
scheduling the appointments as well as to know if they 1. Charting and records
belong to areas susceptible to any kinds of diseases. 2. Tooth numbering system
2. Presenting complaints – the chief complaint should be 3. Preparation for clinical examination
noted in the patients own words and the symptoms are 4. Interpretation and use of diagnostic tests
listed in a chronological order. Examination of orofacial soft tissues
3. History of present illness – the patient is then asked to Soft tissue must be evaluated in a systematic
describe the complaint in detail like the site, severity, fashion.
character, timing and duration, aggravating and reliev- 1. Submandibular glands and cervical nodes
ing factors. 2. Masticatory muscles
Section | I Topic-Wise Solved Questions of Previous Years 5
3. Cheeks, vestibules, mucosa, lips, lingual and to caries as a result of fluorhydroxyapatite forma-
facial alveolar mucosa, palate, tonsillar areas, tion. Restoration is not indicated.
tongue and floor of the mouth d. Proximal surface caries in anterior teeth may be
Examination of teeth and restorations identified by radiographic examination, visual
The tooth should be first evaluated clinically. Vari- inspection (transillumination optional) and/or
ous changes that can be noticed are probing with an explorer.
a. Visual changes in tooth surface texture or colour e. Smooth surface caries occurs on the facial and
b. Tactile sensation when an explorer is used lingual surfaces of the teeth, in gingival areas that
judiciously are less accessible for cleaning. The earliest clin-
c. Radiographs ical evidence is a white spot that partially or
d. Transillumination totally disappears from vision by wetting and
e. Diagnodent reappears on drying.
f. The digital imaging fibreoptic transillumina- f. Root surface caries: Active root caries is detected
tion (DIFOTIM) system by the presence of softening and cavitation. A
g. Quantitative light-induced fluorescence (QLF) careful clinical examination is as important as
h. Electronic caries monitor radiographic examination. This may be difficult
1. Detection of caries in a patient who has attachment loss with no gin-
a. Occlusal surface: gival recession, thereby limiting accessibility for
l It is important to remember the distinction clinical inspection. The caries are detected with
between primary occlusal grooves/fossae and the help of bitewing radiographs.
occlusal fissures/pits as caries are prevalent 2. Clinical examination of amalgam restorations:
in faulty pits and fissures of the occlusal All restorations must be evaluated systematically in
surfaces. a clean, dry and well-lighted field. Clinical evalua-
l Occlusal fissure and pits are deep, tight crevices/ tion of amalgam restorations requires knowledge of
holes in enamel where the lobes failed to co- the condition, visual observation, application of tac-
alesce, partially or completely. Fissures and tile sense with the explorer, use of dental floss and
pits are detected visually. interpretation of radiographs.
l Injudicious use of explorers can cause fracture At least 11 distinct conditions may be encountered
of the weakened enamel and hence the use of when amalgam restorations are evaluated:
an explorer in diagnosing fissure caries is a. Amalgam ‘blues’
strongly discouraged. b. Proximal overhangs
l A tooth is considered carious, if there is chalk- c. Marginal ditching
iness or apparent softening of tooth structure d. Voids
forming the fissure/pit, or brown–grey discol- e. Fracture lines
ouration radiating peripherally from the central f. Lines indicating the interface between abutted
fissure/pit. restorations
l Radiographic diagnosis can be made from a g. Improper anatomic contours
bitewing radiograph when radiolucency is ap- h. Marginal ridge incompatibility
parent beneath the occlusal enamel surface i. Improper proximal contacts
arising from the dental enamel junction. j. Recurrent caries
l Precarious or carious pits are occasionally k. Improper occlusal contacts
present on cusp tips. Typically, these are the 3. Clinical examination of cast restorations: Similar to
results of developmental enamel defects. Cari- amalgam.
ous pits and fissures also occur on the occlusal 4. Clinical examination of composite and other tooth-
two-thirds of the facial or lingual surface of the coloured restorations: Similar to amalgam. Corrective
posterior teeth and on the lingual surface of procedures include recontouring, polishing, repairing
maxillary incisors. or replacing.
b. Proximal surface caries: Can be diagnosed 5. Radiographic examination of teeth and restora-
like occlusal caries through radiographs, care- tions: Patients prone to caries and periodontal
ful clinical examination or fibreoptic transillu- problems should be examined extensively with
mination. radiographic studies. Proximal surface caries, res-
c. Brown spots: Usually gingival to the contact area toration overhangs or poorly contoured restora-
are often seen in older patients whose caries activ- tions can be detected by posterior bitewing and
ity is low. These spots are usually more resistant anterior periapical radiographs.
III. Treatment planning C. Criteria for restoring

A. Introduction l Poor oral hygiene.
1. General considerations l Low frequency of routine dental care because of
l A treatment plan is carefully designed to lack of motivation.

eliminate or control aetiologic factors, repair l History of caries or numerous restorations.
existing damage and create a functional, l Cavitation or a defect is present.
maintainable environment. l Lesion extends to the dentinoenamel junction
l A proper treatment plan depends on thorough (DEJ).

patient evaluation, dentist expertise, under- l High degree of caries susceptibility.
standing of indications and contraindications l Age of the patient.
and a prediction of the patient’s response to l Aesthetic treatment.
treatment. l Treatment of abrasion, erosion and attrition.
The development of a dental treatment plan l Treatment of root surface caries.
for a patient consists of four steps: D. Treatment of root surface sensitivity

a. Examination and problem identification l Fluid shifts are temperature change, air-drying
b. Decision to recommend intervention and osmotic pressure. Any treatment that can
c. Identification of treatment alternatives reduce these fluid shifts by partially or totally
d. Selection of the treatment with the pa- occluding the tubules may help reduce the sen-
tient’s involvement sitivity.
l The dentist is always required to provide the l Dentinal hypersensitivity is treated with topical
best care available to the patient. fluoride, fluoride rinses, oxalate solutions, seal-
l Treatment plans are influenced by patient pref- ants, iontophoresis and desensitizing toothpastes,
erences, motivation, systemic health, emotional dentine bonding agents being the best. When con-
status and financial capabilities. servative treatment fails, restoration is preferred.
l A treatment plan can also be modified by the E. Repairing and resurfacing existing restorations
dentist’s knowledge, experience and training; l Resurfacing or repair of composites, cast restora-
laboratory support; dentist–patient compatibil- tions and amalgam restorations with localized
ity; the availability of specialists and functional, defects should confirm that all carious tooth struc-
aesthetic and technical demands. tures have been removed; it is acceptable and
2. Treatment plan sequencing many times preferable to repair or recontour.
Generally, the concept of greatest need guides l Further reshaping of overcontoured restorations is
the order in which treatment is sequenced. an acceptable form of treatment.

a. Urgent phase F. Replacement of existing restorations
b. Control phase Indications for replacing restorations are as follows:
c. Re-evaluation phase i. Marginal void, especially in the gingival one-
d. Definitive phase third, that cannot be repaired.
e. Maintenance phase ii. Poor proximal contour or a gingival overhang
3. Interdisciplinary considerations in operative that contributes to periodontal breakdown.
treatment planning iii. A marginal ridge discrepancy that contributes
a. Endodontics to food impaction.
b. Periodontics iv. Overcontour of a facial or lingual surface re-
c. Orthodontics sulting in plaque gingival to the height of con-
d. Oral surgery tour and resultant inflammation of gingiva
e. Fixed and removable prosthodontics overprotected from the rubbing–cleansing ac-
B. Indications for operative treatment tion of a food bolus or toothbrush.
Operative preventive treatment v. Poor proximal contact that is either open (re-
l This preventive program should include altering sulting in interproximal food impaction and
the oral environment to encourage remineraliza- inflammation of impacted gingival papilla) or
tion of incipient smooth surface lesions and treat- improper in location or size.
ing caries-prone pits and fissures with sealants. vi. Recurrent caries that cannot be adequately
l Extensive acute caries should be immediately treated by a repair restoration.
eradicated by either a definitive restoration or a vii. Ditching deeper than 0.5 mm of the occlusal
caries-control restoration to help suppress the amalgam margin that is judged carious or
infectious process. caries-prone.
Indications for replacing tooth-coloured restorations l The patients undergoing occlusal rehabilitation
include: and teeth with deep subgingival margins are well
i. Improper contours that cannot be repaired treated with cast metal restorations, because com-
ii. Large voids pared to amalgam and composite restorations, they
iii. Deep marginal staining provide a better opportunity for control of proxi-
iv. Recurrent caries mal contours and for restoration of the difficult
v. Unacceptable aesthetics; restorations that have subgingival margin.
only light marginal staining and are judged
Q.2. Enumerate the various diagnostic aids in the field
noncarious can be corrected by a shallow, nar-
of operative dentistry. Discuss in detail the importance
row and marginal repair restoration
of radiographic examination and its limitation.
G. Indications for direct composite and other tooth-
coloured restorations Ans.
l Composite can be used for many Classes I and II
restorations and to have a clinical longevity simi- [SE Q.2 and SN Q.4]
lar to amalgam restorations.
H. Indications for indirect tooth-coloured restorations {(Usual diagnostic methods of caries detection
l Tooth-coloured restorations that are indirectly 1 . Patient’s complaint
fabricated out of the mouth may be indicated for 2. Meticulous clinical examination
Classes I and II due to aesthetics, strength and 3. Tactile examination
other bonding benefits. 4. Radiographic examination
l Moreover, because of the potential of bonded 5. Tooth separation
restorations to strengthen remaining tooth struc- 6. Dental floss or tape
ture, indirect tooth-coloured restorations may 7. Fibreoptic transillumination)}
also be selected for the conservative restoration of
weakened posterior teeth in aesthetically critical [SE Q.2]
areas. {Recent methods of caries diagnosis
i. Xeroradiography
Indirect tooth-coloured restorations include: ii. Digital radiographic methods
i. Processed composite iv. Digital subtraction radiography
l Although processed composite restorations possess
v. Dyes for detection of caries
improved wear resistance over direct composites, vi. Electrical conductance measurements
they are indicated primarily for conservative Classes vii. Endoscopic filtered fluorescence method
I and II preparations in low to moderate stress areas. viii. Quantitative laser fluorescence
ii. Feldspathic porcelain ix. Alternating current impedance spectrography technique
l Feldspathic porcelain inlays and onlays for Classes I
(ACIST)
and II restorations are highly aesthetic but suffer x. Ultrasonic imaging
from a relatively high incidence of fracture, espe- xi. Optical coherence tomography
cially if subjected to heavy occlusal forces.
l Porcelain restorations also have the potential to wear Radiographic examination
opposing tooth structure. l Conventional, intraoral periapical and bitewing radio-
iii. Cast ceramic graphs are employed to diagnose dental caries. Of

l Cast ceramic inlays and onlays for Classes I and II the two, bitewing radiographs have more diagnostic
preparations offer excellent marginal fit, low abrasion value:}
to opposing tooth structure and superior strength com- I. Role of bitewing radiographs in detecting occlusal
pared to processed composite or feldspathic porcelain. caries
l They offer an excellent aesthetic alternative to cast l Initial enamel caries is difficult to detect on bite-
metal restorations. wing radiograph due to the complicated three-

iv. Computer-generated (computer-aided design [CAD]/ dimensional shape of the occlusal surfaces.
computer-assisted machined [CAM]) The CAD/CAM l Also caries involving the buccal or lingual grooves
inlays and onlays possess high strength and low abra- of molars may mimic occlusal lesions due to
siveness and are highly aesthetic because of the intrin- superimposition.
sic colouration and highly polishable nature of the l Once, the caries has progressed into dentine, it is
material. evident as a radiolucent zone.

[SE Q.2] l Radiolucency may be due to caries, wear, fracture or

cervical burnout.
II. {Role of bitewing radiographs in detecting proxi-
l For accurate reproducibility, standardized geometric
mal caries
angulation, exposure time, processing procedures
l Bitewing radiographs are very valuable in diag-
and analysing facilities are necessary.
nosing proximal caries.
l Radiographic diagnosis is subjective, prone to ob-
l Early proximal enamel lesions are seen as a small
server bias.
radiolucent notch below the contact area in
l Extent of caries as seen in the radiograph is usually
enamel.
lesser than the actual defect.
l Advanced proximal caries is seen as a dark trian-
gular area in the proximal enamel with its base

towards the external tooth surface. Q.3. Discuss different types of contact points and their
l Proximal caries may be scored according to its importance in restorative dentistry.
progress through enamel and dentine towards the Ans.
pulp.}
[SE Q.1]
Uses of bitewing radiographs
l Detecting incipient proximal caries
● {The site of actual contact between two-teeth on the
l Examining many teeth in one radiograph
mesial and distal surface is called contact point.
l Checking cervical margins of restorations Variations
l Noting the size of pulp chambers i. A contact point in posterior teeth is located nearer the
l The progress or arrest of caries facial surface, which causes a larger embrasure.
ii. A contact point in anterior teeth is located nearer the
[SE Q.2]
lingual surface, which causes a larger facial embrasure.
{Proximal caries as seen on bitewing radiograph Types
1 . Sound enamel.
i. Rounded
2. Radiolucency only in enamel.
ii. Broad
3. Radiolucency in enamel extending up to dentinoenamel
iii. Flat
junction.
4. Radiolucency in enamel and outer half of dentine. Purpose of ideal contact point
5. Radiolucency of enamel and reaching inner half of i. To prevent food impaction
dentine. ii. To make areas self-cleanable
6. A cervical radiolucency may be visible sometimes on iii. To conserve healthy gingival tissue
the bitewing radiograph even in the absence of caries. iv. To ensure permanence of proximal restoration
This is called a cervical ‘burnout’ and may be confused v. To improve aesthetic appearance, especially an anterior
as dental caries.} tooth
l Cervical ‘burnout’ – A radiolucent appearance vi. To maintain normal mesiodistal relationship of teeth in
mimicking proximal caries seen at the cervical as- the dental arch}
pect of teeth. This is a perfectly normal appearance
Hazards of faulty contact areas
at the gap between the dense enamel over the crown
Too broad contact
of the tooth and the crest of the alveolar ridge,
l Too broad contact buccolingually or occlusogingi-
where X-rays pass tangentially through the root
vally leads to:
dentine.
i. Improper shunting of food in buccal and lingual
Radiographs direction
Advantages ii. Change in the tooth anatomy and the shape of
l Noninvasive method interdental col
l Disclose sites inaccessible to other diagnostic iii. Increased susceptibility to periodontal diseases,
methods due to nonkeratinization of col
l Permanent record for monitoring progress or arrest Too narrow contact
of the carious lesion l Too narrow contact buccolingually or occlusogingi-
Disadvantages vally leads to:

l Only a two-dimensional image of a three-dimensional i. Vertical/horizontal food impaction
object. ii. Greater food retention of plaque occurs in em-
l Do not reveal the earliest stages of caries development. brasure areas
Contact placed too occlusally l Hatchets

l Contact placed too occlusally leads to a flattened l Hoes
marginal ridge at the expense of occlusal embrasure. (b) Rotary instruments:
Contact placed too buccally/lingually l Burs
l Contact placed too buccally/lingually leads to a flat- l Stones
tened restoration at the expense of buccal/lingual l Discs
proximal wall. 2. Condensing instruments:

l Contact placed too gingivally leads to increased Pluggers and hand chisels
depth of occlusal embrasure at the expense of the 3. Plastic instruments:
size contact area. Spatulas, carriers, carvers, plastic filling instruments,
burnishers, etc.
Loose contact areas
4. Finishing and polishing instruments:
l Loose contact areas create continuity between embra-
(a) Hand:
sures and interdental col leading to food impaction.
l Orangewood sticks
[SE Q.1] l Polishing points
l Finishing strips
{The significance of proper contact areas cannot be over- (b) Rotary:
emphasized as: l Finishing burs
l They promote normal healthy interdental papillae filling
l Mounted brushes and stones
of the interproximal spaces. l Rubber cups and discs
l Improper contacts can result in food impaction between
5. Isolation instruments
the teeth, producing periodontal disease, carious lesions Rubber dam kit
and possible movement of the teeth. Saliva ejector
l Retention of food is objectionable by its physical
High-volume evacuator
presence. Cotton roll holder
l Halitosis results from food decomposition.
6. Miscellaneous instruments
l Proximal contacts and interdigitation of the teeth
Mouth mirror
through occlusal contacts stabilizes and maintains the Probes
integrity of the dental arches. Scissors
l Improper contacts lead to periodontal disease, second-
(II) Tooth nomenclature
ary caries and possible tooth movement.} There are several systems of numbering teeth.
Three popular systems are
SHORT ESSAYS: i. Zsigmondy/Palmer system
ii. American Dental Association (ADA) system
Q.1. Discuss different types of contact points and their iii. Federation Dentaire International (FDI) system
importance in restorative dentistry.
Ans. Zsigmondy/Palmer System
Ref LE Q.3 Primary dentition
Q.2. Discuss the methods of diagnosis of proximal caries Right Left

lesion. Maxilla EDCBA ABCDE
Ans. Mandible EDCBA ABCDE
Ref LE Q.2
Permanent dentition
Q.3. Classify hand instruments and add a note on
nomenclature. Right Left
Ans. Maxilla 87654321 12345678
Mandible 87654321 1 23 4 5 6 7 8
(I) G.V. Black’s classification
1. Cutting instruments:
(a) Hand instruments: Advantages
l Chisels l Simple to use
l Excavators l No confusion between primary and permanent teeth
Disadvantages Q.4. Diagnostic aids to detect caries.

l Oral communication is difficult.
l Opposing and contralateral teeth are indicated by the

Ans.
same number or alphabet, which can be confusing. [Ref LE Q.2]
American Dental Association (ADA) system
Primary dentition
SHORT NOTES:
Right Left
Q.1. Diagnosis of dental caries.
Maxilla ABCDE FGHIJ
Ans.
Mandible TSRQP ONMLK
Usual diagnostic methods of caries detection
Permanent dentition i. Meticulous clinical examination
ii. Tactile examination
Right Left iii. Radiographic examination
Maxilla 12345678 9 10 11 12 13 14
15 16
Recent methods used in diagnosis of caries
i. Digital radiographic methods
Mandible 32 31 30 29 28 27 24 23 22 21 20 19 ii. Computer-aided radiographic method
26 25 18 17
iii. Endoscopic filtered fluorescence method
iv. Quantitative laser fluorescence
Advantage
v. Alternating current impedance spectrography technique
l Each tooth has a separate unique letter or number to
(ACIST)
denote it.
Disadvantage Q.2. Secondary dentine.
l Difficult to remember the letters or numbers of indi-
vidual teeth. Ans.

l Secondary dentine is the dentine that forms after root
{SN Q.3} formation is completed.

l This occurs at a slower rate and the tubules are more
Federation Dentaire International (FDI) System
irregular in shape.
Permanent dentition
l Dentinal tubules curve more sharply as they move from
Right Left primary to secondary dentine.
Maxilla 18 17 16 15 14 21 22 23 24 25 l Secondary dentine is thicker over the roof and floor of
13 12 11 26 27 28 the pulp rather than on the side walls.
Mandible 48 47 46 45 44 31 32 33 34 35
Q.3. FDA tooth numbering system.
43 42 41 36 37 38
Ans.
Primary dentition
Ref SE Q.3
Right Left
Maxilla 55 54 53 52 51 61 62 63 64 65 Q.4. Common diagnostic aids of caries detection.
Mandible 85 84 83 82 81 71 72 73 74 75 Ans.
Advantages Common diagnostic methods of caries detection
l Each tooth has a separate number 1. Patient’s complaint
l Simple to understand and teach 2. Meticulous clinical examination
l Easy to pronounce in conversation 3. Tactile examination
l Easy to transmit over computer and easy for charting 4. Radiographic examination
5. Tooth separation
Disadvantage
6. Dental floss or tape
l May be confused with the ADA numbers
7. Fibreoptic transillumination
Q.5. Uses of radiographs. l This is localized to the area of irritation.

l Reparative dentine may either be formed by existing
Ans.
odontoblasts or by secondary odontoblasts derived from
Uses of radiographs the undifferentiated mesenchymal cells of the pulp.
l As a general rule, patients at higher risk for caries or l Reparative dentine is highly atubular in structure and
periodontal disease should receive more frequent and impervious to most irritants.
more extensive radiographic surveys.
Q.9. Col.
l For diagnosis of proximal surface caries, restoration over-
hangs or poorly contoured restorations, posterior bitewing Ans.

and anterior periapical radiographs are most helpful.
l In a faciolingual vertical section, the papilla may be
l When interpreting the radiographic presentation of
triangular between anterior teeth, whereas in the poste-
proximal tooth surfaces, it is necessary to know the
rior teeth the papilla may be shaped like a mountain
normal anatomic picture presented in a radiograph be-
range, with facial and lingual peaks and the col (‘val-
fore any abnormalities can be diagnosed.
ley’) lying beneath the contact area.
l In a radiograph, proximal caries appears as a dark area
l This col, a central faciolingual concave area beneath the
or a radiolucency in the proximal enamel at or gingival
contact, is more vulnerable to periodontal disease from
to the contact of the teeth. This radiolucency is typically
incorrect contact and embrasure form because it is cov-
triangular and has its apex towards the DEJ.
ered by nonkeratinized epithelium.
Q.6. Tetracycline stains.
Q.10. Percussion.
Ans.
Ans.
l Ingestion of tetracycline in utero by the mother or up to
l A percussion test is performed by gently tapping the
7–8 years by the child can lead to the incorporation of
occlusal or incisal surfaces of the suspected tooth and
tetracycline into dentine during tooth calcification.
adjacent with the end of the handle of a mouth mirror to
l Tetracycline chelates with calcium to form tetracycline
determine the presence of tenderness.
orthophosphate which produces a distinct stain.
l Pain on percussion indicates possible injury to the peri-
According to severity, there are three degrees of tetracy- odontal membrane from pulpal or periodontal inflam-
cline stains mation.
l First degree – light yellow, brown or light grey discol- l Care must be taken when interpreting a positive re-
ouration. This occurs uniformly throughout the crown. sponse on maxillary teeth because teeth in close prox-
l Second degree – more intense stains without banding. imity to the maxillary sinuses also may exhibit pain on
l Third degree – very intense grey stains with horizontal percussion when the patient has maxillary sinusitis.
banding especially in the cervical region.
Q.11. Embrasures.
Q.7. Test cavity.
Ans.
Ans.
i. When two teeth in the same arch are in contact, their
l This test is performed when other methods of diagnosis curvatures adjacent to the contact areas form spillway
have failed. spaces called embrasures or spillways.
l A small Class I cavity is prepared with high speed no. ii. The spaces that widen out from the area of contact labi-
1 or 2 round but with proper air and water coolant, till it ally or buccally and lingually are labial or buccal and
reaches the DEJ in an unanaesthetized tooth. lingual interproximal embrasures, respectively.
l Sensitivity or pain felt by the patient is an indication of iii. Above the contact areas incisally and occlusally, the
pulp vitality. spaces, which are bounded by the marginal ridges as
l No endodontic treatment is indicated; a sedative cement they join the cusps and incisal ridges, are called the
is then placed in the cavity. incisal or occlusal embrasures.
l If no pain is felt, pulp is necrotic and endodontic treat- iv. The gingival embrasure or interproximal space is a tri-
ment is indicated. angular space formed by the contact areas of two teeth
Q.8. Tertiary dentine. and supporting bone.
Q.12. Mention two diagnostic aids used for the diagnosis
Ans.
of caries.
l This is the dentine which is formed in response to exter-
Ans.
nal irritants like attrition, abrasion, erosion, trauma,
caries or restorative procedures. [Ref SN Q.1]
Topic 2
Preliminary Considerations for Operative Dentistry
LONG ESSAYS:
1. What is the importance of ‘moisture control in operative dentistry’? Give different methods of controlling mois-
ture during operative procedures.
2. Discuss pain control during cavity preparation.
3. How will you avoid injury to the soft tissues and supporting structures of a tooth during cavity preparation?
4. Enumerate methods of sterilization. Discuss the importance of sterilization of operative instrument.
5. Explain rubber dam application in detail.
6. Discuss the importance of isolation of the operating field and various methods to achieve it in conservative
dentistry. [Same as LEQ 1]
7. Discuss the importance of gingival tissue management in conservative dentistry. Describe the various techniques
of managing the gingival tissue. [Same as LEQ.3]
SHORT ESSAYS:
1. Discuss the methods and importance of tooth isolation during operative procedures. [Ref LE Q.1]
2. Discuss the retraction cord. [Ref LE Q.3]
3. Discuss the gingival tissue management. [Ref LE Q.3]
4. Describe infection control.
5. Describe the pain control during operative procedures. [Ref LE Q.2]
6. Discuss the barrier techniques in infection control.
7. Discuss the moisture control in operative dentistry. [Same as SEQ.1]
8. Discuss the direct method of isolation. [Same as SEQ 1]
9. Discuss the gingival retraction. [Same as SEQ.2]
10. Discuss the management of gingival tissues during operative procedures. [Same as SEQ.3]
SHORT NOTES:
1. Discuss the advantages of rubber dam.
2. Discuss the gingival retraction indications. [Ref LE Q.3]
3. Describe the moisture control in operative procedures. [Ref LE Q.1]
4. Discuss the hot air oven. [Ref LE Q.4]
5. Define the hot salt sterilizer.
6. Define the methods of sterilization. [Ref SE Q.4]
7. Discuss the disinfection of impressions.
8. Discuss sterilization of high-speed handpiece.
9. Define the autoclave. [Ref SE Q.4]
10. Discuss handpiece asepsis. [Same as SNQ.8]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. What is the importance of ‘moisture control in op- [SE Q.1 and SN Q.3]
erative dentistry’? Give different methods of controlling
moisture during operative procedures. {(Moisture control
l Carrying out ideal operative dentistry in a field of sa-
liva and blood is a difficult task as all the restorative
Ans.
iv. Bleaching
procedures and adhesive materials require a clean dry
v. High-risk patients, e.g. hepatitis B or HIV-
field to obtain their best properties.
infected patients.
l Proper isolation of the working area creates optimum
Contraindications
conditions and hence improves the quality of the
i. Teeth that have not erupted sufficiently to
treatment performed.
support a retainer
l Isolation eliminates saliva, sulcular fluid and gingival
ii. Some third molars
bleeding from the operating field. It also prevents
iii. Extremely mal-positioned teeth
the hand spray and cutting debris from hindering the
iv. Asthmatic patients with breathing problems
preparation.
v. Patients with latex allergy
l The goals of isolation are
Rubber dam equipment
a. Control of moisture
i. Rubber dam material
b. Retraction
ii. Rubber dam frame
c. Protection
iii. Rubber dam retainers/clamps
d. Improved quality of treatment
iv. Rubber dam punch
Methods of isolation v. Rubber dam stamp
. Indirect methods
A vi. Rubber dam clamp forceps
i. Relaxed position of the patient vii. Rubber dam napkin
ii. Local anaesthesia (LA) viii. Rubber dam lubricant
iii. Drugs (antisialagogues, antianxiety drugs and ix. Other retainers
muscle relaxants) x. Modelling compound
B. Direct methods [SE Q.1]
i. Rubber dam
ii. Throat shields {ii. Throat shields
iii. Gingival retraction i. They are used to recover small objects.
iv. Cotton rolls and cellulose wafers ii. These are indicated when there is danger of
v. High-volume evacuators and saliva ejectors)} aspirating or swallowing small objects.
iii. A gauge sponge is unfolded and spread over
. Indirect methods
A the tongue and the posterior part of the mouth.
i. Relaxed position of the patient: iii. Gingival tissue retraction
l The patient is made to relax, so that there is no Gingival tissue retraction refers to apical and lateral
unnecessary excess salivation. displacement of gingival tissue to aid in proper vis-
ii. LA: ibility and accessibility during subgingival tooth
l LA plays an important role in eliminating the preparation and to aid in proper flow of impression
discomfort and controlling moisture. material into the area.
iii. Drugs: Methods of gingival tissue retraction
l Drugs such as atropine and propantheline are sug- 1. Physicomechanical method
gested in patients with excessive salivation. Atro- 2. Chemical method
pine 0.3–1 mg, 1–2 h before the procedure and 3. Electrosurgical method
propantheline bromide 7.5–15 mg, 30–45 min 4. Surgical method}
before the procedure are given as a last resort. a. Physicomechanical method
B. Direct method This involves mechanically forcing the gingi-
val tissue away from tooth surface, laterally
[SE Q.1] and apically.
{i. Rubber dam Methods:
The use of rubber dam ensures absolute moisture 1. Copper bands
control in the mouth. It isolates one or more teeth that 2. Aluminium shell
are to be worked upon from the rest of the mouth.} 3. Temporary acrylic resin copings
Indications 4. Application of extra-heavy weight rub-
Although rubber dam is used routinely, it is espe- ber dam
cially indicated in following situations: 5. Replacement of cotton twigs in the gin-
i. Endodontic procedures gival sulcus
ii. Excavation of deep caries 6. Placement of cotton twigs impregnated
iii. Subgingival restorations and adhesive with zinc oxide eugenol. This pack should
restorations remain for a minimum of 48 h.
b. Chemical method l Patient experiences less pain.

l This method involves carrying various l Improves access and visibility.
chemicals into gingival sulcus. l No dehydration of oral tissues.
l These chemicals coagulate blood and tissue l Quadrant dentistry is facilitated.
fluids. Chemicals used are as follows: l Debris is removed from operating site.
1. Vasoconstrictors like epinephrine and l Precious metals are more readily salvaged.
norepinephrine l Evacuator tip is placed just distal to the tooth
2. Biologic fluid coagulants like alum, alu- to be prepared.
minium chloride, aluminium potassium l Saliva ejector removes saliva that collects on
sulphate, tannic acid, etc. the floor of the mouth.
c. Electrosurgical method l Saliva ejector, disposable and inexpensive
1. Here, four types of action can be produced plastic ejectors that can be shaped by bending
at the electrode end, namely cutting, coagu- with the fingers are preferred.
lation, fulguration and desiccation.
2. For gingival tissue retraction, mostly cut- Q.2. Discuss pain control during cavity preparation.
ting and rarely coagulation actions are em- Ans.
ployed.
d. Surgical method [SE Q.5]
1. This involves surgical excision of interfer-
ing gingival tissue using a sharp scalpel {Pain is the most motivating factor for the patient’s to visit
blade or surgical knife. the dentist. Moreover, dental treatment is also considered a
2. Surgical methods include gingivoplasty and painful procedure. A gentle and caring attitude towards the
rotary gingival curettage (gingettage). patient helps in calming them down and reducing the anxi-
ety. The other methods of controlling pain are
[SE Q.1]
{iv. Cotton roll isolation Local anaesthesia
1. Partial isolation with cotton rolls, absorbent wa- l LA is the most commonly used method in operative
fers and saliva ejectors provide a rapid and effec- dentistry to control pain.
tive control of the operating field. l It is necessary to ascertain of the pulpal status and
2. Isolation of maxillary teeth: A medium-sized cot- the patient’s attitude before deciding to give LA.
ton roll is placed in facial vestibule. l Some patients do not need anaesthetizing until the
3. Isolation of mandibular teeth: Medium-sized cot- procedure involves a vital pulp or exposed dentine,
ton rolls are placed in the facial vestibule and a whereas anxious patients may need LA for the sim-
larger one between the teeth and the tongue. plest of the procedures.
4. Cellulose wafers may be used to retract the cheek l Most procedures in operative dentistry are performed
and provide additional absorbency. either under a regional nerve block or a local infiltra-
5. Cotton rolls and wafers must be replaced as soon tion anaesthesia, which blocks the pathways of pain-
as they become saturated. ful impulses.
6. Dry cotton rolls are moistened before they are l A vasoconstrictor like epinephrine is added to pro-
removed to prevent the pulling of the epithelial long the action of the anaesthetic by decreasing the
covering of the mucosa. rate of absorption of the anaesthetic into the blood.
v. High-volume evacuators and saliva ejectors 1. Lidocaine 2% 1 epinephrine 1:50,000
Evacuators are used to suck out the aerator water 2. Bupivacaine 0.5% 1 epinephrine 1:200,000
spray. The speed of suction is high and the tip is ei- Techniques of LA
ther made of plastic or steel. Saliva ejectors have the The techniques of LA commonly used in operative
same function except that they work at much slower dentistry are
rate.} (i) Infiltration anaesthesia
Advantages (ii) Regional block anaesthesia}
l Very rapid removal of water from the operating (iii) Topical anaesthesia
site creating a ‘washed’ field, which improves (i) Infiltration anaesthesia: It consists of supra-
access and visibility. periosteal injection where the anaesthetic is
l Rapid clearance of cutting debris from the deposited near the nerve endings in the oper-
tooth as well as solid pieces of old restorative ating site. This is usually employed while
material. working on maxillary teeth.
(ii) Regional block anaesthesia: It consists of a (iv) EDA: It stimulates the larger diameter A-fibres,
nerve block where the anaesthetic solution is which transmit the sensation of touch, pressure
deposited near a nerve trunk at a distance from and temperature. Therefore, sensation of pain
the operating site. This technique is used while transmission is inhibited by smaller A delta–
working on mandibular posterior teeth. fibres and C-fibres. The pain sensation is not felt
(iii) Topical anaesthesia: Prior to administering as the brain does not get these impulses. Sero-
the anaesthesia, a topical anaesthetic such as tonin and endorphins levels increase in the blood
benzocaine or lidocaine gel or spray must be and this plays a secondary role in pain control.}
applied over the mucosa to minimize the dis- Q.3. How will you avoid injury to the soft tissues
comfort due to needle penetration. and supporting structures of a tooth during cavity
[SE Q.5] preparation?
Ans.
{Advantages of LA
i. Patient cooperation: Once the LA has become (SE Q.2, Q.3 and SN Q.2)
effective, the patient is more relaxed and coop-
erative due to the absence of pain. {(Sometimes restorative procedures encroach towards
ii. Control of saliva: Complete anaesthesia of all the gingiva, especially when caries extend subgingivally.
tissues in the operating site controls salivation. In such situations, it becomes necessary to protect the
iii. Reduced blood flow: The vasoconstrictor in the adjacent soft tissues from injury at the same time ensur-
local anaesthetic reduces blood flow in the oper- ing longevity of the restorative material.
ating site, thus controls bleeding in the area.
iv. Operator efficiency: Due to the above-mentioned Indications for gingival tissue management
factors, the operator’s efficiency is greatly enhanced. l Control of gingival haemorrhage or fluid flow
l Subgingival extension of margins
Alternative methods to control pain
l Aesthetics
In patients with a very low threshold of pain or those who
l Enhancing retention
are extremely apprehensive, additional methods may be
l Recording preparation margins during impressions
employed to control pain and anxiety. These include:
(i) Premedication with antianxiety agents or seda- l Removal of gingival overgrowth)}
tives
[SE Q.3]
(ii) Inhalation sedation
(iii) Hypnosis {Methods of gingival tissue management
(iv) Electronic dental anaesthesia (EDA) There are several methods available for gingival tissue
(i) Premedication with antianxiety agents or retraction. These may be employed according to the needs
sedatives: This technique can be used as an of the given situation. They include:
adjunct to LA in order to calm the patient dur- (i) Physicomechanical methods
ing the dental treatment. The patient should (ii) Chemicomechanical methods
always be accompanied by someone as their (iii) Chemical methods
reflexes will be depressed. The agents used are (iv) Rotary curettage
a. Diazepam (benzodiazepine derivative) (v) Surgical methods
administered orally in a dose of 2–10 mg, (vi) Electrosurgical methods
1 h prior to the dental appointment (i) Physicomechanical methods
b. Alprazolam (benzodiazepine derivative) These methods are employed in cases of healthy
0.25–0.5 mg, 1 h prior to the dental gingiva with adequate attached gingiva as they me-
appointment chanically displace the gingival tissues outwards and
c. Midazolam 2–5 mg, 1 h prior to the dental apically away from the tooth surface. The methods
appointment employed are
(ii) Inhalation sedation: For patients with com- (a) Rubber dam: Heavy, extra-heavy and special
plain of mild to moderate pain nitrous oxide heavy gauges of rubber dam provide adequate
with oxygen is usually preferred. It is one of mechanical displacement of the gingiva. For
the safest methods of sedation. extra retraction, the no. 212 clamp (cervical
(iii) Hypnosis: If the dentist is familiar with the clamp) can be used.
principles of hypnosis, it can be used as an (b) Wooden wedges: Wedges placed interproxi-
adjunct to LA and may be used to control the mally mechanically depress the gingiva, thus
tense patient, feel relaxed and cooperative. providing retraction.
(c) Rolled cotton twills: Rolled cotton twills can l Place the cord into the gingival sulcus using a plastic
be mechanically packed into the gingival sul- instrument or a cord packer. The cord packer has a
cus to produce retraction. Zinc oxide eugenol blunt working end with serrations.
impregnated cotton twills can also be used for l Start by gently pushing the cord at an axial angle of
gingival retraction. the tooth. This site provides better stabilization of the
(d) Retraction cords: Plain retraction cords can be packed cord.
gently forced into the gingival sulcus to dis- l Next proceed to the lingual surface. Apply gentle
place the gingiva laterally from the tooth. They pressure laterally and against the tooth surface to
may be woven from readymade cotton or syn- pack the cord. Wrap around the lingual surface and
thetic fibres. Retraction cords may be braided or continue labially till the cord overlaps the initially
nonbraided and are available in various sizes – placed end.
000, 00, 0, 1, 2 and 3. l Leave the cord in place for 5–10 min to achieve ad-
(ii) Chemicomechanical methods equate retraction.

Use of chemicals along with retraction cord provides l Slightly moisten the cord before removal so as to
safe and predictable gingival retraction. The chemicals avoid injury to the delicate epithelial lining of the
used are as follows: gingiva.
(a) Vasoconstrictors: These include adrenaline and l Finally, record the impression or proceed with the
noradrenaline. They cause haemostasis and restoration.}

local vasoconstriction, thus reducing haemor-
rhage and gingival fluid seepage. They can, [SE Q.3]
however, cause increased heart rate and elevated {(iii) Chemical methods
blood pressure. They are contraindicated in pa- l Several caustic chemicals like sulphuric acid, tri-
tients with cardiovascular disease, hypertension chloracetic acid, negatol (a 45% combination of
and diabetes mellitus. metacresol sulphonic acid and formaldehyde), etc.
(b) Astringents/biologic fluid coagulants: These have been used for chemical cautery of the gingival
agents act by coagulating the blood and gingival tissues.
fluids in the sulcus. The commonly used agents l Nowadays, only trichloracetic acid is still used.
are l It is a crystalline substance that becomes liquid on
(i) Alum 100% air exposure. The plastic tip is dipped in the liquid
(ii) Aluminium chloride 15%–25% and placed at the site where haemostasis is to be
(iii) Ferric sulphate 15.5% achieved.
(iv) Tannic acid 15%–25% (iv) Rotary curettage
l Tissue coagulants: These include the fol- l This is a troughing technique and is also known as
lowing chemicals: gingettage.
(i) Zinc chloride 8% l It is used to produce minimal removal of gingival
(ii) Silver nitrate} epithelium during subgingival placement of resto-
Tissue coagulants act by coagulating the ration margins.
surface layer of the sulcular and free l It is done using a chamfer diamond point in a high-
gingival epithelium along with any flu- speed handpiece.
ids present in the sulcus. This serves as l However, this technique is not controlled and can
a barrier for further seepage. Its side cause overextension and excessive bleeding.
effects on prolonged use are necrosis, (v) Surgical methods
ulceration and changes in the contour or This procedure requires surgical removal of gingival hy-
position of the gingiva. pertrophy or gingival in extensive subgingival trauma with
[SE Q.2] the help of surgical blades and periodontal instruments.
For 2 weeks, temporary restoration is placed and only
{Guidelines for gingival retraction using chemico after the gingival healing is considered adequate the
mechanical methods permanent restoration will be placed.
l Keep the operating area dry. (vi) Electrosurgical methods
l Select an appropriate size of the cord that is neither Principles of electrosurgery
too thick nor too thin. It uses alternating current at high frequency, concen-
l Cut a suitable length of the cord, so that it surrounds trated at tiny electrodes to perform various actions.
the entire circumference of the tooth. They are used when the site is inaccessible, espe-
l Soak the cord in aluminium chloride or ferric sulphate. cially to remove hypertrophied gingiva. There are
four actions based on the amount of energy pro- (i) Steam pressure sterilization autoclaving
duced: This technique uses superheated steam under pres-
a. Cutting: This is done precisely using minimal sure and kills the microorganisms by protein coagu-
energy and does not induce any bleeding. lation. It consists of a double-walled chamber to
b. Coagulation: When greater energy is used, hold the instruments and steam circulates under high
there is surface coagulation of the tissues, gin- pressure.
gival fluid and blood. Requirements for proper autoclaving
c. Fulguration: This is done using considerable l Wrap instruments in thin cloth, paper, steam-
energy. As a lot of heat is generated, there is permeable plastic or perforated cassettes.

deeper tissue involvement associated with car- l Instruments and packages must be properly
bonization. arranged to allow free circulation of the pres-

d. Desiccation: This includes massive tissue de- surized steam.
struction and is uncontrolled in its action.} l Use fresh distilled water for each cycle. Re-
Recent techniques for gingival retraction frain from using tap water as it contains miner-
In recent times, several new techniques are available als that can form deposits on the inner surface
for gingival retraction. These include: of the autoclave.
i. Lasers: l Carbon steel instruments and burs should be
l Lasers are gaining popularity in dentistry dipped in a corrosion-inhibitor solution (2%
since they can produce bloodless incision, sodium nitrite) before being wrapped. This
controlled tissue removal and rapid, pain- will prevent them from corroding.
free healing. l Sterilization will not occur unless the autoclave
l CO2 lasers, Nd-YAG lasers and argon lasers is operated at the appropriate pressure and tem-
are being used for soft tissue surgery. For perature for an adequate length of time. Opti-
gingival tissue retraction and excision, Nd- mum pressure and temperature must be reached
YAG and diode lasers are recommended. before timing the sterilization cycle.
l The technique is slower than scalpel surger- Types of autoclaves
ies and the instrument is expensive. a. Downward displacement autoclaves – They
ii. Retraction by dilatation of the gingival sulcus: cause downward displacement of air as steam
l Gingifoam technique can be used to dilate enters the top of the chamber. Their efficacy is
the gingival sulcus. low.
l It uses a modified silicone elastomer avail- b. High vacuum autoclaves – They are also
able as a base and catalyst paste. The base known as rapid cycle autoclaves. In these, air
paste contains polydimethylsiloxane and is evacuated by vacuum suction before steam
the catalyst contains tin. enters the chamber. These autoclaves perform
l On mixing the two pastes, the reaction rapid and effective sterilization than conven-
produces hydrogen gas within the sili- tional autoclaves and are presently popular in
cone matrix resulting in the formation of dentistry.
a foam.
l This foam expands the gingival sulcus, thus Sterilization cycles for autoclaves
causing retraction.
Temperature
Q.4. Enumerate methods of sterilization. Discuss the Cycle (°C) Pressure (lb) Time (min)
importance of sterilization of operative instrument. Standard 121 15 20
Ans. Flash 134 30 7–10
Sterilization Advantages
Sterilization is the method of removal of all microorganisms l Most rapid and effective method of steriliza-
in the vegetative and spore forms. It is necessary to clean tion.

and sterilize the instruments by accepted methods before l Does not destroy cotton or cloth products.
reuse. There are four accepted methods of sterilization: l Provides excellent penetration of packages.
i. Steam pressure sterilization (autoclave) l Sterilization can be verified.
ii. Dry heat sterilization (dryclave) Disadvantages

iii. Chemical vapour pressure sterilization (chemiclave) l Corrosion of carbon steel instruments (antirust
iv. Ethylene oxide sterilization agent may be used to prevent this).

l May damage plastic and rubber items. l The chemical vapour kills microorganisms by de-
l Dulls unprotected cutting edges. stroying vital protein systems.
l Instruments are packed in paper, muslin or steam-
permeable plastic. The sterilizer must be preheated

{SN Q.4} before use.
(ii) Dry heat sterilization/dryclave Sterilization cycle for chemiclave
l This method effectively sterilizes instruments at
Temperature (°C) Pressure (lb) Time (min)
high temperatures above 160°C as dry heat kills
microbes through oxidation. 132 20 20
l The apparatus is a dry heat oven which has
heated chambers to allow air to circulate by grav- Advantages

ity flow (gravity convection). l Does not corrode metals.
l The instruments are placed at least 1 cm away l Rapid and efficient cycle time.
from each other for quick sterilization. Some- l Load comes out dry.
times, blowers and fans are provided to distribute Disadvantages

heated air. l High cost of equipment.
l The instruments should be wrapped lightly in l Vapour odour may be offensive and requires
aluminium foil. Paper and cloth packs should be increased ventilation.

avoided as they may char. l The solution supplied by the manufacturer has
to be used.
Sterilization cycles for dry heat oven l Handpieces cannot be sterilized by this method.
Apparatus Temperature (°C) Time (min) (iv) Ethylene oxide sterilization

l This method uses automatic devices filled with eth-
Conventional dry heat 160 90
oven ylene oxide gas at temperatures below 100°C to
sterilize complex instruments and delicate materials.
Mechanical convec- 320–375 6–12
l Ethylene oxide is highly penetrable and kills micro-
tion oven
organisms by chemically reacting with nucleic acids.
Advantages l The sterilization cycle takes several hours and once
l Rapid cycles are possible at high tempera- over, aeration for 24 h or more is needed before the
tures. instruments can be used.
l Burs and carbon steel instruments do not Advantages
rust, if they are well dried before steriliza- l Most gentle for sensitive equipment like hand-
tion. pieces.
l Large load can be placed. l Operate effectively at low temperatures.
l Sterilization can be verified. Disadvantages

l Low cost of the equipment. l High cost
Disadvantages l Prolonged time
l Heat sensitive items like rubber or plastics l Best for hospitals, not practical for dental clinics
may be damaged. l Ethylene oxide gas is potentially mutagenic and
l At lower temperatures, sterilization cycles carcinogenic

are prolonged.
l Sterilization is ineffective, if there is heavy
Types of instruments and recommended sterilization
instrument loading and crowding. methods
Instruments Method of Sterilization

Stainless steel operative instru- Autoclave
l Inaccurate calibrations and settings may be a ments
source of error.
Endodontic instruments Autoclave
(iii) Chemical vapour pressure sterilization
l This method employs chemical vapour of a mixture
Dental handpieces Autoclave
of formaldehyde, alcohol, ketone, acetone and water. Carbon steel instruments Dry heat oven or chemiclave
l When this solution is heated under pressure, it forms
Dental burs and abrasives Dry heat oven or chemiclave
a gas that sterilizes instruments.
v. Newer methods of sterilization it to settle against the gum margin beneath the jaw.
Various newer methods of sterilization are employed for Similarly position it beneath the lingual jaw of the
specific purposes. clamp. Check if the dam has passed through both
l Gamma rays are used to sterilize suture materials, contacts and then apply the napkin and frame.
syringes, disposable needles and other heat sensi- Advantages
tive items. l Quick and simple technique
l Ultraviolet light is used to purify the air in the l Minimal trauma to the gingiva
dental operatory but it is not very effective. l Good vision of the clamp and tooth during
l Hydrogen peroxide vapour, gas plasma sterilization placement

and the use of lasers are still under investigation. . Clamp and rubber dam placed together
b
In this technique, also winged clamps are preferred.
Q.5. Explain rubber dam application in detail. l First select the suitable winged clamp and verify
its trial fit on the required tooth.

Ans.
l A large hole is punched in the dam and it is
Rubber dam application techniques stretched over the wings of the clamp. The bow is
Steps prior to the application of the rubber dam include the then positioned to the distal aspect of the tooth to
following: be isolated.
i. Check the patient’s mouth to check for calculus depos- l The clamp and rubber dam combination is carried
its and sharp edges on restorations. to the mouth by means of the clamp forceps. The
ii. Perform oral prophylaxis if plaque and calculus are clamp is first seated on the lingual side and then
present, also polish any sharp edges on restorations. on the buccal side.
iii. Test contact areas of teeth in the area to be isolated to l Then, the rubber dam is moved over the wings
allow easy passage of the rubber dam sheet. with a blunt instrument till it is positioned around
iv. The gingival area is anaesthetized so as to prevent pain the cervical margin of the tooth.
during clamp placement. l Finally, the rubber dam frame and napkin are
v. Finally, the operating field is rinsed and dried. applied.

Advantage
Rubber dam can be placed by one operator but it is more
l Useful in third molar regions.
efficient with an assistant.
Disadvantages
Isolation with rubber dam may involve a single tooth or
l Limited vision during clamp placement
multiple teeth.
l May traumatize the gingiva
Single-tooth isolation c. Clamp placed after the rubber dam

This technique requires the help of an assistant for quick
This can be done in the following situations:
application.
i. Pit-and-fissure sealants
l First select an appropriate clamp and check its
ii. Class I restorations
fitness over the required tooth.
iii. Class V restorations
l The rubber dam is taken and a correct size hole is
iv. Endodontic procedures
punched preferably a large one.
For posterior teeth, clamps are necessary for rubber dam l The dam is stretched over the crown of the tooth
retention while in anteriors other alternatives may be used. and through its proximal contacts. It is pulled api-
Whenever a clamp is applied, three techniques of rubber cally, so that the gingival margin is visible buc-
dam placement are possible: cally and lingually.
l The clamp is then positioned accurately.
Rubber dam placement for single tooth
l Finally, the frame and napkin are fitted.
a. Clamp placement prior to rubber dam
Advantage
b. Clamp and rubber dam placed together
l Easy to apply for anterior teeth
c. Clamp placed after the rubber dam
Disadvantages
a. Clamp placement prior to rubber dam l Requires an assistant for easy application
l First select the appropriate winged clamp. l Difficult access for posterior teeth
l Large hole is punched for easy placement of the rub-
ber dam over the clamp. Two overlapping holes Rubber dam application for multiple teeth
allow easy stretching of the dam over the clamp. Many teeth need to be isolated for the following situations:
l Stretch the dam first over the bow of the clamp. Next i. Bleaching
stretch it over the buccal jaw of the clamp and allow ii. Class II restorations
iii. Multiple restorations and quadrant dentistry holes are punched on the dam. The dam is
l When only a few teeth require restorations, one stretched over the tooth to be treated and one ad-
tooth on either side of the teeth under treatment jacent tooth on each side. Clamps or wedges may
should be isolated to improve access and visibility. then be placed to stabilize the dam.
l Clamps are placed on the tooth distal to the involved
Q.6. Discuss the importance of isolation of the operating
tooth.
field and various methods to achieve it in conservative
dentistry.
The isolation is extended across the arch for clear access
and good retention of the rubber dam when several teeth Ans.
need isolation.
[Ref LE Q.1]
a. Isolation of anterior teeth
l The isolation involves all six anterior teeth and with Q.7. Discuss the importance of gingival tissue manage-
the first premolars serving as anchor teeth. Clamps or ment in conservative dentistry. Describe the various
auxiliary aids like wedges, wedjets or a strip of dam techniques of managing the gingival tissue.
material are used.
Ans.
l First, the rubber dam is secured over the anchor
teeth. [Ref LE Q.3]

l Next the remaining teeth are exposed through the
punched holes by stretching the dam through all the SHORT ESSAYS:
contacts.
l A flat plastic instrument is used to invert the rubber Q.1. Discuss the methods and importance of tooth isola-
dam and floss ligatures are tied at the neck of all the tion during operative procedures.
exposed teeth to hold the dam in place. Finally, the Ans.
napkin and frame are fitted.
b. Isolation of posterior teeth [Ref LE Q.1]
l For isolation of all the posterior teeth, the rubber dam
Q.2. Discuss the retraction cord.
is passed over the canine or incisors in the same
quadrant or across the midline. Ans.
l Holes are punched in the dam for the individual
[Ref LE Q.3]
teeth. The clamp is positioned over the posterior
most tooth and then stretched over it. Q.3. Discuss the gingival tissue management.
l Following this, the dam is stretched over the anterior
Ans.
anchor tooth and retained by a clamp or wedjet.
Special situations [Ref LE Q.3]
a. For matrix placement
Q.4. Describe infection control.
When a matrix band has to be placed on a
clamped tooth, the matrix band serves the purpose Ans.
of a clamp. Hence, the clamp has to be removed l Infection control is compulsory in dentistry as the den-
and replaced by the matrix retainer and band. In- tist either can get the infection from the patient or he can
terdental wedges help in additional retention. spread the infection from one patient to another patient
b. For cervical cavities or from himself to the patient.
For proper retraction, a heavier rubber dam is pre- l OSHA: Occupational Safety and Health Act was passed
ferred. In anterior teeth, the no. 212 cervical re- by US Congress in 1970.
tainer is used. The hole in the rubber dam sheet is l SOPS: Standard Operating Procedures is a term used in
punched facial to the arch form. Impression com- former OSHA regulations.
pound is softened and placed over the clamp.
If the jaws of the clamp are not in the optimum Regulations of OSHA
position, the clamp can be modified by heating it (a) Provision for hepatitis B vaccination
in a Bunsen burner flame. This will help in stabi- (b) Universal precautions such as:
lizing the clamp and in a more gingival retraction l Careful handling of sharp instruments.
c. Split dam l Use of devices to reduce contamination risks (high-
This technique is used in fractured crowns or an- volume suction, rubber dam and protective sharp
teriors with ceramic crowns or veneers to prevent containers).
chipping of the crown margins. Two overlapping (c) Personal protective equipment: gloves, mask, gown.
(d) Housekeeping is related to clean-up instruments, opera-

{SN Q.6 and SN Q.9}
tory equipment, floors, walls and management of waste,
and sterilization procedures. A. Autoclaving
(e) Implement engineering controls to reduce the produc- l In this apparatus, the material is exposed to 121°C
tion of contaminated spatter, mist, aerosol, for example for 15–20 min at 15 lb pressure/sq. inch.
rubber dam, high-volume suction. l It is used to sterilize – culture media, rubber
(f) Implementation of work practice controls to minimize goods, syringes, gowns and instruments.
the splashing, spatter or contact of bare hands with Sterilization of burs in autoclaving
contaminated surfaces, for example when using the l Burs are placed in 2% sodium nitrate contain-
brush to scrub instruments hold the instruments well ing bottles; either glass beakers or metal bea-
down in the sink and brush away from yourself. kers are kept in autoclave for sterilization.
(g) Never contact telephones, switches and door handles
with soiled gloves.
(h) Provision of proper washing facilities – washing hands {SN Q.6}
after removing gloves. B. Chemical vapour pressure sterilization
(i) Maintenance of proper sterilization of instruments. l Sterilization by chemical vapour under pressure,
(j) Removal of blood-contaminated waste properly and
i.e. 131°C – 20 lb pressure sq. inch – 30 min.
disposed thoroughly. l Uses: Sterilization of corrosion sensitive burs,
(k) Provision of laundering of protective garments used for metallic instruments and pliers.
universal precautions. C. Dry heat sterilization
(l) Safe handling of needles. l Red heat: Directly by holding on flame used for
Disinfection of surfaces and equipment in the dental office needles, forceps and inoculating wires.
The surfaces and equipment which do not permit steril- l Hot air oven: Carbon steel instruments and burs.
ization should be treated with disinfectant prior to seating l Incineration: Hospital dressings are burnt.
the patient and in between patients, for example operating D. Ethylene oxide sterilization
light handles, chair controls, tray arms and release levers, l Used to sterilize complex instruments and deli-
three-way syringe handles. cate materials.

l Detergent solutions assist in removing dried blood. l Ethylene oxide gas at high temperature below
l Alcohol, 90% isopropyl or 70% ethyl alcohol aids in 100°C for several hours.
solubilizing dried blood and saliva.
l 70% isopropyl alcohol has become an effective agent E. Sterilization of handpieces and related rotary
for surface decontamination in dental office. instruments
l Scrubbing with disinfectant
Methods to reduce cross-infection
l Steam sterilization
l Safety glasses should be worn to protect eyes from l Chemical vapour pressure
splatter and aerosols and to avoid injury. l Cleaning with soap
l Masks should be worn for protection against aerosols l Wiping with alcohol
and any blood or saliva emanating from the oral cavity. F. Sterilization of impressions
l Gloves should be worn routinely due to risks in treating l Washing the impression with disinfectant solution,
patients who may themselves be unaware that they are such as 3% phenol, ethyl alcohol and formaldehyde
carriers of infectious disease.
Q.5. Describe the pain control during operative
procedures.
{SN Q.6} Ans.
Methods of sterilization [Ref LE Q.2]

. Autoclaving – steam pressure sterilization
A Q.6. Discuss the barrier techniques in infection control.
B. Chemical vapour pressure sterilization
C. Dry heat Ans.
D. Ethylene oxide sterilization Barrier techniques of protection
E. Sterilization of handpieces and related rotary instru-
ments (i) Handwashing
l Meticulous hand care can prevent the transmission of
F. Sterilization of impressions
infections to a major extent.
l Thorough handwashing must be done before and Q.7. Discuss the moisture control in operative dentistry.
after each patient using a mild antiseptic such as 3%
Ans.
parachlorometaxylenol (PCMX) or 4% chlorhexi-
dine gluconate. [Ref LE Q.1]
l This can control transient pathogens.
Q.8. Discuss the direct method of isolation.
l Handwashing is also necessary while changing
gloves as even good quality gloves may have minor Ans.

pinholes or leaks.
[Ref LE Q.1]
(ii) Treatment gloves
l The clinician must wear treatment gloves during Q.9. Discuss the gingival retraction.
all treatment procedures as there are chances of
Ans.
contacting the patient’s blood, saliva or mucous
membrane, which may transmit infection from the [Ref LE Q.3]
patient to the dentist.
Q.10. Discuss the management of gingival tissues during
l Fresh gloves must be used for every patient. Torn or
operative procedures.
punctured gloves must be discarded immediately.
(iii) Protective eyewear, masks and hair protection Ans.
l The operator must protect his eyes from spatter by
[Ref LE Q.3]
wearing protective glasses with solid side shields.
l These can be disinfected between patients.
SHORT NOTES:
l Face shields are required when there is heavy spat-
ter such as during ultrasonic scaling, crown and Q.1. Discuss the advantages of rubber dam.
bridge preparation, etc. Ans.
l Mouth masks are a must to protect the dentist’s oral
and nasal mucosa from aerosol and spatter of blood Rubber dam is one of the most effective means of isolating
or saliva. teeth. It was introduced by Barnum in 1864.
l Rectangular masks with folds have the highest fil-
Advantages
tration rate. l Maintains dry and clean operating field
l Masks must be changed whenever they become
l Improves the accessibility and visibility
moist or visibly soiled. l Prevents the aspiration of instruments
l The operator’s hair has to be kept away from the
l Enhances the operator’s efficiency
treatment field by means of a surgical cap. l Potentially improves the properties of dental materials
(iv) Overgloves l Acts as barrier between patient and operator and thus
l These are made of lightweight, inexpensive, clear
prevents cross-infection between them
plastic. l Increases efficacy by minimizing patient conversation
l They are put over treatment gloves while handling
and need for frequent rinsing
cabinets, answering the telephone, making entries l Avoidance of contamination – most of the dental mate-
in the dental chart, etc. So that treatment gloves are rials perform to their optimal level if contamination is
not contaminated. avoided
(v) Rubber dam isolation and high-volume evacuation
l There have been reports of transmission of various
Q.2. Discuss the gingival retraction indications.
airborne infections from aerosol and spatter during Ans.
use of rotary equipment. Hence, use of high-volume
[Ref LE Q.3]
evacuation and rubber dam isolation is valuable in
controlling infection transmission. Q.3. Describe the moisture control in operative proce-
l It has been reported that high-volume evacuation dures.
can control up to 80% of the contamination pro- Ans.
duced by aerosol.
(vi) Preprocedural mouth rinse [Ref LE Q.1]
l A chlorhexidine mouthwash (0.1%–0.2%) prior to Q.4. Discuss the hot air oven.
treatment greatly reduces the intraoral microbial
load and the risk of cross-infection from patient to Ans.
dentist. [Ref LE Q.4]
Q.5. Define the hot salt sterilizer. Q.8. Discuss sterilization of high-speed handpiece.
Ans. Ans.
Hot salt sterilizer Handpiece sterilization
l Apparatus consists of a metal cup in which table salt l Dental handpieces are semicritical items.
is kept at a temperature 425°F. l While using the handpiece in the patient’s mouth,
l A thermometer is used always to measure the tem- blood, saliva, tooth-cutting debris and restorative
perature. materials may be drawn into its working portion.
l Root canal instruments such as broaches, files and l Handpieces have to be properly sterilized between
reamers are sterilized for 5 s. patient exposures to prevent cross-infection.

l Absorbent points and cotton pellets for 10 s. Protocol for sterilizing handpieces
Advantages l Prior to removing the handpiece from the dental unit,
l Use of ordinary salt instead of metal or beads. clean it by wiping visible debris using a suitable
l Eliminates the risk of clogging the root canal. disinfectant such as alcohol.
l Run it for a minimum of 30 s to discharge residual
Q.6. Define the methods of sterilization.
water and air.
Ans. l Next, clean the handpiece thoroughly with a soap or
[Ref SE Q.4] detergent solution.

l Now reattach handpiece to the unit and run dry.
Q.7. Discuss the disinfection of impressions. l Most handpieces should be lubricated before steril-
Ans. ization using a lubricant delivered from an aerosol.

Excess lubricant should be expelled. An automatic
Infection control for impressions handpiece cleaning unit connected to the air supply
can also be employed to clean and lubricate the hand-
l Impressions which have been placed in the patient’s piece. This is more efficient than the manual method.
mouth can transfer infection to laboratory personnel. l Finally, place the handpiece in a paper pack, seal it
l It is important to decontaminate these items before they
and sterilize by autoclaving.
are transferred to the dental laboratory. l Sterilization methods: Handpieces can be effectively
The following steps have to be taken: sterilized by means of the autoclave or by ethylene
l Thoroughly wash the impression or other pros-
oxide sterilization. These methods are safe, provided
thetic items under running tap water to remove the handpiece has been thoroughly cleaned and oil
saliva, blood and debris. for lubrication is completely cleared out.
l Disinfect the surface of most items including elas-
tomeric impressions by immersion in 2% gluteral- Q.9. Define the autoclave.

dehyde or chlorine compounds for 10 min. The Ans.
time of immersion varies according to the manu-
facturer’s instructions. [Ref SE Q.4]
l For alginate impressions, spray an iodophor as Q.10. Discuss handpiece asepsis.
soaking may distort the impressions.
Ans.
l Store the items in separate sealed plastic bags
before transfer to the laboratory. [Same as SN Q.8]
Topic 3
Cariology
LONG ESSAYS:
1. Define dental caries. Classify and enumerate sequelae. Briefly write management of mesiocclusal caries in a
mandibular first molar tooth.
2. Discuss aetiology and management of hypersensitive dentine.

3. Classify pulpal lesions. Differentiate between reversible and irreversible pulpitis.
4. Discuss caries activity test and mention it in detail.
5. Describe the aetiology and treatment of pain in the tooth after placing restoration.
6. Describe in detail the prophylactic treatment of dental caries. [Same as Q1]
7. Describe deep caries management. [Same as Q1]
8. How do you diagnose dental caries? Add a note on aetiology and classification of dental caries.
[Same as LEQ.1]
9. Discuss the management of hypersensitive dentine. [Same as LEQ.1]
10. Discuss hypersensitive dentine in relation to its mechanism and management. [Same as LEQ 2]
11. Discuss dentine hypersensitivity, with emphasis on various theories. Also mention its management.
[Same as LEQ 2]
1 2. What are the causes of dentinal hypersensitivity? Describe the methods of its management. [Same as LEQ 2]
13. Discuss control of pain during operative procedures. [Same as LEQ.5]
14. Discuss pain control procedures during cavity preparation. [Same as LEQ.5]
SHORT ESSAYS:
1. Discuss hypersensitivity. Also mention the management of hypersensitive dentine. [Ref LE Q.2]
2. Define and classify caries. Add a note on diagnosis of caries.
3. Discuss root surface caries.
4. Discuss phoenix abscess.
5. Discuss the pulp polyp.
6. Mention the aetiological factors of pulpal diseases. [Ref LE Q.3]
7. Discuss the affected and infected dentine.
8. Discuss pit and fissure caries.
9. Define the theories of hypersensitivity. [Same as SEQ.1.]
10. Mention causes of hypersensitivity and management of the same. [Same as SEQ.1.]
11. Discuss the tooth hypersensitivity. [Same as SEQ.1.]
12. Define and classify dental caries. Write a note on secondary caries. [Same as SEQ.2]
13. Discuss phoenix abscess – cause, symptoms and treatment. [Same as SEQ.4]
SHORT NOTES:
1. Discuss the secondary dentine. [Ref SE Q.2]
2. Discuss the irreversible pulpitis. [Ref LE Q.3]
3. Discuss the affected and infected dentine. [Ref SE Q.7]
4. Discuss the caries activity tests.
5. Discuss the pink tooth.
6. Discuss the phoenix abscess. [Ref SE Q.4]
7. Discuss the caries detecting dyes. [Ref SE Q.2]
8. Discuss the geriatric caries.
9. Discuss the cemental caries. [Ref SE Q.3]
10. Discuss saliva tests for caries risk assessment. [Ref SN Q.4 SAME ANSWER]
11. Discuss the pit and fissure sealants. [Ref SE Q.8]
12. Define ART.
13. Discuss the preventive measures of dental caries.
14. Discuss the disclosing solution.
15. Discuss the infected dentine. [Same as SNQ.3]
16. Discuss the fissure sealants. [Same as SNQ.11]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Define dental caries. Classify and enumerate se- l Heredity
quelae. Briefly write management of mesiocclusal caries l Caries can be inherited from parents especially from
in a mandibular first molar tooth. the mother.
l Race
Ans.
l Caries may be dependent on different cultural and
It is an infectious, microbiologic disease of the teeth dietary influences.
that results in localized dissolution and destruction of the l Geographic environment
calcified tissues. l Areas where there is more of phosphate content in
food or fluoride content in water will cause less cries.

Aetiology of dental caries
l Occupation
Primary factors
l Workers working in bakeries or confectionaries are
l Tooth
more susceptible to caries.
l Dental plaque
l Diet Classification
l Time i. Based on the location
l Pit and fissure caries
I. Tooth
l Smooth surface caries
(a) Susceptible tooth surfaces
l Root surface caries
Nonself-cleansable areas are more prone to de-
ii. Based on the speed of caries progression
velop caries as they provide stagnation areas for
l Chronic caries
dental plaque. Pits and fissures have the highest
l Arrested caries
recurrence of dental caries.
l Acute or rampant caries
(b) Biochemical characteristics of teeth
iii. Based on whether it is new or recurrent caries
Newly erupted teeth and patients with vitamins A
l Initial or primary caries
and D or mineral deficiencies, hypoplasia and hy-
l Recurrent or secondary caries
pomineralized teeth are more prone to caries.
iv. Based on extent of the caries
II. Dental plaque
l Incipient caries
Dental plaque has a high concentration of Streptococ-
l Cavitated caries
cus mutans and Lactobacillus acidophilus. These mi-
v. Based on pathway of spread of caries within the tooth
crobes produce extracellular polysaccharides that help
l Forward caries
them to adhere to tooth structure. High amounts of
l Backward caries
acids are produced and this cause dissolution of the
vi. Based on number of tooth surfaces involved
tooth structure.
l Simple caries
III. Diet
l Compound caries
Soft and sticky food, refined carbohydrates and consump-
l Complex
tion of snacks between meals are predisposed to caries.
vii. Based on the treatment and restoration design
IV. Time
l Class I caries
During long intervals of undisturbed plaque stagna-
l Class II caries
tion, acids are produced that lower the pH and hence
l Class III caries
cause dissolution of the tooth structure.
l Class IV caries
Modifying factors l Class V caries
l Saliva l Class VI caries
l Saliva helps in flushing action, buffering capacity, viii. Based on if caries are completely removed or not
antimicrobial effect and remineralizing property. l Residual caries
l Systemic health ix. Based on the age of the patient
l Systemic conditions that predispose to poor oral hy- l Nursing bottle caries
giene or xerostomia like diabetes, radiation, etc. l Adolescent caries
cause caries. l Senile caries
l Sex x. Based on the tooth surfaces to be restored
l Females are more susceptible to caries due to early l Occlusal surface
eruption of teeth. l Mesial surface
l Distal surface Here, the intertubular dentine is demineralized, odonto-

l Facial surface blast processes are damaged and fine crystals are seen in
l Buccal surface the lumen of the dentinal tubules. But no bacteria are
l Lingual surface found in this zone.
Zone 3: Transparent dentine
Aids used for diagnosis of caries
This is superficial to the subtransparent dentine. It is
Traditional methods
softer than normal dentine and exhibits mineral loss in
a. Clinical methods
the intertubular dentine. No bacteria are seen here and
l Patient compliant
the collagen cross-linking is intact. So this layer is ca-
l Visual examination
pable of remineralization.
b. Mechanical methods
Zone 4: Turbid dentine
l Tactile examination
This is the next superficial layer. Dentinal tubules are
l Tooth separation
widened and distorted due to bacterial penetration.
l Dental floss or tape
There is considerable demineralization and collagen is
Radiographic methods irreversibly denatured. This zone is incapable of remin-
a. Conventional radiographic methods eralization and must be removed before restoration.
l Intraoral periapical radiographs Zone 5: Infected dentine
l Bitewing radiographs This is the outermost zone. It has decomposed dentine
b. Advanced radiographic methods with destruction of dentinal tubules and collagen. A
l Xeroradiography high concentration of bacteria is seen. This zone has to
l Digital radiographic methods be removed to prevent the spread of infection.
l Computer-aided radiographic methods Clinically, Zones 4 and 5 constitute the infected dentine.
l Digital subtractions radiography The deeper Zones 2 and 3 are the affected dentine.
Optic methods Q.2. Discuss aetiology and management of hypersensi-
l Fibreoptic transillumination tive dentine.
l Digital fibreoptic transillumination
Ans.
l Optical coherence tomography (OCT)
Fluorescence method [SE Q.1]

l Quantitative laser fluorescence {Dentine hypersensitivity is characterized by short and sharp
l Endoscopic filtered fluorescence method pain arising from exposed dentine in response to stimuli typically
Lasers thermal, evaporate, tactile, osmotic or chemical and which can-
l Diagnodent
not be ascribed to any other form of dental defect or pathology.
l Dye-enhanced laser fluorescence
Aetiology of dentine hypersensitivity
Enamel loss
Other recent methods l Occlusal wear
l Caries detector dye l Toothbrush abrasion
l Ultrasonic probe imaging l Dietary erosion
l Visible luminescent spectroscopy l Abfraction
l Vanguard electronic caries detector l Parafunctional habits
l Electrical conductance measurements Cemental loss
l Alternating current impedance spectroscopy technique l Gingival recession
l Periodontal disease
Sequelae of caries progress in dentine
l Root planning
Zones of dentinal caries
l Periodontal surgery
Three changes are seen as caries spread in dentine:
l Weak organic acids demineralize the dentine.
Theories of dentine hypersensitivity
l The organic content of dentine, especially collagen un-
Tooth sensitivity to various stimuli is a peculiar problem
dergoes degeneration and dissolution. faced by many adult patients. The exact mechanism of
l Breakdown of the structural integrity and bacterial invasion.
dentine hypersensitivity is not very clear but several
theories have been proposed to explain this phenome-
Various zones seen in carious dentine are non. They include:
Zone 1: Normal dentine l Direct innervation theory
The deepest zone of carious dentine is normal with normal l Odontoblast deformation theory/transducer
collagen, odontoblastic processes and intertubular dentine. mechanism
Zone 2: Subtransparent dentine l Hydrodynamic theory
Direct innervation theory Fluorides – agents such as sodium fluoride and

Nerve fibres present within the dentinal tubules initiate stannous fluoride act by forming fluoroapatite
impulses when they are injured and this causes dentinal within the tubules which block fluid movement
hypersensitivity. within the dentine.
Odontoblast deformation theory/transducer mechanism Fluoride ionthoporesis – this method transfers
This theory suggests that the odontoblasts or their pro- fluoride ions into the dentine for the purpose of
cesses are damaged when external stimuli are applied to desensitization. It is known to provide a more long-
exposed dentine. As a result of this, they conduct im- term relief from exposed hypersensitive dentine.
pulses to the nerves in the predentine and underlying Potassium oxalate – the oxalate ions react with
pulp from where they proceed to the central nervous calcium ions in the dentinal fluid to form insolu-
system. ble calcium oxalate crystals that can block the
Hydrodynamic theory (M. Brannstrom) tubules and prevent fluid movement.
Presently, the hydrodynamic theory proposed by Varnishes
Brannstrom is the most accepted mechanism to explain l Dentine adhesives: Recently, the use of dentine
dentinal hypersensitivity. Structurally, the dentine has bonding agents to treat dentine hypersensitivity
over 30,000 dentinal tubules/mm. These are filled with has become popular. They seal the exposed den-
dentinal fluid which is the intercellular fluid of the tine by micromechanically bonding to it through
pulpal connective tissue. In a vital tooth, there is a con- the formation of an interdiffusion hybrid layer.
stant and slow outward movement of this fluid through l Placement of restorations: Whenever a consid-
the dentinal tubules. erable amount of dentine is lost, it becomes neces-

The hydrodynamic theory states that whenever exposed sary to replace the missing tooth structure. Usu-
dentine is stimulated by tactile, chemical, thermal or ally, a glass ionomer or a composite resin
osmotic stimuli, there is rapid movement of the dentinal restoration may be placed.
fluid either towards the pulp or outwards. l Use of lasers: Recently, lasers like CO2, Nd:YAG,
Management of dentine hypersensitivity Er:YAG, diode and He:Ne lasers have been em-
There are basic mechanisms by which dentine hyper- ployed to treat hypersensitive dentine.
sensitivity can be managed. Desensitization by blocking pulpal sensory nerves
Desensitization by occluding the dentinal tubules l This mechanism of treating dentine hypersensitivity
l It consists of blocking dentine fluid movement by oc- works by reducing the excitability of the sensory
cluding the surface of dentinal tubules. nerves in the pulp in response to various stimuli.
a. Formation of a smear layer over exposed dentine: l Desensitizing toothpastes containing potassium
Achieved by isolating the affected tooth and bur- are used to block the pulpal sensory nerves from
nishing the dentine dry for a few minutes with an transmitting pain impulses.}
orangewood stick. But it provides only temporary
Q.3. Classify pulpal lesions. Differentiate between re-
relief.
versible and irreversible pulpitis.
b. Use of topical agents to occlude the dentinal tubules:
This method employs various agents like: Ans.
Calcium hydroxide – when mixed with distilled
[SE Q.6]
water to form a thick paste, it increases the remin-
eralization of the exposed dentine, thus reducing {(i) According to Ingle
dentine permeability. Bacterial
Calcium phosphate pastes – it works by block- l Coronal ingress
ing the tubules and the dentine permeability is l Radicular ingress
reduced by 85%. The products commercially Traumatic

available are GC tooth mousse containing amor- l Acute
phous calcium phosphate and casein phospho l Chronic
peptide. Iatrogenic
Silver nitrate – it reduces fluid movement by l Cavity preparation
precipitating protein or silver chloride within the l Restoration
dentinal tubules. However, it stains the dentine l Intentional extirpation
and also damages the pulp and gingiva. l Orthodontic movement

Strontium chloride – it acts by penetrating the l Periodontal and periapical curettage
tubules and forming strontium apatite, which oc- l Rhinoplasty
cludes the exposed dentinal tubules. l Intubation

Chemical l Placement of a fresh amalgam filling in contact with

l Restorative materials gold restoration
l Disinfectants l Chemical stimuli:
l Desiccants l Sweet or sour foodstuffs
Idiopathic l Silicate or self-curing acrylic filling
l Ageing l Bacteria from caries
l Internal resorption l Using high speed without a coolant
l External resorption l Following insertion of restoration, patients often
l Hypophosphatemia complain of mild sensitivity to temperature changes,

(ii) Other factors especially cold. Such sensitivity may last 2–3 days or
Preoperative factors a week, or even longer, but it gradually subsides. This
l Cervical exposed dentine sensitivity is a characteristic feature of reversible
l Tooth surface loss-erosion, attrition, abrasion pulpitis.
and abfraction
Symptoms
l Caries
l Symptomatic reversible pulpitis is characterized by
l Trauma
sharp pain lasting for a moment.
l Tooth subluxation or avulsion
l It is mainly triggered by cold than hot food or beverages.
l Tooth fracture – enamel, dentine and pulp exposure
l It subsides as soon as the stimulant is removed.
l Periodontal disease
l The clinical difference between reversible and irreversible
Intraoperative factors
pulpitis is quantitative; the pain of irreversible pulpitis is more
l Tooth preparation
severe, lasts longer and may trigger without any stimulus.
l Intracoronal
l Extracoronal Diagnosis
l Iatrogenic pulp exposure l Diagnosis is based on patient’s complaint and by clini-
l Other restorative procedures cal tests.
l Local anaesthesia (LA) l The pain is sharp and lasts for a few seconds and gener-
l Pin placement ally disappears when the stimulus is removed.

l Cavity cleaning l A tooth with reversible pulpitis reacts normally to per-
l Impression taking cussion and palpation without any mobility. The peri-
l Temporization apical tissue is normal on radiographic examination.
l Electrosurgery l Vitality test shows positive response.
l Orthodontics
Histopathology
l Restorative materials
l Reversible pulpitis may range from hyperaemia to mild-
l Dentine liners
to-moderate inflammatory changes limited to the area of
l Temporary materials
the involved dentinal tubules, such as dentinal caries.
l Permanent materials}
l Microscopically, the following are seen:
Reversible pulpitis l Reparative dentine
Definition l Disruption of the odontoblast layer
Reversible pulpitis is a mild-to-moderate inflammatory l Dilated blood vessels
condition of the pulp, caused by noxious stimuli in which l Extravasation of oedemal fluid and the presence of
the pulp is capable of returning to the normal state follow- immunologically competent
ing the removal of stimuli. l Chronic inflammatory cells along with few acute in-
flammatory cells.
Aetiology
Reversible pulpitis may be caused by any irritation that Treatment
is capable of injuring the pulp, for example: l The best treatment of reversible pulpitis is prevention.
l Trauma l Periodic evaluation of teeth for cariogenic or noncario-
l Thermal shock, as from preparing a cavity with a dull genic lesions.

bur without a coolant or keeping the bur in contact with l Care should be taken while preparing cavities and an
the tooth for too long or from overheating during polish- appropriate base/varnish should be placed to prevent
ing a restoration damage to the pulp.
l Excessive dehydration of a cavity with alcohol or chlo- l When the pain persists despite proper treatment, the
roform pulpal inflammation should be regarded as irreversible,

l Irritation of exposed dentine at the neck of the tooth and the treatment for which is pulp extirpation.
Irreversible pulpitis l If the pulp is not exposed by the carious process, a drop
Definition of pus may be expressed, when one gains access to the
pulp chamber.
l A radiograph may also show exposure of the pulp.
l In irreversible pulpitis, thermal and electric tests elicit

{SN Q.2}
pain that persists even after the removal of stimulus.
Irreversible pulpitis is a persistent inflammatory condi-
tion of the pulp, symptomatic or asymptomatic, caused Histopathology
by a noxious stimulus. l Microscopically, one can see areas of abscess and zone
of necrotic tissue with microorganisms.
Aetiology l If carious process advances, penetrating the pulp, areas
l Bacterial of ulceration develop that drain through carious pulpal
l Chemical exposure into oral cavity and reduce the intrapulpal
l Thermal pressure and pain.
l Mechanical l Histologically, one sees areas of necrosis, polymorpho-
Symptoms nuclear leucocytes infiltration and zone of fibroblastic

l In the early stages of irreversible pulpitis, a parox- proliferation forming wall of the lesion. Calcific masses
ysm of pain may be caused by sudden temperature may be present.
changes, particularly cold, sweet or acid foodstuffs.
Pain is increased by heat and sometimes relieved by
cold, although continued cold stimuli may intensify {SN Q.2}
the pain. Treatment
l The patient describes the pain as a sharp piercing or
l Pulpectomy followed by proper shaping, cleaning
shooting, and it is generally severe. and obturation
l Postendodontic restoration
l It may be intermittent or continuous.

l Patient complains of pain during bending over or lying Q.4. Discuss caries activity test and mention it in detail.
down (change in posture); this may be due to changes in
Ans.
the intrapulpal pressure. Patients are often kept awake at
night due to pain. Caries activity tests measure the degrees to which the
l The patient may also have pain referred to adjacent local environment challenge (e.g. dietary effect on micro-
teeth, to temple or sinuses when the upper posterior bial growth and metabolism) favours the probability of
teeth are involved or to the ear when lower posterior carious lesions. A caries activity test facilitates the clinical
teeth are involved. management of patients for the following reasons:
l In later stages, the pain is more severe and is generally l To determine the need and extent of personalized pre-
described as boring, gnawing or throbbing. ventive measures.
l Apical periodontitis is usually absent. However, when l To serve as an index of the success of therapeutic measures.
infection or inflammation extends to the periodontal l To motivate and to monitor the effectiveness of educa-
ligament, it is observed. tion progress relating to dietary and oral hygiene proce-
dures.
Diagnosis
l To manage the progress of restorative procedures.
l Inspection generally discloses a deep cavity/caries ex-
l To identify high-risk groups and individuals.
posing the pulp.
l On gaining access to the exposure, one may see the Indications for caries activity test
greyish, scum-like layer over the exposed pulp and l Should have maximum correlation between predicted
surrounding dentine. This layer is composed of food and actual caries development.
debris, degenerated polymorphonuclear leucocytes, l Should have reliability and validity, i.e. the test must be
microorganisms and blood cells. Surface of the pulp is consistently accurate and reproducible.
eroded. An odour of decomposition is present in this l Should have simplicity with regard to technical proce-
area. dures and skills required. The results should be obtained
l Probing into this area is not painful to the patient till rapidly, within hours or few days.
deeper areas of pulp are reached. l Should have measurement of mechanisms involved in
l At this level, both pain and haemorrhage occur. caries process.
l Should be inexpensive, noninvasive, easy to evaluate 2. Calorimetric Synder test

and applicable to any clinical setting. Snyder devised this calorimetric caries activity test in
1. Lactobacillus colony count test 1951. It measures the ability of salivary microorganisms
This caries activity test was introduced by Hadley in to form organic acids from a carbohydrate medium. The
1933. medium contains an indicator dye, Bromocresol green.
Principal involved This dye changes colour from green to yellow in the
This test estimates the number of acidogenic and range of pH 5.4 to 3.8. Indirectly, this test is also a mea-
aciduric bacteria in the patient’s saliva by counting sure of acidogenic and aciduric bacteria.
the number of colonies appearing on tomato pep- Procedure
tone agar plates (pH 5.0) after inoculation with a l 0.2 mL stimulated saliva collected by chewing
sample of saliva. A selective medium favouring paraffin before breakfast is thoroughly mixed
the growth of aciduric lactobacilli is the basis of with 10 mL melted agar containing medium in a
the test. test tube (cooled to 50°C, allowed to solidify and
Procedure then incubated at 37°C).
l Immediately after arising, the patient chews a l The amount of acid produced by acidogenic or-
small piece of paraffin. ganisms is detected by changes in pH indicator,

l The saliva that accumulates in the following and is compared to an uninoculated control tube
3 min period is collected in a sterile container. after 24, 48 and 72 h of incubation. The rate of
The saliva collected is shaken to mix it. The saliva colour change from green to yellow is indicative
sample is diluted to 1:10 dilution by pipetting of the degree of caries activity.
1 mL of saliva sample into a 9 mL tube of sterile l This test essentially estimates the number of both
saline solution. aciduric and acidogenic organisms in saliva be-

l This is shaken, and a 1:100 dilution is made by cause it relies on the production of additional acid
pipetting 1 mL of the 1:l0 dilution into another under already acidic culture condition.
9 mL tube of sterile saline solution. Advantages
l The 1:100 dilutions is mixed thoroughly, and l Relative simple to carry out.
0.4 mL of each dilution is spread on the surface of l Tests are of value in assessing the oral environ-
an agar plate containing 20 mL of cooled lique- ment mental cariogenic challenge.

fied agar (Rogasa SL Agar plate). l Only one tube if medium and no serial dilutions
l The plates are incubated for 3–4 days at 37°C. are required.
A count of the number of Lactobacillus colonies Disadvantages
that develop is counted. l Time consumed is more.
l Counting is done by using colony counter l Sometimes the colour changes are not so clear.
equipped with bright lights and a large magnify- 3. The swab test
ing glass. Principle involved
l The number of lactobacilli per millimetre saliva l It is based on the same principle as the Snyder’s
is calculated by multiplying the number of colo- test.
nies on the plate by the dilution factor of its in- l The oral flora is sampled by swabbing the buccal
oculums. surfaces of the teeth with a cotton applicator,

Advantages which is subsequently incubated in the medium.
l Useful for monitoring the effectiveness of restor- l The change in the pH following a 48 h incubation
ative dentistry and care completion. is read on a pH meter or the colour change is read
l Simple to carry out. by the use of a colour comparator.
l Useful as a screening test for caries activity in Advantages
large groups. l Test is of value in predicting caries increments,
Disadvantages particularly in children with low or no previous

l Inaccurate for predicting the onset of caries. caries experience.
l It does not completely exclude the growth of other l No collection of saliva is required.
relatively aciduric organisms. 4. Streptococcus mutans level in saliva

l Counts involving single individuals are not as Principle
reliable. This test measures the number of S. mutans colony-
l It only takes few minutes to do the test, but the forming units per unit volume of saliva and culturing
results are not available for several days. of the plaque samples from discrete sites, such as an
l Counting is a tedious procedure. occlusal fissure proximal area is used for detecting
and quantitating S. mutans colonized on teeth. Incu- l Most procedures in operative dentistry are performed ei-
bation is done on Mitis Salivarius Agar (MSA); se- ther under a regional nerve block or a local infiltration an-
lective streptococcal medium with addition of high aesthesia, which blocks the pathways of painful impulses.
concentrated of sucrose (20%) and 0.2 U bacterium l A vasoconstrictor like epinephrine is added to prolong
per millilitre (Mitis Salivarius-bacitracin [MSB]) the action of the anaesthetic by decreasing the rate of
suppress the growth of most non-S. mutans colonies. absorption of the anaesthetic into the blood.
Procedure 1. Lidocaine 2% 1 epinephrine 1:50,000
The sample of organisms is obtained by the use of 2. Bupivacaine 0.5% 1 epinephrine 1:200,000
tongue blades (wooden spatulas), which are then
Techniques of LA
pressed against S. mutans selective MSB agar in
The techniques of LA commonly used in operative den-
special Petri dishes. The agar plates are incubated at
tistry are
37°C for 48 h in 95% at 5% CO2 gas mixture.
(i). Infiltration anaesthesia
Interpretation
(ii). Regional block anaesthesia
Levels of S. mutans .105/mL of saliva are unac-
ceptable. Colonization of a new surface does not (i). Infiltration anaesthesia consists of supraperiosteal
occur readily unless the level of S. mutans reaches injection where the anaesthetic is deposited near the
4.5 3 104/mL for smooth surface and 103/mL for nerve endings in the operating site. This is usually
occlusal fissures. Investigators have found that in employed while working on maxillary teeth.
unstimulated saliva collected from children who (ii). Regional block anaesthesia consists of a nerve block
were caries-free, S. mutans found was about 0.1% where the anaesthetic solution is deposited near a nerve
of the total viable count, whereas in children who trunk at a distance from the operating site. This technique
had DMFS score of 5 or more, the value was about is used while working on mandibular posterior teeth.
0.85%.
Topical anaesthesia: Prior to administering the anaes-
Advantage
thesia, a topical anaesthetic such as benzocaine or lidocaine
l Since the frequency of isolation of S. mutans is
gel or spray must be applied over the mucosa to minimize
high prior to initiation of lesions as contrasted to
the discomfort due to needle penetration.
lactobacilli, so the clinician utilizes this count as
Advantages of LA
an adjacent in caries management.
1. Patient cooperation: Once the LA has become effective,
Disadvantages
the patient is more relaxed and cooperative due to the
This test has problems such as:
absence of pain.
l Difficulty of distinguishing between a carrier
2. Control of saliva: Complete anaesthesia of all tissues in
state and cariogenic infection.
the operating site controls salivation.
l S. mutans may constitute less than 1% of total
3. Reduced blood flow: The vasoconstrictor in the local
flora of plaque.
anaesthetic reduces blood flow in the operating site,
l Mutans tends to be located at specific sites only.
thus controlling bleeding in the area.
Q.5. Describe the aetiology and treatment of pain in the 4. Operator efficiency: Due to the above-mentioned fac-
tooth after placing restoration. tors, the operator’s efficiency is greatly enhanced.
5. Alternative methods to control pain.
Ans.
In patients with a very low threshold of pain or those
Pain is the most motivating factor for the patient’s to
who are extremely apprehensive, additional methods may
visit the dentist. Moreover, dental treatment is also consid-
be employed to control pain and anxiety. These include:
ered a painful procedure. A gentle and caring attitude to-
(i). Premedication with antianxiety agents or sedatives
wards the patient helps in calming them down and reducing
(ii). Inhalation sedation
the anxiety. The other methods of controlling pain are:
(iii). Hypnosis
Local anaesthesia (iv). Electronic dental anaesthesia (EDA)
l This is the most commonly used method in operative (i). Premedication with antianxiety agents or sedatives:
dentistry to control pain. This technique can be used as an adjunct to LA in or-
l It is necessary to ascertain of the pulpal status and the der to calm the patient during the dental treatment. The
patient’s attitude before deciding to give LA. patient should always be accompanied by someone as
l Some patients do not need anaesthetizing until the pro- their reflexes will be depressed. The agents used are:
cedure involves a vital pulp or exposed dentine, whereas a. Diazepam (benzodiazepine derivative) adminis-
anxious patients may need LA for the simplest of the tered orally in a dose of 2–10 mg, 1 h prior to the
procedures. dental appointment.
b. Alprazolam (benzodiazepine derivative) 0.25–0.5 mg, Q.13. Discuss control of pain during operative proce-
1 h prior to the dental appointment. dures.
c. Midazolam 2–5 mg, 1 h prior to the dental appoint-
ment. Ans.
(ii). Inhalation sedation: For patients with complain of
[Same as LEQ.5]
mild-to-moderate pain, nitrous oxide with oxygen is usu-
ally preferred. It is one of the safest methods of sedation. Q.14. Discuss pain control procedures during cavity
(iii). Hypnosis: If the dentist is familiar with the principles preparation.
of hypnosis, it can be used as an adjunct to LA and
may be used to control the tense patient, feel relaxed Ans.
and cooperative.
(iv). EDA: It stimulates the larger diameter A-fibres which [Same as LEQ.2]
transmit the sensation of touch, pressure and tempera-
ture. Therefore, sensation of pain transmission is inhib- SHORT ESSAYS:
ited by smaller A delta–fibres and C-fibres. The pain
sensation is not felt as the brain does not get these im- Q.1. Discuss hypersensitivity. Also mention the manage-
pulses. Serotonin and endorphins levels increase in the ment of hypersensitive dentine.
blood and this plays a secondary role in pain control. Ans.
Q.6. Describe in detail the prophylactic treatment of [Ref LE Q.2]
dental caries.
Q.2. Define and classify caries. Add a note on diagnosis
Ans. of caries.
[Same as LEQ.1] Ans.
Q.7. Describe deep caries management. It is an infectious, microbiologic disease of the teeth that
Ans. results in localized dissolution and destruction of the calci-
fied tissues.
[Same as LEQ.1]
Q.8. How do you diagnose dental caries? Add a note on Classification
aetiology and classification of dental caries. i. Based on the location
l Pit and fissure caries
Ans. l Smooth surface caries
[Same as LEQ.1] l Root surface caries
ii. Based on the speed of caries progression

Q.9. Discuss the management of hypersensitive dentine.
l Chronic caries
Ans. l Arrested caries
l Acute or rampant caries
[Same as LEQ.2]
iii. Based on whether it is new or recurrent caries
Q.10. Discuss hypersensitive dentine in relation to its l Initial or primary caries
mechanism and management. l Recurrent or secondary caries
Ans. iv. Based on extent of the caries

l Incipient caries
[Same as LEQ.2] l Cavitated caries
Q.11. Discuss dentine hypersensitivity, with emphasis v. Based on pathway of spread of caries within the
on various theories. Also mention its management. tooth
l Forward caries
Ans. l Backward caries
[Same as LEQ.2] vi. Based on number of tooth surfaces involved

l Simple caries
Q.12. What are the causes of dentinal hypersensitivity? l Compound caries
Describe the methods of its management. l Complex caries
Ans. vii. Based on the treatment and restoration design

l Class I caries
[Same as LEQ.2] l Class II caries
l Class III caries Optic methods

l Class IV caries l Fibreoptic transillumination
l Class V caries l Digital fibreoptic transillumination
l Class VI caries l OCT
viii. Based on if caries are completely removed or not

Fluorescence method
l Residual caries
l Quantitative laser fluorescence
ix. Based on the age of the patient
l Endoscopic filtered fluorescence method
l Nursing bottle caries
l Adolescent caries Lasers

l Senile caries l Diagnodent
x. Based on the tooth surfaces to be restored l Dye-enhanced laser fluorescence
l Occlusal surface
Other recent methods
l Mesial surface
l Caries detector dye
l Distal surface
l Ultrasonic probe imaging
l Facial surface
l Visible luminescent spectroscopy
l Buccal surface
l Vanguard electronic caries detector
l Lingual surface
l Electrical conductance measurements
l Alternating current impedance spectroscopy technique
i. Patient’s compliant
l Patients compliant itself provides a clue about the
{SN Q.1} presence of caries. The patient may complain of
Secondary dentine sensitivity to thermal changes, mild-to-moderate
l Secondary dentine is the dentine that forms after root toothache.
formation is completed. ii. Visual examination
l A grey hue in the marginal ridge can be a suspicion
l This occurs at a slower rate and the tubules are more
irregular in shape. of a proximal cavity under that ridge.

l Careful examination of the patient’s teeth under clean
l Dentinal tubules curve more sharply as they move
from primary to secondary dentine. and dry conditions using good illumination may re-
l Secondary dentine is thicker over the roof and floor
veal the visual signs like cavitation of the tooth sur-
of the pulp rather than on the side walls. face. Brownish discolouration of pits and fissures.
l Opacity beneath pits and fissures or marginal ridges.
iii. Tactile examination

Use of a sharp explorer
Usually, curved explorers are used for examination
Diagnostic methods in the detection of dental caries are of occlusal pits and fissures, while interproximal
as follows: explorers are used to detect proximal caries.
Traditional methods Tactile findings
a. Clinical methods l Binding or catch of the explorer tip
l Patient compliant
l Cavitation at the base of a pit or fissure
l Visual examination
l Softness at the base of a pit or fissure and discon-
b. Mechanical methods tinuity of enamel surface
l Tactile examination
iv. Bitewing radiographs
l Tooth separation
Role of bitewing radiographs in detecting occlusal
l Dental floss or tape
caries
Radiographic methods l Bitewing radiographs have greater importance in
a. Conventional radiographic methods diagnosis of proximal caries in both enamel and

l Intraoral periapical radiographs dentine.
l Bitewing radiographs l The proximal enamel lesion appears as a desk
b. Advanced radiographic methods triangular area on a bitewing radiograph.

l Xeroradiography l The lesion may be seen just in outer enamel/
l Digital radiographic methods throughout the depth of enamel, in the enamel

l Computer-aided radiographic methods and outer dentine/reaching through the dentine.
l Digital subtractions radiography Pulp is often exposed by carious process in later.
Early lesions are seen as a small radiolucent

l x. Ultrasonic probe imaging
notch below the contact area in enamel. l Here, an ultrasonic probe is used to send and re-
l Advanced proximal caries are seen as a dark tri- ceive sound waves from the surface of the tooth.
angular area in the proximal enamel with its base l Normal enamel produces no echoes, while initial
towards the external tooth surface. white spot lesions produce weak surface echoes
v. Fibreoptic transillumination and areas with cavitation produce echoes of higher
l Carious lesions have a lowered index of light trans- amplitude.
mission. When the teeth are examined with a fibre-
Q.3. Discuss root surface caries.
optic light source, caries appears as a darkened
shadow. Ans.
l After drying the tooth, a fibreoptic probe can be
placed in the buccal or lingual embrasure directly

beneath the contact area between the two adjacent {SN Q.9}
teeth. l Cemental caries occurs on the root surfaces of teeth.
l In posterior teeth, a strong light source is required.
Located exclusively on the cementum and dentine of
Fibreoptic light with the beam reduced to 0.5 mm the root surfaces of the teeth.
diameters has been used. If caries is present, it is l Cemental caries progresses more rapidly than enamel
evident as a dark shadow beneath the marginal caries. Associated with ageing process.
ridge. l The cementum covering the root surface is relatively
vi. Lasers thin and provides little resistance to caries attack.
l Diagnodent is a diode-laser detector. It can be used
l Root surface caries begins directly on dentine. It is
to determine the soundness of tooth structure on U-shaped in cross section and spreads more rapidly
occlusal surfaces. because dentine has less resistance to caries attack.
l The caries-induced changes in teeth lead to in-
creased fluorescence at specific excitation wave- Clinical features

lengths. l It appears as slowly progressing chronic lesion.
l The signal appears as a number on the device on a l Gingival recession is associated with root surface
scale of 0–99. The higher the number, the more the caries.
caries. l It is usually found in mandibular molar and premolar
region.
l Tooth surfaces involved in decreasing order of fre-
{SN Q.7} quency are buccal, lingual and interproximal.
vii. Caries detector dye Radiographic features
l Various dyes such as silver nitrate, methyl red l The carious process is best described as scooping
and alizarin stain have been used to detect cari- out, which results in radiographic appearance usu-
ous sites by change of colour. ally, described as ‘ill-defined saucer-like crater’.
l Dyes are useful to detect the carious dentine. l If peripheral surface area is small, the appearance of
Originally, 0.5% basic fuchsin in propylene gly- carious lesion will be notched rather than saucer like.
col was used.
l Basic fuchsin stains the infected, demineralized
dentine selectively, while the affected dentine Q.4. Discuss phoenix abscess.
remains unstained. Ans.
l Currently, basic fuchsin is considered to be car-
cinogenic. Hence, it has been replaced by 1%

acid red dye in propylene glycol. {SN Q.6}
Phoenix abscess is an acute exacerbation of a chronic
viii. Enamel dyes lesion. This is an acute inflammatory reaction superim-
l Calcein
posed on an existing chronic lesion-like cyst or granu-
l Procion
loma.
l Brilliant blue Aetiology
ix. Dentine dyes l When the periradicular tissue reaction to noxious
l Acid red stimuli from the diseased pulp is in a state of
l Basic fuchsin
l Mechanical irritation from chewing or bacterial irrita-

equilibrium, a granuloma or a cyst is formed, this
tion provides chronic low-grade irritation.
is asymptomatic.
l Sometimes in an influx of necrotic products or bac- Symptoms
teria from a diseased pulp may react to cause an l Asymptomatic except when food particles cause dis-
acute inflammatory response. This may also be seen, comfort during mastication.
when the body defence is lowered or mechanical l It appears as pinkish red globule of tissue protruding
irritation during Root canal treatment (RCT.) from pulp chamber, which bleeds on probing usually
seen in teeth of children and adolescent with resistant
Symptoms
pulp.
l The first symptom is tenderness on percussion. Tooth
may be slightly extruded and mobile. Diagnosis
l Patient may or may not have swelling. Swelling l Clinically, visible polyp bleeds easily. The stalk of the
when localized and if left untreated may become dif- polyp should be traceable to the pulp chambers to dif-
fuse, causing asymmetry of the patient’s face. In case ferentiate it from gingival polyp.
of upper canines, it may also extend to the eyelids. l Radiograph shows open cavity with distinct access to
l Patients may present with favour, malaise and lymph- pulp chambers.
adenopathy. l Thermal test shows feeble or no response.
l Tissue at the surface appears taut and inflamed, pus l Electric pulp tester requires more current than normal to
starts to form beneath it. This liquefaction is due to produce response.

activity of the proteolytic enzymes (trypsin and ca-
Histopathology
thepsin).
l Surface is covered by stratified squamous epithelium.
l As the liquefaction continues, tissue ruptures due to
l Pulp shows granulation tissue, which is vascular. Con-
pressure to form a sinus tract, which opens on the
nective tissue shows polymorphonuclear leucocytes,
labial/buccal mucosa. This process is the beginning
plasma cells and nerve fibres along the epithelial layer.
of chronic alveolar abscess. This tract ultimately
heals by granulation, once the root canal is treated. Treatment
l The pulp is removed with sharp curettes followed by
RCT.
Diagnosis
l Radiographs show well-defined periradicular radiolu- Q.6. Mention the aetiological factors of pulpal diseases.
cencies indicating a lesion. Ans.
l Tooth does not respond to electrical or thermal tests.
[Ref LE Q.3]
Histopathology
l Areas of liquefaction necrosis with disintegrating Poly Q.7. Discuss the affected and infected dentine.
morpho nuclear leucocytes (PMNLs) and cellular debris Ans.
are surrounded by lymphocytes and plasma cells.
{SN Q.6}
{SN Q.3}
Treatment
Infected dentine
l Drainage and RCT.
l This is more superficial layer which is soft and leath-
ery in consistency and light brown in colour.
l It has a high concentration of bacteria and the colla-
Q.5. Discuss the pulp polyp. gen is irreversibly denatured.
Ans. l This layer is not remineralizable and must be there-
fore removed.
It is a productive pulpal inflammation of a cariously l It is sensitive to touch.
exposed pulp characterized by the overgrowth of granulo- l It is stained by caries detecting dyes.
matous tissue into carious activity. The resultant polyp is l It should be removed.
lined by stratified epithelium of oral mucosa.
Affected dentine
Aetiology l This is the deeper layer which is dark in consistency
l Slow progressive pulpal exposure in large open cavity
and dark brown in colour.
in young resistant pulp.
Q.13. Discuss phoenix abscess – cause, symptoms and

l It does not contain bacteria and is reversibly
treatment.
denatured.
l This layer must therefore be preserved. Ans.
l It is not stained by caries detecting dyes.
[Same as SEQ.4]
l It is capable of demineralization. It should be
retained.
SHORT NOTES:
Q.8. Discuss pit and fissure caries. Q.1. Discuss the secondary dentine.
Ans. Ans.
l (Pit and fissure caries are seen in pits and fissures found [Ref SE Q.2]
on the occlusal, buccal and lingual surfaces of the pos- Q.2. Discuss the irreversible pulpitis.
terior teeth as well as the lingual surfaces of the maxil-
lary anteriors. Ans.
l The typical outline form and the anatomic form of the [Ref LE Q.3]
particular tooth varies.
l Outline is never a straight line from one point to an-
Q.3. Discuss the affected and infected dentine.
other, rather it is in the form of smooth curves that pre- Ans.
serve as much strong cusp as possible. This is called
circumventing the cusp. [Ref SE Q.7]
l Include all carious pits and fissures, place margins on Q.4. Discuss the caries activity tests.
sound tooth structure and not on weak or unsupported
enamel. Ans.
l Avoid terminating the margins on extreme eminences Caries activity tests measure the degrees to which the local
such as cusp heights or ridge crests. environment challenge (e.g. dietary effect on microbial
l Restrict the depth to a maximum of 0.2 mm into den- growth and metabolism) favours the probability of carious
tine for an ideal conservative preparation of an occlusal lesions. The various caries activity tests are:
pit and fissure cavity. The depth should be maintained l Lactobacillus colony count test
at 1.5 mm, measured at the central fissure. l Calorimetric Synder test
l When two pits and fissure cavities are less than l The swab test
0.5 mm apart, they should be joined to eliminate a weak l S. mutans level in saliva
enamel wall between them. l Dip slide method for S. mutans count
l Provide adequate access for proper tooth preparation l Salivary buffer capacity test
as well as placement and finishing of the restoration.) l Enamel solubility test
Q.9. Define the theories of hypersensitivity. l Salivary reductase test

l Alban test
Ans.
l S. mutans screening test
[Same as SEQ.1] l Fosdick calcium dissolution test
Q.10. Mention causes of hypersensitivity and manage- l Dewar test
ment of the same.

Q.5. Discuss the pink tooth.
Ans.
Ans.
[Same as SEQ.1]
Internal resorption is an idiopathic slow or fast progressive
Q.11. Discuss the tooth hypersensitivity.
resorptive process occurring in the dentine of the pulp
Ans. chamber or root canals of teeth. It is initiated in the pulp
[Same as SEQ.1] cavity and results in loss of dentine.
Q.12. Define and classify dental caries. Write a note on Aetiology
secondary caries. l History of trauma
l Persistent chronic pulpitis
Ans.
l Calcium hydroxide pulpotomy
[Same as SEQ.2] l Idiopathic

Clinical features l The restorative material used is glass ionomer

l Occurs in the pulp space. cement.
l In the pulp chamber, the granulomatous tissue replaces l This type of treatment is recommended in remote areas,
the resorbed dentine which is visible through the enamel where dental equipment is not available.
giving it a pink tooth appearance. The pulp usually re-
Q.13. Discuss the preventive measures of dental
mains vital and asymptomatic (very rarely necrotic).
caries.
Treatment
Ans.
l Pulpectomy
Dental caries can be prevented by the following mea-

Q.6. Discuss the phoenix abscess.
sures:
Ans. l Tooth brushing
l Interdental cleaning aids

[Ref SE Q.4] l Dental floss or tape
l Wooden sticks
Q.7. Discuss the caries detecting dyes.
l Interdental brushes
Ans. l Single tufted brushes
l Dentifrices
[Ref SE Q.2]
l Disclosing agents
Q.8. Discuss the geriatric caries. l Professional tooth cleaning measures
l Chemical measures for plaque control

Ans.
l Chlorhexidine
l Caries occurring in the elderly population is mostly l Diet modification
characterized by involvement of root surfaces. l Salivary stimulants
l This happens because of gingival recession coupled l Fluorides
with other factors such as reduced salivation and poor l Pit and fissure sealants
oral hygiene. l Current methods of caries prevention
l This is called senile caries. l Lasers
l Genetic modalities
Q.9. Discuss the cemental caries.
l Polymeric coatings
Ans. l Caries vaccine
l Passive immunization
[Ref SE Q.3]
Q.10. Discuss saliva tests for caries risk assessment. Q.14. Discuss the disclosing solution.
Ans. Ans.
[Ref SN Q.4] l Dental plaque is translucent and has a colour similar to
that of teeth.
Q.11. Discuss the pit and fissure sealants. l In order to remove plaque effectively, it must be stained
Ans. for the patient to see it clearly.

l Disclosing agents are solutions, tablets or wafers con-
l Pit and fissure sealants have cariostatic properties. taining a red vegetable dye-like erythrosine.
l They obstruct the pits and grooves physically. l When applied on tooth surfaces with cotton swabs or
l This helps to prevent the penetration of fermentable
diluted in mouthwashes, they can stain the bacterial
carbohydrates. plaque. Disclosing agents are used after tooth brushing
l As a result the remaining bacteria can not produce acid
to improve plaque control measures.
in cariogenic concentration.
l Sealants are affective as they remain bonded to tooth. Q.15. Discuss the infected dentine.
Q.12. Define ART. Ans.
Ans. [Ref SE Q.7]
l A traumatic restorative treatment is a procedure based Q.16. Discuss the fissure sealants.
on removing carious tooth tissues using hand instru-
Ans.
ments alone and restoring the cavity with tooth adhesive
materials. [Same as SN Q.11]
Topic 4
Instruments and Separation
LONG ESSAYS:
1. Define ‘dental matrix’ and classify various types of dental matrix and enumerate ideal properties of dental
matrix.
2. Classify speeds in dentistry. Write in detail the advantages of high speed and ultra high speed diagnosis in
dental practice.
3. Classify and describe the various hand cutting instruments.
4. How will you gain the active separation of teeth in operative dentistry?
5. Discuss the instrument formulae and instrument rule.
6. Discuss enamel hatchet and hoes.
7. Discuss the bur and its design.
8. Define contact area. Describe the importance of contact and contours in restorative dentistry. How would you
get a good contact for various restorative materials?
9. Define matrix. Describe the matrices and retainers used while restoring class II cavity. [Same as LEQ.1]
10. Classify speeds in dentistry. [Same as LEQ.2]
11. What is high speed? Classify and describe its advantages and disadvantages. [Same as LEQ.2]
12. Classify and write in detail about operative hand instruments. Add a note on instrument formula. [Same as LEQ.3]
13. Classify and discuss hand cutting instruments and rotary instruments used in operative dentistry. [Same as LEQ.3]
14. Discuss the disadvantages of using low speed and high speed in operative dentistry. [Same as LEQ.3]
15. Classify hand instruments. Write a note on instrument formula and on each instruments. [Same as LEQ.3]
16. Classify hand cutting instruments used in conservative dentistry. Elaborate on modified chisels and instrument
formula. [Same as LEQ.3]
17. How will you achieve separation of tooth in operative procedures? [Same as LEQ.4]
18. Discuss monoangled chisel and hoe. [Same as LEQ.6]
19. Discuss the cutting and finishing bur. [Same as LEQ.7]
SHORT ESSAYS:
1. Discuss matrices. [Ref LE Q.1]
2. Define separators. Discuss objective and indications of separation. [Ref LE Q.4]
3. Discuss the instrument formula. [Ref LE Q.5]
4. Discuss finger rests and guards.
5. Discuss the angle former.
6. Discuss the gingival marginal trimmer and enamel hatchet. [Ref LE Q.3]
7. Discuss the amalgam carver.
8. Discuss abrasion.
9. What is high speed? Classify and describe its advantages and disadvantages.
10. Discuss dental burs. [Ref LE Q.7]
11. Define rake angle.
12. Define contacts and contours. [Ref LE Q.8]
13. Explain wedges.
14. Discuss diamond abrasives.
15. Discuss the design of automatrix.
16. Discuss Tofflemire matrix retainers. [Same as SEQ.1]
17. Discuss matrices and retainers used in restorative dentistry. [Same as SEQ.1]
1 8. Discuss matrices and matrix retainers. [Same as SEQ.1]

19. Define matrix. Describe various matrices. [Same as SEQ.1]
20. Define matrix. Discuss different types of matrices. [Same as SEQ.1]
21. Discuss matrix band and retainers used for restorations. [Same as SEQ.1]
22. Define matrix. Describe the matrices and retainers used while restoring class II cavity. [Same as SEQ.1]
23. Classify matrices. Write about auto matrix system. [Same as SEQ.1]
24. Classify nonmetallic matrices. [Same as SEQ.1]
25. How will you achieve slow separation? [Same as SEQ.2]
26. Classification and principles of tooth separators. [Same as SEQ.2]
27. Discuss indications of separation of teeth. [Same as SEQ.2]
28. Discuss separation of teeth. [Same as SEQ.2]
29. Discuss mechanical separators. Describe the purpose of separation of teeth. Also mention the mechanical sepa-
ration, different types and advantages. [Same as SEQ.2]
3 0. Discuss the instrument formula for hand cutting instruments. [Same as SEQ.3]
31. Discuss the four unit instrument formulae. [Same as SEQ.3]
32. Discuss the enamel hatchet. [Same as SEQ.6]
33. Discuss the hatchet and hoe. [Same as SEQ.6]
34. Discuss marginal trimmers. [Same as SEQ.6]
35. Discuss the gingival marginal trimmer. [Same as SEQ.6]
36. Define high speed. [Same as SEQ.9]
37. Define ultra speed. [Same as SEQ.9]
38. Discuss the bur design. [Same as SEQ.10]
39. Discuss the bur blade design. [Same as SEQ.10]
40. Discuss wedges – types and methods of wedging. [Same as SEQ.13]
41. Define the anatomic matrix. [Same as SEQ.15]
SHORT NOTES:
1. Define wedges.
2. Define matrices.
3. Define automatrix.
4. Define separators. [Ref LE Q.4]
5. Classify speed. [Ref SE Q.9]
6. Define airotor.
7. Define hatchet. [Ref LE Q.6]
8. Discuss mouth mirror.
9. Discuss exploring instruments.
10. Discuss balancing of the hand instrument.
11. Define bur design.
12. Discuss burs and diamonds points.
13. Define sonic instrument.
14. Define gingival marginal trimmer.
15. Define S-shaped matrix.
16. Define embrasures.
17. Discuss copper band matrix.
18. Discuss the significance of contacts and contours. [Ref LE Q.8]
19. Discuss chisel and its modifications.
20. Discuss the instrument formula. [Ref LE Q.3]
21. Discuss rake angle. [Ref SE Q.11]
22. Define spoon excavator. [Ref LE Q.6]
23. Define Wedelstaedt chisel.
24. Define angle former.
25. Discuss the role of matrix and wedges. [Same as SNQ.2]
26. Discuss the functions of matrix band. [Same as SNQ.2]
2 7. Define matrices/retainers. [Same as SNQ.2]

28. Discuss the matrix and the uses. [Same as SNQ.2]
29. Define matrices and retainers. [Same as SNQ.2]
30. Discuss the matrix retainers and band. [Same as SNQ.2]
31. Define universal matrix retainers. [Same as SNQ.2]
32. Discuss the Tofflemire universal matrix retainer. [Same as SNQ.2]
33. Define Tofflemire retainers. Discuss matrices and matrix retainer. [Same as SNQ.2]
34. Discuss the Elliot’s separator. [Same as SNQ4]
35. Discuss the purpose of separation of teeth. [Same as SNQ4]
36. Explain the separation of teeth and mechanical separators. [Same as SNQ4]
37. Discuss the separation of teeth. [Same as SNQ4]
38. Discuss the slow separators. [Same as SNQ4]
39. Describe tooth separation. [Same as SNQ4]
40. Discuss the tooth separation in restorative dentistry. [Same as SNQ4]
41. Discuss rapid separators. [Same as SNQ4]
42. Describe mechanical separators. [Same as SNQ4]
43. Discuss speed in dentistry. [Same as SNQ5]
44. Define ultra speed. [Same as SNQ5]
45. Define high speed. [Same as SNQ5]
46. Discuss slow speed. [Same as SNQ5]
47. Discuss dental burs. [Same as SNQ.11]
48. Discuss 245 bur. [Same as SNQ.11]
49. Describe advantages and disadvantages of dental bur. [Same as SNQ.11]
50. Define sonic handpiece. [Same as SNQ.13]
51. Discuss the importance of contacts and contours. [Same as SNQ.18]
52. Discuss the importance of buccal contours. [Same as SNQ.18]
53. Discuss the contacts and contours in restoration dentistry. [Same as SNQ.18]
54. Discuss the D-11 instrument. [Same as SNQ.20]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Define ‘dental matrix’ and classify various types of l Rigidity: The matrix should be rigid enough to confine
dental matrix and enumerate ideal properties of dental the restorative material as it is condensed under pressure
matrix. and should not get displaced easily from its position.
l Provide proper proximal contact and contour: The
Ans.
matrix should be versatile enough to provide the desired
proximal contour and contact in various situations.
[SE Q.1]
l Positive proximal pressure: The matrix should exert a
{‘Matrix’ is a device used during restorative procedures to positive pressure against the adjacent tooth during inser-
hold the plastic restorative material within the tooth while tion of the restoration, so that after its removal normal
it is setting. contact between the teeth is established.
l Nonreactive: It should not react or stick to the restor-
Ideal requirements of a matrix
ative material.
In order to achieve a functionally acceptable restoration,
l Inexpensive: The matrix must be relatively inexpensive.
the matrix must satisfy the following requirements:
l Ease of application: The matrix should be simple in its Functions of a matrix
design and easy to apply. l To confine the restorative material while it is hardening.
l Not be cumbersome: The retainer or its handle should l To establish optimal contacts and contours for the
not interfere with the condensation of the restoration or restoration.
patient comfort. l To prevent gingival overhangs of the restoration.
l Ease of removal: After the restoration has hardened, the l To provide an acceptable surface texture for the
matrix should be removed without any difficulty. restoration.
Parts of a matrix Advantage

There are two basic parts in a matrix: l Provides ideal contours
(a) Band Disadvantage

(b) Retainer l Difficult to apply
T-shaped matrix band

Matrices for class II l These are premade T-shaped stainless steel matrix
The following matrices and retainers are used in class II bands.

conditions: l The long arm of the T is bent or curled to encompass
l Automatrix the tooth circumferentially and to overlap the short

l Tofflemire matrix horizontal arm of T. This section is then bent over the
l Custom-made matrix long arm, loosely holding it in place.
l Precontoured matrix Indication
l T-shaped matrix band l It is indicated for class II cavities involving one or
l S-shaped matrix band both proximal surfaces of a posterior tooth.

l Soldered matrix band Advantages
l Ivory matrix no. 1 l Rapid and easy to apply
l Ivory matrix no. 8 l Simple and inexpensive
l Black’s matrices Disadvantage

l Anatomical matrix} l Not very stable
Precontoured matrix
Ivory no. 1
l This consists of small, precontoured dead soft-metal
1. It is a unilateral matrix which is available for premo-
matrices ready for application to the tooth.
lars and molars.
l They are selected according to the tooth to be re-
2. This matrix consists of a 55 band, which encircles
stored and wedged to adopt the gingival contours.
one proximal surface of a posterior tooth.
Indications
3. Gingival edge has shorter length that allows the re-
l For both amalgam and composite restorations.
tainer to draw the band tight at the gingival margin.
l For small class II cavities involving one or both
Indications
proximal surfaces in posterior teeth.
l It is indicated for restoring a unilateral class II
Advantages
cavity especially, when the contact on the unpre-
l Ease of application.
pared side is very tight.
l The metal ring also affords slight tooth separation.
Disadvantage
l Provides better proximal contours for posterior
l Problems in placing and removing
composite restorations.
Ivory no. 8 Disadvantages
1. It consists of a band that encircles the entire crown of l Expensive
the tooth. l Bands may become dented easily

2. The circumference of the band can be adjusted by the Soldered matrix band
adjusting screw present in the retainer. l Also, called seamless copper band matrix. Copper
Indications bands of assorted sizes make excellent matrices.

l It is indicated in class II with buccal or palatal l This band is made by taking a measurement of the
extension, class II with no adjacent tooth, Mesio neck of the tooth and soldering a band of metal to fit.
Occlusal Distal (MOD) and complex cavities. Indications
Disadvantage l Indicated in badly broken down teeth, especially
l Problems in placing and removing. for pin-retained amalgam restorations with large
S-shaped matrix band buccal and lingual extensions.
l This is a metal matrix band moulded into an S-shape l Complex situations like class II cavities with large
by contouring. buccal or lingual extensions.

l After the band is positioned and contoured over con- Advantage
touring teeth, it is stabilized using wedges and im- l Provides excellent contours
pression compound. Disadvantage

Indications l Time-consuming process
l For class II slot preparations Compound-supported matrix (custom-made matrix)
l For class III restorations on the distal surface of l It is entirely handmade and contoured specifically for
canines each individual case.

l The band is contoured with an egg-shaped burnisher l Here, the rotary power is transferred to the handpiece
on a paper pad to appropriate proximal as well as by a belt that runs from an electric engine over a se-
facial and lingual contours of the prepared tooth. ries of pulley and a three piece extension cord arm.
Indications Presently, low speeds are only used for:
l For complex situations like pin-amalgam restora- (i) Caries excavation
tions (ii) Refining cavity preparation
l For restoring class II cavities involving one or (iii) Finishing and polishing restoration
both proximal surfaces Medium speeds
Advantages l These were introduced subsequent to the develop-
l Highly rigid and stable ment of low speeds.

l Provides good access and visibility for placing the l The drive for these handpieces comes from a small
restoration electric motor attached directly to the handpiece, and

l Most efficient means of reproducing contact and the speed of this is controlled by a foot control or a
contour control on the electric motor.
Disadvantage l Another alternative is the air motor which is directly
l Time-consuming process connected to the air–water line of the dental unit and
the handpiece is attached to it.
[SE Q.1] Medium speeds can be used for:
(i) Cavity preparation (but high speeds are more
{Tofflemire matrix effective)
l This is also referred to as the universal matrix. It
(ii) Placing retention grooves and bevels
was designed by B R Tofflemire. This matrix is usu-
(iii) Areas of limited visibility
ally preferred for most class II amalgam restorations.
High speeds
l The Tofflemire retainer is available in two sizes:
l These were introduced in the 1950s and ever since
(i) Standard – for use in the adult dentition
have become the most popular rotary cutting speeds.
(ii) Small – for use in the primary dentition
l The very high speeds of over 200,000 rpm are
Indications
achieved by a small air-driven rotor or turbine
l For class I cavities with buccal or lingual exten-
mounted in bearings in the head of a contra-angle
sions
handpiece.
l For class II cavities on one or surfaces of a poste-
l The handpiece is run by compressed air which flows
rior tooth
through a control box and is carried by a flexible
Advantages
hose to the back of the handpiece.
l Ease of use
l High-speed handpieces always contain a system,
l Produces good contact and contour for most
which directs water spray at the cutting head of
amalgam restorations
the bur.
l Rigid and stable
l The airotor handpiece has a low torque and will stall
Disadvantages
if excessive pressure is applied.
l Does not provide optimum contour and contact
l This serves as an excellent safety measure.
for posterior composite restorations
l The small and versatile instruments can achieve
l Not useful for extensive class I restorations}
efficient setting in these instruments.
Q.2. Classify speeds in dentistry. Write in detail the High speeds can be used for:
advantages of high-speed diagnosis ultra high speed in (i) Removing old restorations
dental practice. (ii) Completing most of the cavity preparation
(iii) Tooth reduction for crown preparations
Ans.
Advantages
The rotational speed of an instrument is measured in l Removes tooth structure with less pressure,
revolutions per minute (rpm). vibration and heat generation.

There are three speed ranges used in operative dentistry: l The number of rotary cutting instruments are
1. Low or slow speeds – below 12,000 rpm reduced.

2. Medium or intermediate speeds – 12,000–200,000 rpm l Better control in operating.
3. High speed – over 200,000 rpm l Instruments last longer.

Low speeds l More patient friendly as it is has less vibrations
l These were the first speed ranges used in operative and requires less time.
dentistry. l Several teeth can be treated at the same time.
Disadvantages a hand cutting instrument. This is called instrument

l Can cause gingival crawling. formula.
l May remove a large amount of tooth structure.
Q.3. Classify and describe the various hand cutting in-

{SN Q.20}
struments.
It consists of three units based on the metric system:
Ans.
I. Unit blade width – This denotes the width of the
Marzouk’s classification blade expressed in 1/10th of a millimetre.
Exploring instruments II. Unit blade length – This indicates the length of the
Mouth mirrors, explorers, periodontal probes and cotton blade expressed in millimetres.
tweezers. III. Unit blade angle – This represents the angle of the
Instruments for tooth structure removal blade relative to the long axis of the handle of the
(A) Hand cutting instruments – Chisels, excavators and instrument expressed in centigrades.
special forms of chisels. 1 centigrade 5 1/100th of a circle,
(B) Rotary cutting instruments – Handpieces, burs and i.e. 1/100 3 360 5 3.6°.
abrasives. So, 1 centigrade 5 3.6°.
Restoring instruments Most instruments have a three-number formula.
Cement spatulas, plastic filling instruments, amalgam Some instruments like the gingival margin trimmer
carriers, condensers, burnishers, carvers, files and knives. (GMT) and angle former have the cutting edge
Finishing and polishing instruments other than at right angles to the blade. For these
Finishing strips, finishing burs, brushes and rubber cup. instruments a fourth unit is added.
Exploring instruments IV. Unit primary cutting edge angle – This denotes the
These instruments are used for examining the mouth angle between the cutting edge and the long axis of
and teeth. They are the basic instruments needed during the handle of the instrument. This is also expressed
each appointment for diagnosis and treatment. They in centigrades.
include:
a. Mouth mirrors
b. Explorers
c. Periodontal probes V. For instruments with four units, the IV unit is placed
d. Cotton tweezers second in the code. The two instruments which have a
Hand cutting instruments four-number formula are:
These were the earliest instruments that were developed l GMT
to remove defective tooth structure. They have sharp l Angle former
cutting edges designed to cleave and plane the enamel The instrument formula is usually placed on the instru-
and to scoop out the carious dentine. ment’s handle using a code of three or four numbers
l Handle: The handles of hand cutting instruments separated by dashes or spaces, for example, Binangle
are usually straight and may be small, medium or hatchet excavator: 15-8-12.
large in diameter. Handles may have serrations to Advantages of hand cutting instruments
provide better grip while the instrument is in use. l No vibration or heat is produced during cutting.
l Shank: The shank connects the handle to the l They are most efficient means for precise intricate
blade which is the working end of the instrument. cutting.

It is smooth and round and tapers from the handle l They can create the smoothest surface of all cut-
to the blade. Generally, shanks have one or more ting instruction.

bends or angles. l They have the longest life span provided if they
l Blade: This is the working end of a hand cutting are resharpened.

instrument. It is connected to the handle by means l They are self-limited in cutting the enamel, i.e. they
of the shank. The blade ends in the cutting edge. will cut only enamel undermined by loss of dentine.
l Cutting edge: This is the edge of the blade which l They can remove large piece of undermined
produces the cutting action of the instrument. It is enamel quickly, thus save time and effort.
in the form of a bevel with different shapes. Chisels
Instrument formula Chisels have a blade, which ends in a cutting edge
GV Black also developed a numeric formula to deformed by a bevel on one side only. The cutting edge of
scribe the dimensions and angles of the working end of the chisel is at a right angle to the handle.
Uses Gingival margin trimmer

Chisels are used for the cutting of undermined enamel. l GMT is a modified enamel hatchet. But the blade
Types of chisels is curved and the cutting edge is other than right
l Straight chisels angle to the axis of the blade.
l Monangle chisels l They are similar to spoon excavators in both of
l Binangle chisels their angles and the dimensions of their blades.

Special chisels Mode of supply
l Angle formers l Available in two pairs constituting a set of four. In
l Enamel hatchets a given size, each pair has a right and a left bev-
l Wedelstaedt chisels elled instrument.
l Gingival marginal trimmers Distal GMTs
Straight chisels l If the cutting edge of one pair makes an acute
l The instrument has a straight blade in line with angle with that edge of the blade away from the
the handle and shank. handle, those are distal GMTs.
l The cutting edge is on one side only. Bevel of the Mesial GMTs
blade is at right angle to the shaft. l If the cutting edge of the other pair makes an
l They are single-planned instruments with the pos- acute angle with that edge of the blade nearer to
sibility of five types of cutting movements, i.e. the handle, those are mesial GMTs.
vertical, right, left, push and pull. Uses
Monangle chisels l For bevelling gingival floor.
l These are similar to straight chisels but the blade l They are primarily lateral cutting instruments.
is at an angle to the shaft. It may be mesially or l For forming sharp angles in the cavity preparation.
distally bevelled. l For trimming the margins of the various walls of
Binangle chisels the cavity preparation.

l There are two angles between the shaft and the l To round or bevel the axiopulpalline angels in
blade. class II cavity preparation.}

l Blade is at a right angle to the shaft as in the hoe. Angle formers
l It may be mesially or distally bevelled. l It is considered as a combination of GMT and
Triple angle chisel chisel.

It has three angles in its shank. It may be mesially or l Bevel is at an angle of 80° with the shaft (forming
distally bevelled. It is used to flatten pulpal floors. an acute angle with the long axis of the blade)
Special forms of chisels with a pointed and linear cutting edge.
l They are single-planned instruments with right or
[SE Q.6]
left bevelling.
{Enamel hatchet l They have three cutting movements, i.e. vertical,
This is a special chisel. It has a straight blade,
l push and pull.
which makes it a single, plane instrument. Uses
l The blade is large and bevelled only on one side. l To cut line and point angles in the preparation for
The cutting edge is parallel to the shaft. gold restoration.
l The shank has one or more angles or curves. l To place bevel on enamel margins.
They may be paired, i.e. right or left or may be
bibevelled. Q.4. How will you gain the active separation of teeth in
l They are the single-planned instruments with operative dentistry?
the possibility of four types of movements, i.e. Ans.
vertical, push, pull and either right or left lateral
cutting. [SE Q.2]
Uses
l For cleaving undermined enamel in proximal
{Tooth movement or separation of teeth is defined as the
process of separating the involved teeth slightly away from
cavities and on buccal and lingual walls, where it
each other or bringing them closer to each other, and/or
is not possible to use a chisel.
changing their spatial position in one or more dimensions.
l The smaller sizes are primarily used in anterior
teeth, although are useful in bicuspids and mo- Need for tooth separation
lars. Larger sizes are mainly used in posterior Teeth need separation for one or more of the following
teeth. reasons:
l Diagnosis: For diagnosis of initial proximal caries es- l Provide the correct contour for the cervical por-
pecially when it does not show up on the radiograph. tions of proximal restorations by adapting the
l Cavity preparation: As a means of convenience form matrix band accurately to the cervical aspect of
for providing adequate access to proximal cavity prepa- the tooth.
rations, as in the case of class II or class III cavity l Prevent gingival overhangs of restorations.
preparations. l Separate teeth to compensate for the thickness of
l Matrix placement: To create space for inserting matrix the matrix band.
bands such as during class II restorations. l Stabilize the matrix band and retainer during con-
l Polishing restorations: For ease of polishing the proxi- densation of the restorative material.
mal surfaces of class III and class IV restorations. l Wedges can be made of two materials: wood or
l Repositioning drifted teeth: To reposition teeth that are plastic.}

tilted or drifted due to caries or faulty restorations back Wooden:
to their correct physiologic relationships. This helps in l Round – Ideal class II preparations
maintaining periodontal health. l Triangular – class II preparations with deep
l Removal of foreign objects: To remove foreign objects gingival margins

that are wedged interproximal between teeth causing Plastic:
periodontal damage.} l Light transmitting – class II composite restora-
tions along with transparent matrices

(SE Q.2 and SN Q.4)
(SE Q.2 and SN Q.4)
{(Methods of achieving tooth separation are
l Rapid or immediate separation {(Special wedging techniques
l Slow or delayed separation. a. Piggyback wedging: When there is gingival re-
I. Rapid or immediate tooth separation cession and the proximal box is shallow gingi-
Here, the tooth movement is achieved rapidly over a vally, a single wedge may be very much apical to
short period of time. It may be achieved by wedge prin- the gingival margin. In such cases, a second usu-
ciple or traction principle. ally smaller wedge is ‘piggy backed’ over the first
Separation by wedge principle wedge.
In this principle, a pointed, wedge-shaped device is b. Double wedging: In this technique, two wedges,
inserted between the contacting teeth to produce the one from the buccal aspect and another from the
desired amount of separation, for example Elliot’s lingual aspect are used to provide close adaptation
separator and wedges. of the matrix band at the cervical aspect of the
(i) Elliot’s separator tooth, mostly used when the proximal box is
l This is a mechanical device. It has a single bow wide.
with two jaws, which can be adjusted by a knob. c. Wedge wedging: This technique is employed pri-
The jaws are positioned in the interdental area marily on the mesial aspect of maxillary first
between the two contacting teeth gingival to the premolars. Since these teeth have fluted areas
contact area, without causing damage to the inter- (concave areas) in the root near the gingival.
dental papilla. Separation by traction principle
l When the knob is turned clockwise, the jaws l This employs a mechanical device to engage the
move towards one another thereby wedging the proximal surfaces of the contacting teeth and
teeth apart. bodily moves them apart to bring about the sepa-
l The degree of separation achieved should not ex- ration.
ceed the thickness of the periodontal ligament, i.e. l For example Ferrier double-bow separator.
not more than 0.2–0.5 mm. Slow or delayed tooth separation

(ii) Wedges l This method creates slow movement of teeth over
Wedges are devices that create rapid separation dur- a period of several days or weeks. It is indicated
ing tooth preparation and restoration.)} when teeth have tilted, drifted or rotated to a con-
siderable extent and rapid separation is not useful.
[SE Q.2]
l There are several means of achieving slow separa-
{Functions of wedges tion. These include:

l Atraumatically retract the rubber dam and gingiva l Rubber dam sheet – a small piece of heavy or
from the gingival margins of proximal tooth prep- extra-heavy rubber dam is stretched and posi-
arations, thus providing temporary control of tioned in the contact area and because of its
bleeding and moisture in the gingival seat area. thickness the tooth gets separated. It takes
1–24 h and it can be removed with the help of separated by dashes or spaces, for example Binangle hatchet
a floss. excavator.}
l Separating rubber band – a rubber band is
Q.6. Discuss enamel hatchet and hoes.
stretched and placed in the interproximal area
to achieve slow separation. Ans.
l Separating ligature wires – orthodontic brass
wire is passed interproximally formed into a
loop and twisted to help teeth separate. This {SN Q.7}
technique can cause gingival trauma. Enamel hatchet
l Oversized resin temporary crowns – oversized l This is a special chisel. It has a straight blade, which
crowns in the mesiodistal dimensions are made makes it a single, plane instrument.
and resin is added periodically for separation. l The blade is large and bevelled only on one side. The
l Orthodontic appliances – they are very effec- cutting edge is parallel to the shaft.
tive and are used when extensive repositioning l The shank has one or more angles or curves. They
of the teeth is needed.)} may be paired, i.e. right or left or may be bibevelled.
Q.5. Discuss the instrument formulae and instrument l They are the single-planned instruments with the
rule. possibility of four types of movements, i.e. vertical,

push, pull and either right or left lateral cutting.
Ans.
Uses
[SE Q.3] l For cleaving undermined enamel in proximal cavi-
{Instrument formula ties and on buccal and lingual walls where it is not
l GV Black also developed a numeric formula to de- possible to use a chisel.
l The smaller sizes are primarily used in anterior teeth,
scribe the dimensions and angles of the working end
of a hand cutting instrument. This is called instru- although useful in bicuspids and molars. Larger sizes
ment formula. are mainly used in posterior teeth.
l It consists of three units based on the metric system:
I. Unit blade width – this denotes the width of the

blade expressed in 1/10th of a millimetre.
{SN Q.22}
II. Unit blade length – this indicates the length of
the blade expressed in millimetres. Spoon excavators
III. Unit blade angle – this represents the angle of l It is a double-planned instrument with the possibility
the blade relative to the long axis of the handle of of right or left cutting movements only.
the instrument expressed in centigrades. l Cutting edge is a semicircular, circumferential bevel
1 centigrade 5 1/100th of a circle, and is sharpened to a thin edge.

i.e. 1/100 3 360 5 3.6°.
Mode of supply
So, 1 centigrade 5 3.6°.
l They are available in pairs, i.e. left and right.
Most instruments have a three-number formula.
Some instruments like the GMT and angle for- Uses
mer have the cutting edge other than at right an- l They are used for the excavation of caries/decayed
gles to the blade. For these instruments a fourth dentine.
unit is added. l They also used for carving amalgam or direct inlay
I. Unit primary cutting edge angle – This denotes wax pattern.

the angle between the cutting edge and the long
axis of the handle of the instrument. This is also
expressed in centigrades. For instruments with
four units, the IV unit is placed second in the Chisels
code. The two instruments which have a four- l Chisels have a blade, which ends in a cutting edge
number formula are formed by a bevel on one side only.
l GMT
l The cutting edge of the chisel is at a right angle to the
l Angle former
handle.
The instrument formula is usually placed on the instru- Use
ment’s handle using a code of three or four numbers l Chisels are used for the cutting of undermined enamel.
Types Classification of dental burs

Straight chisels There are several systems for classifying dental burs:
l Monangle chisels According to the shank design
l Binangle chisels l Straight handpiece shank
l Latch-type angle handpiece shank

Special chisels
l Friction-grip angle handpiece shank
l Angle formers
According to the material of manufacture
l Enamel hatchets
l Stainless steel
l Wedelstaedt chisels
l Tungsten carbide
l Gingival marginal trimmers
According to the shape of the bur head
Monangle chisels l Round
l The instrument has a straight blade in line with the l Straight fissure
handle and shank. l Inverted cone
l The cutting edge is on one side only. Bevel of the blade l Tapered fissure
is at right angle to the shaft. l Pear-shaped
l They are single-planned instruments with the possibility According to the size of the bur head
of five types of cutting movements, i.e. vertical, right, This is according to the manufacturer’s number, ISO
left, push and pull. number and the head diameter.
l The blade is at an angle to the shaft. It may be mesially
[SE Q.10]
or distally bevelled.
Hoe excavator
{Shank design
This represents the mode of attachment of the bur to the
l This instrument has the primary cutting edge of the
specific handpiece.
blade perpendicular to the long axis of the handle. l Straight handpiece shank: This is a simple cylin-
l The blade angle is greater than 12.5°. Some hoes have
der held in the straight handpiece by a metal
longer and heavier blades with contra-angled shanks for chuck that closes to the shank diameter (0.0925").
use on enamel of posterior teeth. l Latch-type angle handpiece shank: This is also
l Applications: For planning cavity walls and forming
cylindrical in shape but the posterior portion of the
line angles in class III and class V cavity preparation for bur shank is flattened on one side. The shank is
direct filling gold restorations. shorter than the straight handpiece and fits closely
into a metal tube within the handpiece (0.0925").
Q.7. Discuss the bur and bur design. The shank fits into a D-shaped socket at the bot-
Ans. tom of the bur tube and the bur is retained by a
retaining latch that slides into a groove found at
[SE Q.10] the shank end of the instrument. This type of shank
is seen in burs used in a contra-angle micromotor
{Dental burs handpiece. The shorter length of the shank allows
A bur is a rotary cutting instrument which has a bladed
better access to posterior regions of the mouth.
cutting head.
l Friction-grip angle handpiece shank: This is
Parts of dental burs designed for use with airotor handpieces. The
The dental bur has three basic parts: shank is a simple cylinder and even smaller in
l Shank dimensions than the latch-type instruments
l Neck (0.0628"). This provides good access to posterior
l Head regions of the mouth. The airotor handpieces into
Shank – The shank is that part of the bur which fits into the which these shanks fit have a metal chuck that
handpiece, accepts the rotary motion and provides a bear- closes to make a positive contact with the bur
ing surface to control the alignment and concentricity of the shank.
instrument. Depending on the type of handpiece into which Material of manufacture
the bur fits, different shank designs are possible. (i) Stainless steel
Neck – The neck serves to connect the shank to the head of l Steel burs are useful to cut dentine at slow speeds,
the bur and transmits the rotational and translational forces but they dull rapidly at higher speeds and are not
to the head. effective in cutting enamel.
Head – This is the working end of the bur and is available l Once dulled, their cutting efficiency is lowered
in various sizes, shapes and materials.} causing increased heat and vibration.
Steel burs are now used only for removing soft

l l Bur blades have two surfaces.
carious dentine and finishing procedures. l Blade face/rake face: Surface of the bur
(ii) Tungsten carbide burs blade on the leading edge of the bur.
l Tungsten carbide burs have heads of cemented l Blade back/clearance face: Surface of the
tungsten carbide held in a matrix of cobalt or bur blade on the trailing edge.
nickel. l Flute/chip spaces: These are the depressed
l Some have carbide heads welded to a steel shank areas in between the bur blades.
and neck. l Radial line: This is the line connecting the
l Carbide burs are harder than steel and perform centre of the bur and the blade.
well at all speeds especially at high speeds. l Rake angle: This is the angle between the rake
l They do not dull during cutting. face and the radial line. This may be:
Bur shapes l Negative: When the rake face is ahead of
This refers to the contour of the bur head. Burs are avail- the radial line or
able in several shapes and the basic shapes for cavity l Positive: When the rake face trails the ra-
preparation are: dial line or

i. Round bur: This has a spherical head-shape. It is l Zero: When the rake face and radial line
used for initial cavity preparation, placement of coincide with each other
retention grooves and for caries removal. l Land: This represents the plane surface im-
ii. Straight fissure bur: This bur has an elongated mediately following the cutting edge.
cylindrical head. This is used for preparing the l Clearance angle: This is the angle between the
walls for amalgam cavity preparations. clearance face and the work that is the tooth.
iii. Inverted cone bur: This bur has a head-shaped l Radial clearance: If the clearance face is
like a portion of a rapidly tapered cone with the curved, it is known as radial clearance.
apex of the cone directed towards the bur shank. l Blade angle: This is the angle between the
This bur is used to provide undercuts for amal- rake face and the clearance face or the rake
gam cavity preparations. face of the land.}
iv. Tapered fissure bur: This bur has a tapered cone-
Q.8. Define contact area. Describe the importance of
shaped head with the small end of the cone di-
contact and contours in restorative dentistry. How
rected away from the bur shank. This bur is used
would you get a good contact for various restorative
for inlay and crown preparations.
materials?
v. Pear-shaped bur: This bur is like an elongated
inverted cone bur with rounded edges. It is used Ans.
for amalgam cavity preparations to produce un- (SE Q.12 and SN Q.18)
dercut preparations with rounded internal angles.
Bur sizes {(Definition
The site of actual contact between two teeth on the me-
Standard bur head sizes sial and distal surface is called contact point.
Head
Variations
l A contact point in posterior teeth is located nearer
shapes Head diameter (mm)
the facial surface, which causes a larger embrasure.
0.5 0.6 0.8 1.0 1.2 1.4
l A contact point in anterior teeth is located nearer
1 1
Round ⁄4 ⁄2 1 2 3 4 the lingual surface, which causes a larger facial
Inverted 33 ⁄21
34 35 36 37 embrasure.
cone Types
l Rounded
Straight 551⁄2 56 57 58 59
fissure l Broad
l Flat.
Tapered 700 701
fissure Purpose of ideal contact point
(cross-cut) l To prevent food impaction.
l To make areas self-cleanable.
l To conserve healthy gingival tissue.
Bur blades l To ensure permanence of proximal restoration.
These are uniformly spaced projections on the bur l To improve aesthetic appearance, especially an
head, which terminate in the cutting edge. anterior teeth.

l To maintain normal mesiodistal relationship of teeth Q.10. Classify speeds in dentistry.

in the dental arch.)}
Ans.
[SE Q.12]
[Ref LE Q.2]
{Hazards of faulty contact areas
Too broad contact Q.11. What is high speed? Classify and describe its ad-
Too broad contact buccolingually or occlusogingi- vantages and disadvantages.
vally leads to: Ans.
l Improper shunting of food in buccal and lin-
gual direction [Ref LE Q.2]

l Change in the tooth anatomy and the shape of
Q.12. Classify and write in detail about operative hand
interdental col instruments. Add a note on instrument formula.
l Increased susceptibility to periodontal dis-
eases, due to nonkeratinization of col Ans.

Too narrow contact
[Ref LE Q.3]
Too narrow contact buccolingually of occlusogingi-
vally leads to: Q.13. Classify and discuss hand cutting instruments and
l Vertical/horizontal food impaction rotary instruments used in operative dentistry.
l Greater food retention of plaque occur in em-
Ans.
brasure areas
Contact placed too occlusally [Ref LE Q.3]
Contact placed too occlusally leads to a flattened mar-
ginal ridge at the expense of occlusal embrasure. Q.14. Discuss the disadvantages of using low speed and
Contact placed too buccally/lingually high speed in operative dentistry.
l Contact placed too buccally/lingually leads to a flat- Ans.
tened restoration at the expense of buccal/lingual
proximal wall. [Ref LE Q.3]
Contact placed too gingivally Q.15. Classify hand instruments. Write a note on instru-
l Contact placed too gingivally leads to increased
ment formula and on each instruments.
depth of occlusal embrasure at the expense of the
size contact area. Ans.
Loose contact areas [Ref LE Q.3]
l Loose contact areas create continuity between em-
brasures and interdental col leading to food impac- Q.16. Classify hand cutting instruments used in conser-
tion. The significance of proper contact areas cannot vative dentistry. Elaborate on modified chisels and in-
be overemphasized as: strument formula.
l They promote normal healthy interdental papillae
Ans.
filling of the interproximal spaces.
l Improper contacts can result in food impaction [Ref LE Q.3]
between the teeth, producing periodontal disease,
Q.17. How will you achieve separation of tooth in opera-
carious lesions and possible movement of the teeth.
tive procedures?
l Retention of food is objectionable by its physical
presence. Ans.
l Halitosis results from food decomposition.
l Proximal contacts and interdigitation of the teeth

[Ref LE Q.4]
through occlusal contacts stabilizes and maintains Q.18. Discuss monoangled chisel and hoe.
the integrity of the dental arches.
l Improper contacts lead to periodontal disease,
Ans.
secondary caries and possible tooth movement.} [Ref LE Q.6]
Q.9. Define matrix. Describe the matrices and retainers
Q.19. Discuss the cutting and finishing bur.
used while restoring class II cavity.
Ans. Ans.
[Ref LE Q.1] [Ref LE Q.7]

SHORT ESSAYS: Guards

Guards are finger positions of the hand opposite to the
Q.1. Discuss matrices. one using the instruments, which protect the soft tissues
Ans. from contact with sharp cutting instruments. Other items
like wedges can also serve as guards to protect the adjacent
[Ref LE Q.1] soft tissues.
Automatrix Q.5. Discuss the angle former.
a. Automatrix bands: These are available in thicknesses of
0.0015 to 0.002 inch. They may be of three widths: Ans.
l Narrow – 3/16th inch l This instrument is a combination of a chisel and GMT.
l Medium – 1/4th inch l This instrument is modified from a chisel by sharpening
l Wide – 5/16th inch the primary cutting edge at an angle to the axis of the
They may be selected according to the height of the blade.
tooth to be restored. l The cutting edge angle is usually 80–85°C making it a
b. Automate II tightening device: This is used to adjust four-unit instrument.

the loop of the band according to the circumference of l The blade of the angle former is bevelled on the sides
the tooth to be restored. also providing it with three cutting edges – one primary
c. Shielded nippers: This device is used to cut the autolock and other two secondary cutting edges.
loop, so that the band can be separated and removed l Since the acute angle of the cutting edge may be di-
from the tooth after the restoration is done. rected to the right or left, it may be a right- or left-
l Indicated for complex amalgam restorations bevelled instrument.
especially when one or more cusps are to be Q.6. Discuss the gingival marginal trimmer and enamel
replaced. hatchet.
Advantages Ans.
l Convenient to use.
l Improved visibility.
[Ref LE Q.3]
l Autolock loop can be placed facially or lingually rapid Q.7. Discuss the amalgam carver.
application.
Ans.
Q.2. Define separators. Discuss objective and indica-
tions of separation. Definition
Amalgam carving is defined as the anatomical sculptur-
Ans. ing of the amalgam materials.
[Ref LE Q.4] Instruments used
Q.3. Discuss the instrument formula. Amalgam carving can be done by the following amal-
gam carvers:
Ans. l Cleoid carvers
l Discoid carvers
[Ref LE Q.5]
l Ward’s carvers
Q.4. Discuss finger rests and guards. l Diamond carvers
l Hollen Beck carvers

Ans.
Rests Hollen Beck carver
l This carver is useful for carving the occlusal, proximal
l While working with hand instruments, rests are pro-
vided to steady the hand. and facial lingual surfaces of the amalgam restorations.
l Rests allow precise control over the instrument without Discoid carver
slippage. l It is a double-planned instrument with the possibility of
l Generally for modified pen and inverted pen grasps, right or left cutting movements only.
rests are provided by placing the ring finger on a tooth l They have a circular blade, with a cutting edge extend-
of the same arch close to the operating site. ing around the periphery except where it joins to the
l For palm and thumb grasp, rests are provided by the tip shank.
of the thumb placed in the tooth being operated on, or l They can be used for the excavation of caries, for carv-
an adjacent tooth. ing metallic restorations.
Cleoid carver Uses

l It is a double-planned instrument with the possibility of l For tooth preparation
lateral cutting movements only. l Removal of old restorations
l Use – In amalgam carving, burnishing and finishing of l Tooth reduction for crown preparations
cohesive and cast gold restoration and in excavation of

Advantages
caries from the areas of difficult access.
l Patient comfort
Diamond carver l Instruments last longer
l It has diamond-shaped nib. l Better control and ease of application
l Several teeth can be treated in a single appointment

Q.8. Discuss abrasion.
l Number of rotary cutting instruments needed is reduced
Ans. l Faster removal of tooth structure with less pressure,
l Diamond abrasives exhibit greater resistance to abra- vibration and heat generation
sion, lesser heat generation and more efficiency in cut-
Disadvantages
ting enamel and dentine. Hence, currently they are more
l More chances of iatral errors
popular than tungsten carbide burs.
l Scarring of adjacent uninvolved tooth
l Cutting mechanism of diamond abrasives is similar to
l Air–water spray can impair the visibility
that of dental burs but they increased hardness of dia-
l Excessive removal of uninvolved tooth structure
monds make them highly resistant to wear.
l It is less tactile, so over cutting of tooth is possible
l Diamonds cut enamel by brittle fracture. They create
l Improper care during preparation results in the slippage
subsurface cracks in the enamel.
of the instrument and tends to injure adjacent hard and
l These are then removed by contact with diamond abra-
soft tissues
sive particles.
l Diamond abrasives cut dentine by ductile fracture. Q.10. Discuss dental burs.
However, they are less efficient than dental burs in cut-
Ans.
ting dentine.
[Ref LE Q.7]
Q.9. What is high speed? Classify and describe its ad-
Q.11. Define rake angle.
vantages and disadvantages.
Ans.
Ans.
Definition
{SN Q.5} {SN Q.21}
Classification l Rake angle refers to the angle that the face of the bur
According to Sturdevent tooth makes with the radial line (refers to direction of
l Low/slow speed – below 12,000 rpm rotation) from the centre of the bur to the blade.
l Medium/intermediate speed – 12,000–200,000 rpm
l High/ultra high speed – above 200,000 rpm
Types
High-speed dentistry l Negative rake angle
l A high speed is a device for holding rotating instru- l Positive rake angle
ments, transmitting power to them and for position- l Zero rake angle
ing them intraorally. The rational speed of an instru-
ment is measured in rpm.
l High speeds were introduced in 1950s and it ranges
{SN Q.21}
over 200,000 rpm. Negative rake angle
l The very high speeds are achieved by a small air- l It forms when the face is beyond or leading the radial
driven rotor or turbine mounted in bearings in the line, in other words it forms when the face is in front
head of a contra-angle handpiece. of the radial line.
l High-speed handpieces always contain a system, l It is used for hard and brittle materials and serves to
which directs water spray at the cutting head of increase tool life by minimizing fracture of cutting
the bur. edge, for example cutting enamel with burs.
Positive rake angle

As the wedge has its greatest width at its base, it will
l It forms when the radial line leads the face, so that provide the right contour for the matrix band cervically
the rake angle is on the inside of the radial line, in and adapt it well against the tooth gingivally.
other words forms when the face is behind the radial Wooden
line. l Round – Ideal class II preparations
l It is used when relatively soft and week materials l Triangular – class II preparations with deep gingival
are cut. Positive rake angle will tend to dig instead margins
of cut. l Light transmitting – class II composite restorations
Zero rake angle

along with transparent matrices
l It forms when the radial line and the tooth face coin- Special wedging techniques
cide with each other. a. Piggyback wedging: When there is gingival recession
and the proximal box is shallow gingivally, a single
wedge may be very much apical to the gingival margin.
In such cases, a second usually smaller wedge is ‘piggy
Q.12. Define contacts and contours.
backed’ over the first wedge.
Ans. b. Double wedging: In this technique two wedges, one
from the buccal aspect and another from the lingual as-
[Ref LE Q.8]
pect are used to provide close adaptation of the matrix
Q.13. Explain wedges. band at the cervical aspect of the tooth. Mostly used
when the proximal box is wide.
Ans.
c. Wedge wedging: This technique is employed primarily
Wedges on the mesial aspect of maxillary first premolars. Since
Wedges are devices that create rapid separation during these teeth have fluted areas (concave areas) in the root
tooth preparation and restoration. near the gingival.
Functions of wedges
Q.14. Discuss diamond abrasives.
l Atraumatically retract the rubber dam and gingiva from
the gingival margins of proximal tooth preparations, Ans.

thus providing temporary control of bleeding and mois- l These are the other category of rotary cutting instru-
ture in the gingival seat area. ments.
l Provide the correct contour for the cervical portions of l They are similar to burs but have diamond abrasives
proximal restorations by adapting the matrix band ac- held by metallic bonding on a steel blank instead of the
curately to the cervical aspect of the tooth. blades that are present in burs.
l Prevent gingival overhangs of restorations. l The diamonds used are industrial diamonds, either natu-
l Separate teeth to compensate for the thickness of the ral or synthetic.
matrix band. l These are crushed to a powder with particles of different
l Stabilize the matrix band and retainer during condensa- sizes, which are then attached to the metal blank.
tion of the restorative material. l Diamond abrasives also have the same parts as that of a
dental bur.
Wedges may be made of two materials:
l The metal blank is shaped into a shank, neck and head.
l Wood or plastic
l The head is slightly undersized but after a uniform
Wooden Wedges are made from soft wood-like pine or
thickness of diamonds and bonding material on all
hard wood-like oak. They may be medicated. Wooden
sides, it achieves the final size.
wedges are usually preferred as they are easy to trim,
l Diamond abrasives exhibit greater resistance to abra-
adapt well, also absorb moisture and swell to provide
sion, lesser heat generation and more efficiency in cut-
adequate stabilization to the matrix band. They are used
ting enamel and dentine. Hence, currently they are more
along with metal matrices. Wooden wedges can be of
popular than tungsten carbide burs.
two shapes:
Triangular – triangular wedges are commercially avail- Classification of diamond abrasives
able. They are preferred for cavities with deep gingival These are also classified in the same manner as dental
margins. The apex must correspond with the gingival burs: based on the shank design, head shapes and sizes.
start of contact area. The two sides must coincide with Apart from the standard head shapes, diamond abrasives
mesial and distal sides of the gingival embrasure, while can also be manufactured in a variety of other shapes such
the broader base must contact the gingiva and retract it. as wheel, flame, football and needle.
Diamond abrasives are available in various particle Removal of automatrix

sizes: l For removing the band, use the shielded nippers to cut
l Coarse the autolock loop.

l Medium l Separate the band into two halves with an explorer and
l Fine carefully remove the band in an oblique direction (fa-

l Extra fine cially and occlusally).
Particle size 125–150 microns
Indications
For complex amalgam restorations especially when one
or more cusps are to be replaced.
Advantages
For cavity preparation procedures, the particle size of
l Convenient to use
the abrasives may be either coarse or medium.
l Improved visibility due to lack of interference from a
Cutting mechanism of diamond abrasives retainer

l The cutting action of diamond abrasives is similar to l Autolock loop can be positioned facially or lingually
that of dental burs, but the increased hardness of dia- l Rapid application
monds makes them highly resistant to wear.

Disadvantages
l Diamonds cut enamel by brittle fracture.
l Bands are flat and difficult to burnish
l They create subsurface cracks in the enamel which in-
l Cannot develop proper proximal contacts and contours
tersect and undermine small areas of the enamel.
l Expensive
Q.15. Discuss the design of automatrix.

Q.16. Discuss Tofflemire matrix retainers.
Ans. Ans.
The automatrix is a retainerless matrix system. It has the [Ref LE Q.1]
following components:
a. Automatrix bands: These are available in thickness of Q.17. Discuss matrices and retainers used in restorative
0.0015–0.002 inch. They may be of three widths: dentistry.
l Narrow – 3/16th inch Ans.
l Medium – 1/4th inch
[Ref LE Q.1]
l Wide – 5/16th inch
They may be selected according to the height of the Q.18. Discuss matrices and matrix retainers.
tooth to be restored. Ans.
b. Automate II tightening device: This is used to adjust
the loop of the band according to the circumference of [Ref LE Q.1]
the tooth to be restored. Q.19. Define matrix. Describe various matrices.
c. Shielded nippers: This device is used to cut the
autolock loop, so that the band can be separated and Ans.
removed from the tooth after the restoration is done. [Ref LE Q.1]
Placement of automatrix Q.20. Define matrix. Discuss different types of matrices.
l Select an appropriate band depending upon the height
Ans.
of the tooth to be restored.
l Adjust the circumference of the band and burnish it us- [Ref LE Q.1]
ing an egg-shaped burnisher. Q.21. Discuss matrix band and retainers used for
Place the band around the tooth and using the automate restorations.
II tightening device to tighten it around the circumference Ans.
of the tooth.
[Ref LE Q.1]
l Place wedges interproximally to adapt the band gingi-
vally to the contour of the tooth. Q.22. Define matrix. Describe the matrices and retain-
l To stabilize the band, soften and adapt impression com- ers used while restoring class II cavity.
pound.
Ans.
l Following this, insert the restoration and allow it to
set. [Ref LE Q.1]

Q.23. Classify matrices. Write about auto matrix system. Q.34. Discuss marginal trimmers.
Ans. Ans.
Q.24. Classify nonmetallic matrices. Q.35. Discuss the gingival marginal trimmer.
Ans.
Ans.
[Ref LE Q.3]
[Ref LE Q.1]
Q.36. Define high speed.
Q.25. How will you achieve slow separation?
Ans.
Ans. [Ref SE Q.9]
[Ref LE Q.4] Q.37. Define ultra speed.
Q.26. Classification and principles of tooth separators. Ans.
Ans. [Ref SE Q.9]
[Ref LE Q.4] Q.38. Discuss the bur design.
Q.27. Discuss indications of separation of teeth. Ans.
Ans. [Ref LE Q.7]

Q.39. Discuss the bur blade design.
[Ref LE Q.4]
Ans.
Q.28. Discuss separation of teeth.
[Ref LE Q.7]
Ans.
Q.40. Discuss wedges – types and methods of wedging.
[Ref LE Q.4]
Ans.
Q.29. Discuss mechanical separators. Describe the pur-
pose of separation of teeth. Also mention the mechanical [Ref SE Q.13]
separation, different types and advantages. Q.41. Define the anatomic matrix.
Ans. Ans.
[Ref LE Q.4] [Ref SE Q.15]
Q.30. Discuss the instrument formula for hand cutting
instruments. SHORT NOTES:
Ans. Q.1. Define wedges.
[Ref LE Q.5] Ans.
Q.31. Discuss the four unit instrument formulae. Wedge is a wooden or plastic device placed interproxi-
mally, which approximates the band on to the tooth and
Ans. prevents gingival overhand of restoration.
[Ref LE Q.5] Functions
l To immobilize the matrix band.
Q.32. Discuss the enamel hatchet.
l To protect gingival interdental papilla.
Ans. l To protect proximal periodontal tissues.
l To adapt closely the matrix band to the tooth.

[Ref LE Q.3]
l To establish atraumatic retraction of the rubber dam.
Q.33. Discuss the hatchet and hoe. l To prevent the gingival overhanging of the restorative
material.
Ans.
l To create some separation to compensate for the thick-
[Ref LE Q.3] ness of the matrix band and minor drifting of the teeth.
Types of wedging l Automatrix is a retainer less matrix system.

l Piggy back wedging
Indications
l Double wedging
l It is indicated for complex amalgam restorations espe-
l Wedge wedging
cially when one or more cusps are to be replaced.
Q.2. Define matrices.
Components
Ans. l Shielded nippers
l Automatrix bands
Matricing is a procedure whereby a temporary wall is
l Automate II tightened device
created opposite the axial wall surrounding the areas of
tooth structure lost during preparation. The appliance used Advantages
for building these walls is called matrix. l Convenient to use and rapid application
l Auto lock loop can be positioned facially or lingually

Matrix retainer
l Improved visibility due to lack of interference from a
l Matrix retainer is a device by which the band can be
retainer
maintained in its designated position and shape. The
retainer may be a mechanical device, dental floss, a Disadvantages
metal ring or impression compound. l Expensive
l Bands are flat and difficulty to burnish

Functions of matrix
l Cannot develop proper proximal contacts and contours
l Isolates the cavity
l Replaces the missing tooth Q.4. Define separators.

l Produces close adaptation of restorative material
l Retains the restorative material during the placement Ans.

l Allows restoration of contact point and external crown
[Ref LE Q.4]
contour
Q.5. Classify speed.
Tofflemire matrix
l This is also referred to as the universal matrix. Ans.
l It was designed by BR Tofflemire.
l This matrix is usually preferred for most class II amal-

[Ref SE Q.9]
gam restorations. Q.6. Define airotor.
l The Tofflemire retainer is available in two sizes:
(i) Standard – for use in the adult dentition Ans.

(ii) Small – for use in the primary dentition l Airotor handpieces are connected to the air–water line
Indications of the dental unit and are activated by compressed air
l For class I cavities with buccal or lingual extensions
supplied by a compressor.
l The speed range is above 200,000 rpm but they have
l For class II cavities on one or surfaces of a posterior tooth
low torque.
Advantages l The system directs air–water spray towards the working
l Ease of use site.
l Produces good contact and contour for most amalgam l Newer handpieces have fibreoptic light to direct towards
restorations the working site.
l Rigid and stable
Q.7. Define hatchet.
Disadvantages
l Does not provide optimum contour and contact for pos-
Ans.
terior composite restorations Hatchet
l Not useful for extensive class I restorations l This is also called ordinary hatchet or bibevelled hatchet.
l In this instrument, the cutting edge is in same plane as

Q.3. Define automatrix.
the long axis of the handle.
Ans. l It is useful to sharpen the internal angles and prepare reten-
Automatrix tive areas for Direct Filling Gold (DFG) in anterior teeth.
l It is also used in class II cavity preparation in smoothen-
l Matrix is a device used during the restorative proce-
dures to hold the plastic restorative materials within the ing of gingival wall.
tooth while it is setting. [Ref LE Q.6]
Q.8. Discuss mouth mirror. Types

l Straight explorer surfaces for caries – examine the oc-
Ans.
clusal
l It is a single-ended instrument. It consists of a mirror l Curved explorer surfaces of teeth – examine the occlusal
and a handle. l Interproximal explorer caries – examine the interproxima
Types Periodontal probes

l Plain mouth mirror l These are similar to explorers but the working tip is
l Concave mouth mirror blunt and marked with graduations.

l Front-surface mouth mirror l In operative dentistry, they are used to measure the
l Rear-surface mouth mirror depth of the prepared cavity.

l Minimizes visual distortions
Cotton tweezers
l Magnifies the images
l Cotton tweezers or pliers have angled tips and available
l Provides clear image
in various sizes.
l Resistant to scratching
l They are used to place and remove cotton rolls used for
Sizes isolation of teeth.

l Mouth mirrors are usually round in shape at their work- l They can also carry small items like cotton pellets to dry
ing ends and are available in a variety of sizes. the teeth during the examination isolation and cavity
l No. 2 preparation.
l No. 4
l No. 5 Q.10. Discuss balancing of the hand instrument.

l Nos. 4 and 5 Ans.
Design In operative dentistry, instrument can be balanced with
l 5/8" dm the grasps, rests and guards.
l 7/8" dm
l 15/16" dm Instrument grasp

l Modified pen grasp
Uses l Inverted pen grasp
l Direct and indirect vision l Palm and thumb grasp
l Retraction of cheek lips and tongue l Modified palm and thumb grasp
l Helps to reflect light into a specific area of the oral cavity
l End of the handle used for percussion of teeth Rests

l Rests are used to stabilize the hand, confine the instru-
Q.9. Discuss exploring instruments. ment to the working area and prevent injury.
l Rests are made with the fingers that do not engage the
Ans.
instrument.
l These instruments are used for examining the mouth l Rests should be placed on tooth or bony support and
and teeth. They are the basic instruments needed during never on soft tissues.
each appointment for diagnosis and treatment.
Guards
Types l Guards are the finger positions of the hand opposite to
l Mouth mirror the one using the instruments, which protect the soft
l Explorers tissues from contact with sharp cutting instruments.
l Periodontal probes l Wedges can also serve as guards to protect the adjacent
l Cotton tweezers soft tissues.
Mouth mirror Q.11. Define bur design.
Uses
l Direct and indirect vision Ans.
l Retraction of cheek, lips and tongue Dental bur is a rotatory cutting instrument, which has a
l Helps to reflect light into a specific area of the oral cavity bladed cutting head.
l End of the handle used for percussion of teeth
Advantages
Explorers l It is easy to control the instrument.
l These are delicate, pointed instruments used for tactile l It is a familiar and well-known procedure.
examination of tooth surfaces and restorations to iden- l Practitioner’s vision while cutting is relatively good.
tify any irregularities. l Precision is obtainable, i.e. margins are clearly definable.
l Debris can be removed by water lavage and use of suction. l Giromatic handpiece activates a stainless steel barbed
l Less strain to the operator and the patient during tooth broach or reamer in the root canal through a 900 recip-
removal using high speed. rocating arc at a speed up to 1000 cycles/min.
l Not time-consuming during tooth cutting. Several teeth
Disadvantages
can be treated in a single appointment.
l Longer time is needed for preparation.
l They have highest efficiency in removal of enamel (dia-
l Less effective for preparing root canals.
monds) and dentine (carbide burs).
l It may pack the dentinal shavings in the canals.
Disadvantages Q.14. Define gingival marginal trimmer.

l Noise produced with their use is objectionable.
l Dull burs produce a lot of heat and pulpal damage. Ans.

l Cutting with these instruments usually causes pain.
l GMT is a modified enamel hatchet. But the blade is
l Constant use and sterilization can cause them to break
curved and the cutting edge is other than right angle to
down. the axis of the blade.
l Vibrations caused by cutting usually causes cracks or
l They are similar to spoon excavators in both of their
fracture of tooth. angles and the dimensions of their blades.
l Overcutting is easy, if the operator loses control or the
patient moves inadvertently. Uses

l The lips, tongue and cheeks of the patient may be in- l For bevelling gingival floor.
jured if proper care is not taken during the cutting. l They are primarily lateral cutting instruments.
l For forming sharp angles in the cavity preparation.

Parts of a bur l For trimming the margins of the various walls of the
Every bur will have three parts, namely: cavity preparation.
l Head – the portion which carries the cutting blades.
l To round or bevel the axiopulpalline angels in class II
l Shank – the portion connecting the head to the attach-
cavity preparation.
ment part of handpiece. l There is a mesial and distal type of gingival marginal
l Shaft – the portion which is engaged within the hand-
trimmer.
piece, which connects the shank to the head of the bur.
Q.15. Define S-shaped matrix.
Q.12. Discuss burs and diamonds points. Ans.
Ans. S-shaped matrix band
l This is a metal matrix band moulded into an S-shape by
Burs and diamonds points contouring.
l Diamond burs are the dental burs that have diamond
l After the band is positioned and contoured over con-
abrasives held by metallic bonding on steel blank in- touring teeth, it is stabilized using wedges and impres-
stead of the blades that are present in the burs. sion compound.
l Diamond abrasives exhibit greater resistance to abra-
sion, less heat generation and more efficiency in cutting Indications
the enamel and dentine. l For class II slot preparations
Cutting mechanism of diamond burs l For class III restorations on the distal surface of canines
l The cutting action of diamond abrasives is similar to

Advantage
that of dental bur but the increased hardness of dia- l Provides ideal contour
monds make them highly resistant to wear.
l Diamonds cut enamel by brittle fracture. They create
Disadvantage
l Difficult to apply
subsurface cracks in the enamel, which intersect and
undermine small areas of the enamel. Q.16. Define embrasures.
l Diamond abrasives cut dentine by ductile fracture.
Ans.
However, they are less efficient than the dental burs in
dentine. Embrasures are V-shaped spaces that originate at the
proximal contact areas between adjacent teeth and are
Q.13. Define sonic instrument. named after the direction towards which they radiate. There
are four embrasures present:
Ans.
l Facial
Giromatic handpiece l Lingual
l Giromatic handpiece is the engine-driven contra-angle l Incisal
handpiece which can be used for root canal opening. l Occlusal

Functions Q.22. Define spoon excavator.

l Serve as spills ways for the escape of food during mas-
Ans.
tication
l Prevent trapping of food into the contact area [Ref LE Q.6]
l Protect the underlying supporting tissue during mastication
Q.23. Define Wedelstaedt chisel.
Q.17. Discuss copper band matrix.
Ans.
Ans.
l This instrument resembles a straight chisel, but has a
l The copper bands are given shape by heating and slight vertical curvature in its shank.
quenching by dipping in water after which the desirable l It is a single, plane instrument with a bevel on one side
shape can be contoured with the help of curved scissors. of the blade only.
l It may be mesially bevelled or distally bevelled.
Indications
l It is used to cleave undermined enamel.
l For badly broken down teeth especially those receiving
pin amalgam restorations Q.24. Define angle former.

l For complex situations like class II cavities with large
Ans.
buccal or lingual extensions
l This instrument is a combination of a chisel and gingi-
Advantage
val marginal trimmer.
l Provide excellent contour
l The cutting edge angle is usually 80–85°C making it a
Disadvantage four-unit instrument.

l Time-consuming l It may be right or left-bevelled instrument.
Q.18. Discuss the significance of contacts and contours. Q.25. Discuss the role of matrix and wedges.
Ans. Ans.
[Ref LE Q.8] [Ref SN Q.2]
Q.19. Discuss chisel and its modifications. Q.26. Discuss the functions of matrix band.
Ans.
Ans.
l Chisels have a blade, which ends in a cutting edge
formed by a bevel on one side only. [Ref SN Q.2]
l The cutting edge of the chisel is at a right angle to the Q.27. Define matrices/retainers.
handle.
Ans.
Uses
l For cleaving undermined enamel in proximal cavities
[Ref SN Q.2]
and on buccal and lingual walls where it is not possible Q.28. Discuss the matrix and the uses.
to use a chisel.
l The smaller sizes are primarily used in anterior teeth,
Ans.
although are useful in bicuspids and molars. Larger [Ref SN Q.2]
sizes are mainly used in posterior teeth.
Q.29. Define matrices and retainers.
Modifications of chisel
l Gingival marginal trimmer
Ans.
l Enamel hatchet [Ref SN Q.2]
l Angle former
Q.30. Discuss the matrix retainers and band.
Q.20. Discuss the instrument formula.
Ans.
Ans.
Q.21. Discuss rake angle. Q.31. Define universal matrix retainers.

Ans. Ans.
[Ref SE Q.11] [Ref SN Q.2]
Q.32. Discuss the Tofflemire universal matrix retainer. Q.44. Define ultra speed.
Ans. Ans.
[Ref SN Q.2] [Ref SE Q.9]
Q.33. Define Tofflemire retainers. Discuss matrices and
Q.45. Define high speed.
matrix retainer.
Ans. Ans.
[Ref SN Q.2] [Ref SE Q.9]

Q.34. Discuss the Elliot’s separator. Q.46. Discuss slow speed.
Ans. Ans.
Q.35. Discuss the purpose of separation of teeth.
Q.47. Discuss dental burs.
Ans.
Ans.
[Ref LE Q.4]
[Ref SN Q.11]
Q.36. Explain the separation of teeth and mechanical
separators. Q.48. Discuss 245 bur.
Ans. Ans.
Q.37. Discuss the separation of teeth.
Q.49. Describe advantages and disadvantages of dental
Ans. bur.
[Ref LE Q.4] Ans.
Q.38. Discuss the slow separators. [Ref SN Q.11]
Ans.
Q.50. Define sonic handpiece.
[Ref LE Q.4]
Ans.
Q.39. Describe tooth separation.
[Ref SN Q.13]
Ans.
[Ref LE Q.4] Q.51. Discuss the importance of contacts and contours.
Q.40. Discuss the tooth separation in restorative Ans.

dentistry.
[Ref LE Q.8]
Ans.
Q.52. Discuss the importance of buccal contours.
[Ref LE Q.4]
Ans.
Q.41. Discuss rapid separators.
Ans. [Ref LE Q.8]
[Ref LE Q.4] Q.53. Discuss the contacts and contours in restoration

dentistry.
Q.42. Describe mechanical separators.
Ans.
Ans.
Q.43. Discuss speed in dentistry. Q.54. Discuss the D-11 instrument.
Ans. Ans.
[Ref SE Q.9] [Ref LE Q.3]
Topic 5
Fundamentals in Tooth Preparation
LONG ESSAYS:
1 . Define cavity and cavity preparation. Describe the various concepts of cavity design for amalgam restorations.
2. Compare and contrast cavity for class II amalgam and gold restorations.
3. Describe the cavity preparation for class III composites.
4.
Compare the features of a class II preparation for a silver amalgam restoration and a gold inlay restoration.
[Same as LEQ.1]
5 . Write differences in class II cavity for silver amalgam and gold inlay. [Same as LEQ.2]
SHORT ESSAYS:
1. Discuss the causes and management of hypersensitivity.
2. What do you mean by ‘Extension for Prevention’? How is this principle applied during the cavity preparation
of various classes?
3. Describe the classification of cavities.
4. Define air abrasion.
5. Describe the circumferential tie.
6. Discuss reverse class II amalgam restoration.
7. Discuss outline form.
8. Discuss retention form.
9. Discuss acid etching.
10. Describe pit and fissure sealants.
11. Discuss G.V. Black’s classification of cavity. [Same as SEQ.3]
12. Discuss air abrasion in operative dentistry. [Same as SEQ.4]
13. Discuss obtaining retention form of class I and II amalgam. [Same as SEQ.8]
14. Define acid etch technique. [Same as SEQ.9]
15. Discuss fissure sealants. [Same as SEQ.10]
SHORT NOTES:
1. Discuss enameloplasty.
2. Describe reverse curve.
3. Define attrition, abrasion and erosion.
4. Describe the management of deep and shallow cavity.
5. Define bevels.
6. Define isthmus.
7. Define smear layer.
8. Define cavosurface angle.
9. Define tunnel preparation.
10. Discuss proximal box preparation in class II cavity.
11. Define prophylactic odontotomy.
12. Discuss cavity design for class II inlay.
13. Discuss the preparation of teeth.
14. Discuss trephination. [Same as SNQ.1]
15. Define abfraction. [Same as SNQ.3]
16. Define reverse bevels. [Same as SNQ.5]
1 7. Define trephination. [Same as SNQ.9]

18. Describe general features of an inlay cavity. [Same as SNQ.12]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Define cavity and cavity preparation. Describe enamel and prevents damage to the proximal sur-
the various concepts of cavity design for amalgam face of the adjacent tooth.
restorations. l No. 245 bur is used on the pulpal floor adjacent to
the remaining mesial marginal ridge, proceeding

Ans. Cavity refers to a defect in the tooth enamel or in both gingivally, moving in a buccolingual direction
enamel and dentine due to carious process. depending on the buccolingual extent of the con-
Cavity preparation/tooth preparation tact area.
This refers to the mechanical alteration of a defective, l The ditch is cut along the exposed mesial denti-
injured or diseased tooth to best receive a restorative mate- noenamel junction, two-thirds at the expense of
rial, which will re-establish the normal form, function and the dentine and one-third at the expense of
aesthetics of the tooth. enamel.
Initial cavity preparation l The proximal ditch cut is extended gingivally just
i. Establishing the occlusal step beyond the caries and then the bur can be removed
l Cavity preparation should begin by making a from the cavity and held in the facial embrasure to
punch cut in the pit closest to the involved proxi- verify whether it has cleared the gingival limit of
mal surface. the contact area.
l No. 245 bur in an airotor handpiece should be l The proximal ditch is made wider gingivally, so
held parallel to the long axis of the crown. that the walls of the proximal preparation con-
l Initial depth should be maintained at 1.5–2 mm. verge towards the occlusal aspect.
Extend distally along the central fissure. l This provides retention form to the proximal box,
l Pulpal floor should be maintained flat at 1.5 mm conservation of the marginal ridge as well as in-
or 0.1–0.2 mm into the dentine. clusion of caries at the gingival level.
l The outline form should extend to include all l The remaining weakened enamel wall may then
the carious pits and fissures, circumventing the by fractured by gentle pressure with a spoon ex-
cusps. cavator.
l The facial, lingual and distal walls should have a iv. Finishing the proximal box and enamel walls
small degree of occlusal convergence, so as to l Using an enamel hatchet or a biangle chisel,
provide undercut retention form for the cavity cleave the remaining undermined proximal
preparation. enamel. Thus, proximal walls with cavosurface
l A dovetail retention form is provided at the distal angle of 90° can be established.
pit area by including any radiating fissures from l On the facial and lingual margins of the proximal
the distal pit. box, the ideal clearance should be 0.2–0.3 mm

l This prevents mesial displacement of the final from the adjacent tooth.
restoration. l The ideal gingival clearance from the adjacent
ii. Extending the occlusal step proximally tooth is 0.5 mm and can be smoothened by
l Preparation should be extended mesially till it is enamel hatchet.
0.8 mm short of cutting through the mesial mar- l Finishing the proximal box, enamel walls may be
ginal ridge into the contact area using same bur. done by hand instruments or by careful use of
l Next, the occlusal step in the mesial side is rotary instruments.
made slightly wider faciolingually (to the ex- v. Primary resistance form
tent of the contact area with the adjacent tooth) Primary resistance form can be achieved:
because additional width is needed for the prox- l Flat pulpal and gingival floors perpendicular
imal box. along the long axis of the tooth.

iii. Preparation of the proximal box l Minimal width for the cavity, so that strong
l The proximal box preparation begins with the cusps and ridge areas remain with enough
‘proximal ditch cut’, to isolates the proximal dentine support.
l Outline form should extend only in areas of Silver amalgam Class II cast gold inlay
minimal occlusal contact.
l Walls of the cavity l Walls of the cavity diverge
l Rounding the internal angles to reduce stress
converge occlusally occlusally
concentration on the tooth.
l Depth of the cavity preparation should be such
l Width of the cavity is l Width of the cavity is
one-fourth the intercuspal one-third the intercuspal
that it allows adequate bulk of amalgam resto- distance distance
ration.
l To establish a butt joint l Occlusal cavosurface
vi. Primary retention form
with amalgam, occlusal angle is 135°–145° to
Primary retention form can be achieved by: cavosurface angle is 90° achieve a lap, sliding fit
l Occlusal convergence of the facial and lingual with the inlay
walls both in the occlusal step and in the
l Gingival bevel ranges l No undercuts should be
proximal box areas. from 15° to 20° present in the preparation
l Dovetail design of the occlusal step.
l Undercuts improves the l More clearance should be
Final cavity preparation stage retention in the restoration given proximally
vii. Removal of any remaining defective enamel and
infected carious dentine l Minimal clearance is l If indicated subgingival
given proximally, not extension of gingival seat
l Any infected carious dentine on the pulpal floor or
more than 0.5 mm from is given
axial wall is removed by using a round bur at slow the adjacent tooth
speed or by making a ‘stepped’ preparation pulp-
l Gingival seat should be l Secondary retention is
ally or axially without deepening the entire wall. located supra gingivally given by grooves, slots,
l If any old intact base or liner without any recur- internal boxes, skirts,
rent caries it may be left behind. collars and reverse bevel
l If caries is extensive on the gingival floor, it has to
l Secondary retention is l Proximal margin may
be removed by extending the entire gingival wall provided by grooves, slots, show primary and a
or a ‘stepped’ gingival floor can be created by pins and amalgam secondary flare
means of a spoon excavator. l Proximal walls are pro- l Internal angles are well
viii. Pulp protection vided with a primary flare defined
The pulpal and axial walls are needed to be pro- l Internal line angles are l Bevels are placed at the
tected with a cement base. rounded occlusal and gingival
ix. Secondary resistance and retention forms cavosurface margins to
The conditions where additional resistance is neces- provide frictional retention
sary, it may be achieved by: l Reverse curve may be l Reverse curve is not given
l Extensions of the external walls should be present in the proximal in proximal outline
restricted. outline
l Rounding the axiopulpal line angle by using the
gingival margin trimmer which increases the bulk

of the restorative material and reduces the stress
concentration within the restorative material.
l Retention locks are given to enhance the reten-
Q.3. Describe the cavity preparation for class III com-
tion form of the proximal portion of the cavity posites.
and this can be done using no. 169 L bur at the Ans.
axiofacial and axiolingual line angles.
l They should be placed in the facial and lingual
Class III cavity preparation for composite resins
l Class III caries is smooth surface caries found on the
proximal walls (0.2 mm inside the Dentino
Enamel Junction (DEJ)), not at the expense of proximal surfaces of anterior teeth, usually slightly gin-
the axial wall. gival to the proximal contact.
l It does not involve the incisal angle of the tooth.
Q.2. Compare and contrast cavity for class II amalgam l The approach for the preparation may be from the
and gold restorations. facial or the lingual direction, but lingual approach is
Ans. preferred more because:
l For enhancement of aesthetics, facial enamel is
Silver amalgam Class II cast gold inlay conserved.
As there is no surface in-
l l As there is surface in- l Unsupported facial enamel may be preserved for
volvement, outline form is volvement, outline form is bonding with composite resin.
narrow wide
l On final restoration, discolouration is less visible.
Facial approach is indicated when: l This is prepared using a flame-shaped diamond point,
l Caries is located more facially. producing a cavosurface angle of 45°.
l Irregular alignment of teeth. l The bevel may be 0.25–0.5 mm in width. It is avoided
l Caries is extensive or a faulty old restoration placed on gingival margins and centric contact areas.
from a facial approach needs replacement.
Modified class III cavity preparation
Conventional class III cavity preparation Indication: For small to moderate carious lesions, it is
l Conventional class III is indicated for root surface le- based on the extent of the caries.
sions. l It is made as conservatively as possible and preferably
l The gingival portion of a large class III cavity prepara- from the lingual approach.
tion may be prepared using the conventional design, as l Using a no. 1 or 2 round diamond point approach, the
it is unusual to have entire lesion on the root surface. lesion from the lingual aspect perpendicular to the tooth
surface.
Root surface lesions
l Access is opened only to the extent of caries.
l The cavity preparation is done using a no. 1 or 2 round
l The preparation walls diverge externally from the axial
bur. The outline form is prepared on the root surface
depth in a concave manner creating a bevelled or flared
extending the external walls perpendicular to the root
margin as well as conservation of internal tooth structure.
surface.
l The depth is usually limited to 0.2 mm into dentine.
l The initial axial depth is maintained at 0.75 mm.
l Bevels may be placed on the enamel margin when re-
l Access is improved by opening the preparation slightly
quired using a flame-shaped diamond.
to the facial or lingual aspect depending upon the ap-
proach. Q.4. Compare the features of a class II preparation for
l Any remaining caries on the axial wall can be elimi- a silver amalgam restoration and a gold inlay restora-
nated with a spoon excavator or a steel round bur and tion.
the pulp should be protected with a calcium hydroxide
Ans.
liner or a glass ionomer base depending upon the depth.
l For better retention of the composite resin on the root [Ref LE Q.2]
surface, grooves may be placed in the axiogingival and
Q.5. Write differences in class II cavity for silver amal-
axioincisal line angles with a no. 114 round bur to a
gam and gold inlay.
depth of 0.5 mm.
l Thus, the design is like a typical box pattern with defi- Ans.
nite external walls and a 90° cavosurface angle.
[Ref LE Q.2]
Large class III lesions
l In the case of an extensive class III lesion extending
onto the root surfaces, the coronal portion is prepared

SHORT ESSAYS:
using a bevelled conventional design. Q.1. Discuss the causes and management of hyper-
l The root surface portion is prepared in the conventional sensitivity.
manner using a butt joint margin and retention groove in
Ans.
dentine.
Causes of dentinal hypersensitivity
Bevelled conventional class III cavity preparation
A. Enamel loss
l This design is indicated for replacing an existing old
l Occlusal wear
nonadhesive restoration such as silicate or acrylic resin
l Tooth brush abrasion
with composite resin.
l Dietary erosion
l It can also be done for a large carious class III lesion,
l Abfraction
which requires increased resistance and retention.
l Parafunctional habits
l The preparation is preferably done from the lingual
B. Cemental loss
approach.
l Gingival recession
l Begin the preparation using no. 1 or 2 round diamond
l Periodontal diseases
point, close to the adjacent tooth at the incisogingival
l Root planning
level of caries.
l Periodontal surgery
l The bur is held perpendicular to the enamel surface.
l Extend the preparation similar to the conventional de- Management of dentinal hypersensitivity
sign, but here instead of a butt joint cavosurface margin, 1. Desensitization by occluding dentinal tubules
a bevel is incorporated. l Formation of a smear layer over exposed dentine
2. Use of topical agents to occlude the exposed tubules Occlusal two-thirds of the facial and lingual sur-
l
l Calcium hydroxide paste faces of molars.

l Calcium phosphate paste l Lingual pits of maxillary incisors.
l Silver nitrate Class II cavity preparation

l Strontium chloride l This involves one or both the proximal surfaces of
l Fluorides posterior teeth.

l Fluoride iontophoresis Class III cavity preparation
l Potassium oxalate l This includes cavity preparation on the proximal
l Varnishes surfaces of anterior teeth without involving the inci-

l Dentine adhesives sal angle.
3. Placement of restorations Class IV cavity preparation
l Glass ionomer cements l This includes cavity preparation on the proximal
l Composite resins surfaces of anterior teeth with involvement of the

4. Use of lasers incisal angle.
l CO2 laser Class V cavity preparation
l Nd:YAG, Er:YAG lasers l This involves cavity preparation on the gingival one-
l He:Ne laser third of the facial and lingual surfaces of all teeth.
5. Desensitization by blocking pulpal sensory nerves Class VI cavity preparation
l Potassium nitrate toothpastes l This involves cavity preparation on the incisal edges
of anterior teeth or the occlusal cusp heights of pos-

Q.2. What do you mean by ‘Extension for Prevention’?
terior teeth.
How is this principle applied during the cavity prepara-
tion of various classes? Q.4. Define air abrasion.
Ans.
Ans.
l G.V. Black explained the concept of extension for pre-
l Air abrasion unit works by spraying a powerful stream
vention.
of a focused narrow beam of aluminium oxide particles
l He explained that in tooth preparations for smooth-sur-
20.5 micron in size at a pressure of 40–140 psi through
face caries, the restoration should be extended to areas
a fine-angled nozzle.
that are normally self-cleansing to prevent recurrence of
l When these particles are directed against the tooth sur-
caries and this principle is known as extension for pre-
face, they abrade it and prepare conservative cavities.
vention.
l It cuts enamel, dentine and cementum very effectively.
l The extension is necessary to remove the remaining
l The cavities prepared are minimal and saucer shaped
enamel defects, such as pits and fissures.
and is well suited for composite restoration.
l The concept of extension for prevention on smooth sur-
l Example, KCP 2000 Whisper jet (kinetic cavity prepa-
faces has been eliminated, because of the relative caries
ration).
immunity provided by preventive measures, such as
Advantages
fluoride, improved oral hygiene and proper diet.
l Local anaesthesia not required.
l Extension for prevention to include the full length of
l Does not generate heat, vibration or noise.
enamel fissures has been reduced by treatments that
l Conserves the tooth structure.
conserve tooth structure; restored teeth are stronger and
l Well tolerated by patient.
more resistant to fracture which are enameloplasty, ap-
Disadvantages
plication of pit and fissure sealant and preventive resin
l Does not remove soft caries.
or conservative composite restoration.
l Cannot prepare precise cavities needed for large
Q.3. Describe the classification of cavities. restoration.

l Al2O3 dust generated during the procedure can
Ans.
affect patients with chronic respiratory problems
Based on the frequency of occurrence of caries on different like asthma.
areas of teeth, G.V. Black classified the cavities as: l Can damage the adjacent tooth while performing
Class I cavity preparation class II preparation.

It includes cavity preparations involving pit and fissure l It is expensive.
areas of teeth. The areas involved are Indications

l Occlusal pit and fissures in posterior teeth (molars l Minimal class I and class II cavity preparation for
and premolars) composite.

l For abrading the surface of old composite restora- l It is long bevel.

tion prior to repairing them with new composite. l The external enamel wall of the proximal por-
l For abrading ceramic or cast restoration for tion is at 45° to the inner dentinal wall.
bonding. l Indicated in case of normal contact when there
l For widening pits and fissures for pit and fissure is minimum extension of caries in buccolin-
sealant. gual direction.
(b) Secondary flare
Q.5. Describe the circumferential tie.
l It is a flat plane superimposed peripheral to the
Ans. primary flare and is usually prepared in enamel.

l To overcome the microleakage at the junction of inlay– Q.6. Discuss reverse class II amalgam restoration.
cement–tooth interface which is the weakest portion an
Ans.
inlay preparation, the margins of the cavity preparation
are specially designed. l In teeth with broad contacts, if a minimal flare is given
l ‘Circumferential tie’ refers to the design of the cavosur- in the proximal aspect, it would result in location of the
face margins of an inlay cavity preparation. proximal walls within the contact area.
l On the other hand, if excessive flare is given, the proxi-
It is of two types:
mal walls will clear the contact area but will terminate
A. Bevel
past the axial angle of the tooth through the cusps.
l Bevel refers to a cavity wall or floor which is di-
l This would result in unnecessary loss of tooth structure
rected away from the cavity preparation and is placed
and fracture of amalgam at the proximal corners.
on the occlusal and gingival cavosurface margins of
l This is an S-shaped curve given to the proximal walls
the cavity preparation.
(usually the facial wall) by curving them inward to-
According to their shape and extent of tissue involve-
wards the contact area.
ment bevels are of six types:
l This helps in minimal clearance of the contact area
l Partial bevel – It involves only a part of the
while establishing a 90° cavosurface angle. Thus, it
enamel wall and is not more than two-thirds the
helps in enhancing resistance form of the tooth and the
thickness of the enamel and is rarely used to trim
amalgam.
weak enamel rods at the margins.
l Short bevel – This involves the entire enamel wall Q.7. Discuss outline form.
but not dentine and is most commonly used for
Ans.
cast gold inlay cavities.
l Long bevel – This involves all enamel and half of The guidelines to be followed while preparing the outline
the dentinal wall. This may also be used for inlay form are
cavities and the ‘boxed-up’ resistance and reten- l Include only the carious tooth structure.
tion features of the preparation can be preserved. l Place the margins on sound tooth structure.
l Full bevel – This includes the entire enamel and l Remove any enamel undermined by caries.
dentinal wall of the preparation. It is used only as l Make a punch cut starting at the most carious part, with
a last resort as it deprives the preparation of all its a high-speed handpiece oriented parallel to the long axis
resistance and retention form. of the tooth using bur no. 24S.
l Counter bevel – This bevel is used when the cusps l Extend the preparation to include the other defective pit
require capping for protecting them. and fissure.

l Hollow-ground bevel – This is a concave bevel. l Care should be taken so that the cusp outline form ex-
Any of the above bevels may be prepared in this hibits smooth flowing curve.
manner. This bevel is used for base metal alloys l Mesially and distally the preparation should not extend
and castable ceramics as these materials have into the marginal ridges.
poor castability, this design provides bulk for l The mesial and distal walls should exhibit a slight dove-
these materials. tail form which provides retention.

B. Flare l The bur should be slightly tilted towards the respective
l Flare is the flat or concave peripheral portions of the marginal ridges, so that the mesial and distal walls have
facial or lingual proximal walls. a slight occlusal divergence, which will help to preserve
Flares can be: the dentinal support for the marginal ridges.
(a) Primary flare l The initial depth of the cavity preparation is maintained
l It is similar to primary flare given in an amal- at l.5 mm from the central fissure or 0.1–0.2 mm into
gam cavity preparation. dentine.
Q.8. Discuss retention form. Mechanism of etching

l Acid etching converts smooth enamel into a very
Ans.
irregular surface with high depths.
Retention form in class I amalgam restoration
Primary retention form Microscopically, three types of etch patterns have been
Primary retention form is provided by the following described. They are
features of the preparation:
(i). Occlusal convergence of the facial and lingual walls Type I Dissolution of the prism cores
(ii). Occlusal dovetail feature leaving the prism peripheries
intact
Retention form in class II amalgam restoration
Type II Dissolution of the prism
i. Primary retention form peripheries leaving the prism
Primary retention form can be achieved by: cores intact
l Occlusal convergence of the facial and lingual
Type III No prism structures are evident
walls both in the occlusal step and in the proximal
box areas
l Dovetail design of the occlusal step.
ii. Secondary resistance and retention forms

Rinsing
The conditions where additional resistance is neces-
l After etching, the enamel surface should be thor-
sary, it may be achieved by:
oughly rinsed with a continuous stream of water
l Extensions of the external walls should be re-
spray for 5–10 s, so that the acid is completely
stricted.
washed off.
l Rounding the axiopulpal line angle by using the
Drying
gingival margin trimmer which increases the bulk
l This should be followed by proper drying which will
of the restorative material and reduces the stress
produce a frosty, white appearance. Contamination
concentration within the restorative material.
of the etched and dried enamel surface by saliva,
l Retention locks are given to enhance the retention
moisture or blood can prevent proper bonding.
form of the proximal portion of the cavity and this
Mechanism of enamel bonding
can be done using no. 169 L bur at the axiofacial
l Bonding to enamel is micromechanical in nature
and axiolingual line angles.
brought about by the formation of ‘resin tags’ within
l They should be placed in the facial and lingual
the etched enamel.
proximal walls (0.2 mm inside the DEJ) not at the
Bond strength
expense of the axial wall.
l The bond strength of composite resins to etched
Q.9. Discuss acid etching. enamel is 15–25 MPa. This is adequate to resist
shrinkage stresses produced during the polymeriza-
Ans.
tion of composite resins.
In 1955, Buonocore introduced the concept of acid
Q.10. Describe pit and fissure sealants.
etching.
Acid used and its concentration Ans.
l Presently, a 37% concentration of phosphoric acid is
l Pits and fissures occur on the occlusal surfaces of pos-
used to etch enamel.
terior teeth due to incomplete coalescence of enamel
Form of the acid
and these are the susceptible sites for stagnation of food
l The acid is available as a liquid or a gel etchant. Gel
debris, which is easily prone to caries.
etchants are preferred due to their colloidal property.
l Pit and fissure sealants are used to seal these susceptible
They are available in various dark colours like blue
areas for many decades.
for easy identification.
l They consist of self-cured or light-cured composite res-
Acid placement
ins with tints added in order to provide a colour con-
l The acid may be applied by means of a syringe or
trast.
brush. Syringe placement is easy and precise.
Etching time Indications for pit and fissure sealants
l Fifteen seconds etching on the enamel produces i. In high-risk adolescents, teenagers and adults, for pre-
the surface roughness. Etching time may be in- vention of caries.
creased in the case of primary teeth and in teeth ii. Incipient caries in enamel not extending to the denti-
with fluorosis. noenamel junction.
Clinical technique SHORT NOTES:

l Isolation with rubber dam should be done. Cotton rolls
can also be used along with saliva ejector. Q.1. Discuss enameloplasty.
l Slight mechanical preparation of the fissures is done. This Ans.
can be done with a round bur, fissurotomy bur or a 169-L- l Enameloplasty is removal of a shallow, enamel develop-
tapered fissure bur. Preparation of the pit and fissure helps mental fissure or pit to create a smooth, saucer-shaped
to allow better penetration and bonding of the sealant. surface that is self-cleansing or easily cleaned.
Minimal preparation also helps to eliminate the caries. l This prophylactic procedure can be applied to fissures
l Clean the prepared tooth with a slurry of pumice on a and pits and deep supplemental grooves and to some
bristle brush. The bristle brush helps to reach all faulty shallow, smooth-surface enamel defects.
areas. l Pit and fissure sealant application does not require
l The tooth is rinsed thoroughly with water spray to re- any tooth preparation and is a preferred preventive
move all debris. method.
l Then, the tooth is dried and acid etchant is applied on l For more advanced lesions, the preventive resin or con-
the occlusal surface for 30 s with a brush or applicator servative composite restoration may be used, whereby a
tip. small rotary cutting instrument or air abrasion is used to
l Liquid etchants are preferred for this procedure as they prepare fissures and pits, which are restored subse-
penetrate the enamel well. Next, wash the tooth for 20 s quently with composite and sealant.
followed by thorough drying of the etched area.
Q.2. Describe reverse curve.
l A chalky white or frosty appearance indicates proper
etching. Ans.
l A light-cured sealant can be placed into the prepared
l In teeth with broad contacts, if a minimal flare is given
pits and fissures. Using a probe, the sealant can be
in the proximal aspect, it would result in location of the
teased to properly fill the fissure areas.
proximal walls within the contact area.
l This is then polymerized for 20 s using a curing light.
l On the other hand, if excessive flare is given, the proxi-
Presently, flowable composite resins are also used as pit
mal walls will clear the contact area but will terminate
and fissure sealants.
past the axial angle of the tooth through the cusps.
l Finally, the rubber dam is removed and the occlusion is
l This would result in unnecessary loss of tooth structure
checked with an articulating paper.
and fracture of amalgam at the proximal corners.
l Using a white stone, excess is removed and the restora-
l This is an S-shaped curve given to the proximal walls
tion is polished.
(usually the facial wall) by curving them inward to-
Q.11. Discuss G.V. Black’s classification of cavity. wards the contact area.
l This helps in minimal clearance of the contact area
Ans.
while establishing a 90° cavosurface angle. Thus, it
[Ref SE Q.3] helps in enhancing resistance form of the tooth and the
Q.12. Discuss air abrasion in operative dentistry. amalgam restoration.
Ans. Q.3. Define attrition, abrasion and erosion.
[Ref SE Q.4] Ans.
Q.13. Discuss obtaining retention form of class I and II i. Attrition

amalgam. l Attrition is the mechanical wear of incisal or occlu-
sal surfaces of teeth due to frictional contact be-

Ans. tween opposing teeth, which also includes wear of
[Ref SE Q.8] the proximal surfaces at the contact area due to
physiologic tooth movement.
Q.14. Define acid etch technique. ii. Abrasion
Ans. l Abrasion is the abnormal loss of tooth surface be-
cause of direct frictional forces between the teeth

[Ref SE Q.9]
and external objects, or from frictional forces be-
Q.15. Discuss fissure sealants. tween contacting teeth in the presence of an abrasive
medium.
Ans.
l Example, tooth brush abrasion, abrasion due to to-
[Ref SE Q.10] bacco chewing.
iii. Erosion l Isthmus should neither be broad nor narrow.

l Erosion refers to the wear or loss of tooth surface by l If it is very broad, the restoration is strong but the
chemicomechanical action. tooth becomes weak and if the isthmus is narrow,
l This may be due to frequent consumption of citrus the tooth will be strong, but the restoration will be-
fruit juices or as a result of gastric regurgitation. come weak.
iv. Abfraction
Q.7. Define smear layer.
l This refers to microfractures seen in the cervical
areas of teeth due to abnormal tooth flexure. Ans.

l Smear layer is defined as any debris, calcific in nature,
Q.4. Describe the management of deep and shallow cavity.
produced by reduction or instrumentation of enamel,
Ans. dentine or cementum.
l The morphology, composition and thickness of the
l In case of deep cavity, not extending to the pulp but
smear layer depend upon the method of tooth prepara-
reaching up to dentine, complete excavation of caries
tion.
should be done first.
l It is thickest when the tooth is cut by means of a coarse
l Soft caries should be removed completely.
diamond point without a coolant.
l Infected dentine should be removed completely.
l This smear layer is easily washed away from the enamel
l Affected dentine can be spared as it can help regenerat-
but remains adherent to the dentine surface.
ing the secondary dentine.
l After complete removal of the caries, calcium hydrox- It has two components:
ide should be placed, as it helps in the formation of l Superficial smear layer – This is loosely attached to the
secondary dentine. underlying dentine up to a depth 1–1.5 mm.
l On top of calcium hydroxide, base should be applied. l Smear plugs– These occlude the dentinal tubules. The
l Then, the cavity should be filled with the desired restor- smear plugs may extend up to a depth of 10 microns to
ative material. 1 mm.
l In case of shallow cavities, if it is soft caries, complete
Currently, three strategies are used to treat the smear
removal should be done.
layer prior to bonding:
l After proper cavity preparation, base should be applied,
i. Modifying the smear layer prior to bonding
followed by desired restoration.
ii. Removal of the smear layer prior to bonding (total etch
Q.5. Define bevels. or etch and rinse approach)
iii. Dissolving the smear layer and incorporating it into the
Ans.
bonding layer (self-etch approach)
Bevel Q.8. Define cavosurface angle.
l Bevel refers to a cavity wall or floor, which is di-
Ans.
rected away from the cavity preparation.
l Bevels are placed on the occlusal and gingival cavo- l Cavosurface angle refers to the angle of the tooth struc-
surface margins of the cavity preparation. ture formed by the junction of a prepared wall and the
Reverse bevel external tooth surface.
l Reverse bevel is placed on the gingival seat. l It varies according to the location of the cavity prepara-
l When it has adequate dimension and there is a need tion on the tooth, the type of the restorative material to
for added retention. be used and the direction of the enamel rods on the pre-
l It is a bevel given on the gingival seat directed to- pared wall.
wards the axial wall. l The actual junction of the prepared wall and the external
l It helps to lock the proximal portion of the restora- tooth surface is called the cavosurface margin.
tion and prevents proximal displacement.
Q.9. Define tunnel preparation.
Q.6. Define isthmus.
Ans.
Ans.
l Tunnel preparation is an alternative for class II cavity
l Isthmus is the junction of the two boxes. preparation in primary and permanent teeth.
l It is the neck portion of the cavity joining two portions of Indication
the cavity, clinically many restorations fail in isthmus area. l Patients with low caries rate and high aesthetic
l In isthmus area, potential tensile forces develop under demand who has small proximal caries without
any type of occlusion. involvement of the marginal ridge.
Contraindications Cavity design for class II inlay

l Difficult to access i. Occlusal step
l Large proximal caries involving marginal ridge ii. Proximal box preparation
l Marginal ridges subjected to excess occlusal loads iii. Removing remaining carious dentine and pulp pro-
Advantages tection
l Marginal ridge is preserved. iv. Placement of retention grooves
l Adjacent tooth is protected. v. Preparation of bevels and flares
l If needed, conventional approach can be adopted.
Q.13. Discuss the preparation of teeth.
Disadvantages
l Marginal ridge may be undermined. Ans.
l Poor visibility.
l Tooth preparation is defined as the mechanical alteration
l Lack of control over caries removal.
of a defective, injured or diseased tooth in order to re-
l Preparation may extend closer to pulp.
ceive best restorative material which will re-establish a
Q.10. Discuss proximal box preparation in class II healthy state for the tooth including aesthetic correction,
cavity. hence indicated along with normal form and function.
Objective
Ans.
l Remove all the defects and preserve the vitality of
l The proximal box preparation begins with the ‘proximal the pulp.
ditch cut’, to isolates the proximal enamel and prevents l Locate margins conservatively.
damage to the proximal surface of the adjacent tooth. l The cavity preparation should be designed in such a
l The no. 245 bur is used on the pulpal floor adjacent way that masticatory forces would neither fracture
to the remaining mesial marginal ridge and proceed- tooth nor restoration.
ing gingivally, moving in a buccolingual direction l Allow aesthetic and functional placement of the re-
depending on the buccolingual extent of the contact storative material.

area.
Q.14. Discuss trephination.
l The proximal ditch cut provides retention form to the
proximal box, conservation of the marginal ridge as Ans.

well as inclusion of caries at the gingival level.
[Ref SN Q.1]
Q.11. Define prophylactic odontotomy.
Q.15. Define abfraction.
Ans.
Ans.
l The procedure of the prophylactic odontotomy involves
[Ref SN Q.3]
minimal preparation and filling with amalgam.
l The developmental, structural imperfections of the Q.16. Define reverse bevels.
enamel, such as pits and fissures, to prevent caries
Ans.
originating in these sites.
l Prophylactic odontotomy is no longer used. [Ref SN Q.5]
Q.12. Discuss cavity design for class II inlay. Q.17. Define trephination.
Ans. Ans.
General feature of inlay cavity design [Ref SN Q.9]
l Preparation path
Q.18. Describe general features of an inlay cavity.
l Inlay taper
l Circumferential tie Ans.

l Additional retention and resistance forms
[Ref SN Q.12]
Topic 6
Basic Concepts in Aesthetic Dentistry and Adhesion
to Tooth Structure
LONG ESSAYS:
1. Enumerate various tooth-coloured restorative materials used in conservative dentistry and describe about resin
cements.
2. Classify dental cements. Give the composition, manipulation and uses of polycarboxylate cement.
3. Give composition, manipulation, indications and advantages of silicate cement.
SHORT ESSAYS:
.
1 Define cavity liners.
2. Define bases.
3. Define luting cements.
4. Describe zinc phosphate cement.
5. Discuss zinc polycarboxylate cement. [Ref LE Q.2]
6. Describe zinc oxide eugenol cement.
SHORT NOTES:
. Define adhesive cement.
1
2. Discuss types and definition of adhesion.
3. Define biocompatible materials.
4. Define hue.
5. Classify and describe uses of zinc phosphate cement. [Ref SE Q.4]
6. Define cavity sealer, liner and base.
7. Define IMR.
8. Define cavity varnish.
9. Define intermediate restorative materials.
10. Discuss modified zinc oxide eugenol cement.
11. Define dentine adhesives. [Ref SN Q.2]
12. Define cavity liners. [Ref SN Q.6]
13. Define temporary restorative materials. [Ref SN Q.7]
14. Define interim restoration. [Ref SN Q.9]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Enumerate various tooth-coloured restorative ma- 2 . Composite
terials used in conservative dentistry and describe about 3. Glass ionomer cements
resin cements. 4. Ceramics
Ans.
Resin cements
Various tooth-coloured restorative materials are l Synthetic resin cements based on methyl methacry-
1. Resin cements late are in use since 1952.
l Resin cements have got popularity since 1986, be- Light cure
cause of their use in the cementation of porcelain l Single component system
veneers and ceramic crowns. l As light-cured filling resins
Applications l Time of exposure to the resin should never be less
l Cementation of crown and bridges than 40 s

l Cementation of porcelain veneers
Q.2. Classify dental cements. Give the composition, ma-
l For direct bonding of orthodontic brackets to acid-
nipulation and uses of polycarboxylate cement.
etch enamel.
Classification Ans.
l Filled resins
Various classifications of dental cements are as follows:
l Unfilled resins
Composition According to Craig

Powder
l Resin matrix (diacrylate monomer)
l Inorganic fillers
Functions Cements
l Coupling agents (organosilanes)
Liquid Final cementation of com- Zinc phosphate, zinc silicophos-

pleted restorations phate, reinforced zinc oxide
l Methyl methacrylate
eugenol, zinc polycarboxylate,
l Tertiary amine
glass ionomer
Setting reaction
Temporary cementation of Zinc oxide eugenol, noneugenol
l Setting is caused by a peroxide-initiator and amine-
completed restorations or zinc oxide
accelerator system cementation of temporary
l Setting time: 4–10 min restorations
Mode of polymerization High-strength bases Zinc phosphate, reinforced zinc
l Chemical (conventional peroxide–amine induction oxide eugenol, zinc polycarbox-
system) ylate, glass ionomer
l Light activation
Temporary fillings Zinc oxide eugenol, reinforced
Properties zinc oxide eugenol, zinc
l Compressive strength: 180 MPa. polycarboxylate
l Tensile strength: 30 MPa (4000 Psi).
Low-strength bases Zinc oxide eugenol, calcium
l Film thickness: 10–25 microns. hydroxide
l Bond strength to enamel: 7.4 MPa (1070 Psi).
Liners Calcium hydroxide in a suspen-
l Enamel bonding can be attained by acid-etch technique. sion
l Dentine bonding can be attained by dentine-
Varnishes Resin in a solvent
bonding agents like organophosphates, HEMA
(2-Hydroxyethyl Methacrylate) and 4-META Root canal sealer Zinc oxide eugenol, zinc
polycarboxylate
(4-Methacryloxy ethyl trimellitate anhydride).
l Biological properties: Irritating to pulp. Gingival tissue pack Zinc oxide eugenol
l Pulp protection via calcium hydroxide is necessary.
Surgical dressing Zinc oxide eugenol, zinc oxide
l Solubility: Insoluble in oral fluids. preparation
l Polymerization shrinkage: high.
Cementation of orthodontic Zinc phosphate, zinc polycar-
l Adhesion properties: They do not adhere to tooth bands boxylate
structure, which may lead to microleakage.
Orthodontic bonding Acrylic resin, composite resin
Manipulation
Powder/liquid system or two-paste system
l Two components are combined by mixing on a
paper pad. [SE Q.4]

l Mixing time is 20–30 s.
l Removal of the excess cement is difficult, if it is

{Polycarboxylate cement was the first cement system de-
veloped with a potential for adhesion to tooth structure.
delayed until the cement has polymerized.
l Enamel acid-etch technique for retention of direct Mode of supply
filling resin restorations has led to the use of res- The polycarboxylate cement is available as powder and
ins for bonding orthodontic brackets, directly to liquid in bottles. Some manufacturers supply this cement as
the tooth surface. precapsulated powder/liquid system.}
Phillips classification Setting time: 7–9 min

The setting time can be increased by cooling the
Cement Principal uses Secondary uses
glass slab. It also depends on the method of
Zinc phosphate Luting agent for resto- Intermediate resto- manufacture of powder and liquid.
rations and orthodon- rations, thermal in-
Properties
tic bands sulating bases, root
canal restorations i. Mechanical properties
(a) Compressive strength: Polycarboxylate cement
Zinc phosphate Intermediate restora-
is inferior to zinc phosphate cement.
with silver or tions
copper salts 55 MPa – 8000 Psi.
(b) Tensile strength: Its tensile strength is slightly
Copper phos- Temporary and inter-
phate (red or mediate restorations
higher than that of zinc phosphate cement.
black) 6.2 MPa – 900 Psi.
ii. Powder/liquid ratio: Increase in P/L ratio increases
Zinc oxide eu- Temporary and inter- Root canal restora-
genol restora- mediate restorations, tions, periodontic
strength.
tions luting agent, thermal bandage iii. Molecular weight of polyacrylic acid also affects the
insulating base strength.
Pulp capping agent iv. A mix from a low viscosity liquid is weaker than a
Polycarboxylate Luting agent, thermal Luting agent for high viscosity.
insulating base orthodontic bands, i. Solubility and disintegration
intermediate resto- It tends to absorb water and is slightly more soluble
rations
than zinc phosphate 0.06%.
Silicate Anterior fillings The marginal dissolution of cement is more when
Silicophosphate Luting agent for resto- Intermediate resto- used as cementing medium.
rations rations, luting A reduction in the P/L ratio results in a signifi-
agent for orthodon- cantly higher solubility and disintegration in the
tic appliances oral cavity.
Glass ionomer Coating for eroded ar- Pit and fissure seal- ii. Biocompatibility
eas, luting agent for ant, anterior resto- The polycarboxylate cement, in terms of pulpal re-
restorations rations, thermal sponse, is classified as mild.
insulating bases
The pH of the liquid is 1.0–1.7 and that of freshly
Resin Luting agent Temporary restora- mixed cement is 3.0–4.0. After 24 h, pH of the
tions
cement is 5.0–6.0.
Calcium Pulp capping agent, They are less irritant to the pulp than zinc phosphate
hydroxide thermal base cement, because:
a. The liquid is rapidly neutralized by the pow-
der. The pH of polycarboxylate cement rises
[SE 7.4]
more rapidly than that of zinc phosphate.
{Composition b. Penetration of polyacrylic acid into the den-
Powder tinal tubules is less because of its higher mo-
lecular weight and larger phosphate molecules.
Zinc oxide Basic ingredient The histological reactions are similar to zinc oxide
Magnesium oxide Principle modifier and also eugenol cements, but more reparative dentine is
aids in sintering observed with polycarboxylate.
Other oxides like bismuth and Small amounts iii. Adhesion
aluminium An outstanding characteristic of zinc polycarboxyl-
Stannous fluoride Increases strength, modifies ate cement is that the cement bonds chemically with
setting time and imparts anti- the tooth structure due to the ability of the carboxyl
cariogenic proprieties group in the polymer molecules to chelate with cal-
cium in the tooth structure.
The bond strength to enamel ranges from 3.4 to 13.1
Liquid MPa and that of dentine is 2.07 MPa.
l Aqueous solution of polyacrylic acid, or copolymer The adhesion of a polycarboxylate to clean dry sur-
of acrylic acid with other unsaturated carboxylic face of enamel is much greater than that of other
acids, i.e. iticonic, maleic or tricarboxylic acid. cements under ideal conditions of manipulation.
iv. Optical properties Manipulation

They are very opaque due to large quantities of un- i. Dry field is required during manipulation.
reacted zinc oxide. ii. Exposure of the cement to oral fluids prior to forma-
v. Thermal properties tion of final reaction products results in increased
Polycarboxylate cements are good thermal insulators. solubility and a poor surface.
Uses iii. The liquid is dispensed just prior to the mixing, in
i. It is primarily used for cementation of restoration order to preserve the acid–water balance.
and thermal insulating base. iv. Mixing is done with an agate, plastic or cobalt–
ii. It is also used as an intermediate restoration. chromium spatula. The steel spatulas are contraindi-
iii. Primarily for luting permanent restorations. cated, as they are liable to be abraded by the silicate
iv. As bases and liners. powder leading to discolouration of the mix.
v. Used in orthodontics for cementation of bands. Procedure
vi. Also used as root canal fillings in endodontics.} i. Powder/liquid ratio: Approximately around 1.6 g of
powder/4 mL of liquid.
Q.3. Give composition, manipulation, indications and
ii. The powder is dispensed on a thick, cool, dry glass
advantages of silicate cement.
slab and divided into two or three large increments.
Ans. The increments are then rapidly folded into the liquid
over a small area, in order to preserve the gel structure.
Silicate cements are available as powder and liquid. The
iii. Particles of the powder should be properly wetted.
powder is a finely ground ceramic that is essentially an
Mix for 1 min.
acid-soluble glass. The composition of silicate cement is as
iv. The mixed material should have consistency like
follows:
putty. The surface of the mix should have a shiny
Powder appearance.
v. If the mix is too thick it produces crumbly mass.
Approximate vi. Too much of liquid increases the setting time, re-
Components wt% Functions duces pH and strength, increases solubility and
Silica (SiO2) 40% Provides strength makes it more prone to staining.
and translucency vii. The mixed material should be inserted into the cav-
ity in one portion. If small increments are used,
Alumina (Al2O3) 30% Provides Al, Ca,
K ions by reacting complete bonding between the portions will not oc-
with phosphoric cur and the set material will be weaker.
acid viii. A cellulose acetate strip is held against the setting
Sodium fluoride (NaF) material in the cavity. The strip is removed after the
material sets. Gross excess cement is then removed
Cryolite (Na3 AlF6) 23% Acts as a flux,
melting point or
from the margins at that time. The restoration is the
fritting temperature painted with a water insoluble varnish to protect it
from contact with oral fluids.
Calcium fluoride (CaF2)
ix. Finishing and polishing:
Calcium phosphate Acts as modifiers l The final finishing should be delayed for several
Ca(H2PO4)•2H2O (opacifiers)
days. Early finish could disturb or fracture the
Or margin before maximum properties are attained.
Lime (CaO) 7% l Silicate cements are subject to dehydration
throughout their lifetime. Therefore, during sub-

Liquid sequent operative procedures, they should be pro-
tected from exposure to air by a coat of vanish or
Approximate silicone grease.
Components wt% Functions
Phosphoric acid 52% Reactor SHORT ESSAYS:
Aluminium phosphate 2% Buffers
Q.1. Define cavity liners.
Zinc phosphate 6% Control setting
or magnesium phosphate time Ans.
Water 40% Controls pH A cavity liner is used like a cavity varnish to provide
barrier against the passage of irritants from cements or
other restorative materials and to reduce the sensitivity of Q.2. Define bases.
freshly cut dentine.
Ans.
l For example, suspensions of calcium hydroxide in a
volatile solvent Cement base

l Type III glass ionomer A base is a layer of cement placed beneath a permanent
l Type IV Zinc Oxide Eugenol (ZOE) restoration to encourage recovery of the injured pulp
Composition and properties and to protect it against numerous types of insults to
l Suspension of calcium hydroxide in an organic liq- which it may be subjected.
uid such as methyl ethyl ketone or ethyl alcohol. Types of bases
Acrylic polymer beads of barium sulphate and cal- Bases are of two categories:
cium monofluorophosphate. i. High-strength bases
l Upon the evaporation of the volatile solvent, the liner ii. Low-strength bases
forms a thin film on the prepared tooth surface.
High-strength bases
l The calcium hydroxide liners are soluble and should
These are used to provide thermal protection for the
not be applied at the margins of restorations.
pulp, as well as mechanical support for the restoration.
l Fluoride compounds have been added to some cavity
Examples: zinc phosphate, zinc polycarboxylate, glass
liners in an attempt to reduce the possibility of sec-
ionomer and reinforced ZOE cements.
ondary carries around permanent restorations or to
Low-strength bases
reduce sensitivity.
Low-strength bases have minimum strength and low
l Cavity liners either possess mechanical strength or
rigidity. Their main functions are to act as a barrier to
provide any significant thermal insulation.
irritating chemicals and to provide therapeutic benefit to
Manipulation cavity liners are fluid in consistency
the pulp.
and can be easily flowed or painted over dentinal
Examples: calcium hydroxide and zinc oxide eugenol.
surfaces. The solvents evaporate to leave a thin-film
Properties of bases
residue that protects the pulp. The paste form is ap-
i. Thermal properties
plied in the cavity and then light cured.
l The base must provide thermal protection to the
Application of cavity varnish
pulp. This property is important especially when
i. It reduces the postoperative sensitivity by reducing
the tooth is restored with metallic restorations.
the microleakage around the margins of newly
ii. Protection against chemical insults
placed amalgam restorations.
l The cement base also serves as a barrier against
ii. It reduces passage of irritants into the dentinal tu-
penetration of irritating constituents, e.g. acids
bules from the overlying restoration or base, e.g.
and monomer from restorative materials.
silicate.
Example, calcium hydroxide and zinc oxide eu-
iii. They also prevent penetration of corrosion products
genol are most effective for it, especially in deep
in to the dentinal tubules in amalgam restorations,
cavities. Polycarboxylate and glass ionomer
thus minimizing tooth discolouration.
bases are also used as chemical barriers in more
iv. They may be used as a surface coating over certain
moderate cavities.
restorations to protect them from dehydration or
iii. Therapeutic effect
contact with oral fluids, e.g. silicate and glass iono-
l Some bases are used for their therapeutic benefit
mer restorations.
to the pulp.
v. They may be applied as a temporary protection on
Examples: calcium hydroxide and zinc oxide
the surface of metallic restoration in cases of gal-
eugenol.
vanic shock.
iv. Strength
vi. Varnish applied over the metallic restorations serves
The cement base must have sufficient strength to:
as a temporary electrical insulator in cases where
l Withstand the forces of condensation
electrosurgery is to be done adjacent to metallic
l Withstand fracture or distortion under mastica-
restorations.
tory stresses, transmitted to it through the per-
vii. Fluorides are released by varnishes containing fluoride.
manent restoration
viii. The use of varnishes is contraindicated with:
l Composite resins Q.3. Define luting cements.
l Glass ionomer
Ans.
l Some cements like zinc oxide eugenol and cal-
cium hydroxide l Cementation is the process by which crowns, restora-

When therapeutic action is expected from them. tions and other devices are fixed or attached to tooth
structure using an intermediate material called cement. Composition

These cements are called luting cements. Composition of zinc phosphate cement is as follows: It
l The synonyms of luting are bonding and cementing. is available as powder and liquid system.
Types of luting or cementation are Powder
i. Temporary cementation
ii. Permanent cementation Zinc oxide 90.2% Principal constituent
Magnesium oxide 8.2% Aids in sintering
i. Temporary cementation
l Temporary cementation of crowns and bridges are Other oxides (like bismuth 0.2% Improves smoothness
trioxide, calcium oxide, bar- of mix
often required to stay in place only until the perma-
ium oxide)
nent structure is ready. Therefore, it must be weak
enough to be easily removed when the permanent Silica 1.4% Filler; aids in sintering
structure is ready for cementation.
l This cement should have some soothing effect on the Liquid
pulp of the freshly prepared vital tooth, which would
Phosphoric acid 38.25% Reacts with zinc oxide
have been traumatized during the preparation.
l Permanent structures (e.g. crowns or bridges) are Water 36.0% Controls rate of reaction
also sometimes cemented temporarily to allow the Aluminium phosphate or 16.2% Buffers to reduce rate
patient to take it for a home trial. Once the patient sometimes zinc phosphate of reaction
feels the permanent structure is satisfactory, it is Aluminium 2.5%
removed and cemented permanently.
Zinc 7.1%
Example, zinc oxide-eugenol-based cement is called
temp bond.
ii. Permanent cementation Q.5. Discuss zinc polycarboxylate cement.
l A permanent cementing material on the other hand
Ans.
should be strong and insoluble in oral fluids.
l It would also be advantageous, if it had some chemi-
[Ref LE Q.2]
cal bonding to the tooth structure. In addition, it Q.6. Describe zinc oxide eugenol cement.
should be fluid enough to flow well to ensure the Ans.
complete seating of the crown or bridge.
Example, zinc phosphate cement, glass ionomer ce- l Zinc oxide eugenol cements have been used extensively
ment, resin cement and polycarboxylate cement. in dentistry since 1890s.
l They are cements of low strength. Also they are the least
Q.4. Describe zinc phosphate cement. irritating of all dental cements and are known to have an
Ans. obtundent effect on exposed dentine.
Classification
According to ADA SP. NO. 30, four types of ZOE
{SN Q.5} cements are as follows:
l Type I ZOE – For temporary cementation
l Zinc phosphate is the oldest of the luting cements and
l Type II ZOE –Permanent cementation
serves as a standard with which newer cements can be
l Type III ZOE – Temporary filling and thermal
compared.
insulation
l The terms ‘Crown and Bridge’ and ‘Zinc Oxyphos-
l Type IV ZOE – Cavity liners
phate’ have also been used for this cement.
ZOE cement is available as:
Applications l Powder and liquid
i. Luting of restorations l Two-paste system
ii. High-strength bases Composition
iii. Temporary restorations
Powder
iv. Luting of orthodontic bands and brackets
Classification Zinc oxide 69.0% Principal ingredient
ADA Specification no. 8 designates them as: White rosin 29.3% To reduce brittleness of set
Type I: Fine grained for luting cement
Type II: Medium grain for luting and filling Zinc stearate 1.0% Accelerator, plasticizer
Zinc acetate 0.7% Accelerator, improves strength are excellent and are approximately the same as
for human dentine. The thermal conductivity of
Magnesium oxide Is added in some powders,
acts with eugenol in a similar
zinc oxide eugenol is in the range of insulators like
manner as zinc oxide cork and asbestos.
26
l Coefficient of thermal expansion: 35 3 10 /°C.
Liquid iii. Solubility and disintegration
l The solubility of the set cement is highest among
Eugenol 85.0 Reacts with zinc oxide
the cements (0.4% by wt).
Olive oil 15.0 Plasticizer l They disintegrate in oral fluids. This break down
is due to hydrolysis of the zinc eugenolate matrix

Setting reaction to form zinc hydroxide and eugenol.
i. The setting reaction and microstructure of ZOE l Solubility is reduced by increasing the P/L ratio.
cement are same as that of the zinc oxide eugenol iv. Film thickness
impression pastes. l The film thickness of zinc oxide eugenol cements
ii. In the first step, hydrolysis of zinc oxide to its hydrox- is 25 microns, which is higher than other cements.
ide takes place. Water is essential for the reaction v. Adhesion
(dehydrated zinc oxide will not react with dehydrated l Their adhesion to enamel or dentine is poor, be-
eugenol). cause of this reason they are not often used for
ZnO + H 2 O → Zn(OH)2 final cementation of crowns and bridges. The
other reasons are low strength and high solubility.
iii. The reaction proceeds as a typical acid–base reaction. vi. Biological properties
l pH and effect on pulp: (pH is 6.6–8.0). They are
Zn(OH)2 + 2HE 
→ ZnE 2 + 2H 2 O
the least irritating of all cements. They exhibit
Base Acid Sallt mild pulpal response.
(Zinc hydroxide) (Eugenol) (Zinc eugenolate) l Bacteriostatic and obtundent properties: They in-
hibit the growth of bacteria and have an anodyne

The chelate formed is an amorphous gel that tends to or soothing effect or obtundent effect on the pulp
crystallize imparting strength to the set mass. in deep cavities, reducing pain.
iv. Setting time is around 4–10 min. vii. Optical properties
The setting time is affected by: The set cement is opaque.
l Particle size: Smaller zinc oxide particles set Manipulation
faster. i. Powder–liquid system
l Powder to liquid ratio: Higher the ratio, faster Powder–liquid ratio: 4:1–6:1 by wt.
the set. After shaking the bottles gently, measured quantity
l Addition of accelerators: Example alcohol, of powder and liquid are dispensed onto a cool glass
glacial acetic acid and water makes the cement slab. The bulk of the powder is incorporated into the
set faster. liquid and saturated thoroughly in a circular motion
l Cooling the glass slab slows the reaction. with a stiff-bladed stainless steel spatula. Smaller
l The set can be retarded by addition of glycol increments are then added until the mix is complete.
and glycerine, which act as retarders. ii. Two-paste system
Properties of ZOE cement are as follows: Equal lengths of each paste are dispersed and mixed
i. Mechanical properties until a uniform colour is observed.
l Compressive strength: They are relatively weak Setting time
cements. The compressive strength therefore It is 4–10 min.
ranges from as low as 3–4 MPa up to 50–55 MPa. ZOE cements set quickly in the mouth due to moisture
The strength can also be increased by reinforcing and heat.
with alumina–EBA or polymers.
l Tensile strength: Ranges from 0.32 to 5.3 MPa.
l Modulus of elasticity (0.22–5.4 GPa): This is an

SHORT NOTES:
important property for those cements intended Q.1. Define adhesive cement.
for use as bases.
Ans.
ii. Thermal properties
21
l Thermal conductivity: 3.98 [Cal. s cm22 (°C/ l Composite
21 24
cm) ] 3 10 . Their thermal insulating properties l Glass ionomer cement
l Polycarboxylate cement Temporary restorative material

l Resin-modified Glass Ionomer cement (GIC) l Temporary restorations are required before placement
of a permanent restoration.
Q.2. Discuss types and definition of adhesion.
l They may help as a treatment while the pulp heals, and/
Ans. or the permanent restoration can be fabricated and

inserted.
l An adhesive is a material, frequently viscous fluids, that
l ZOE is the choice of cement because of its excellent
joins two substrates together and solidifies and is able to
initial sealing ability and kind pulpal response.
transfer a load from one substrate the other.
l Type I ZOE is used universally for sedative treatment,
Types of adhesion temporary coverage and temporary cementation.

l Mechanical adhesion: Penetration of resin and forma-
Q.8. Define cavity varnish.
tion of resin tags within the tooth surface.
l Adsorption: Chemical bonding to the inorganic com- Ans.
ponent (hydroxyapatite) or organic components (mainly
i. Cavity varnish is a material used to provide the barrier
type I collagen) of the tooth.
against the passage of irritants from the restorative ma-
l Diffusion: Precipitation of substances on the tooth sur-
terials and to reduce the penetration of oral fluids at the
faces to which resin monomers can bond mechanically
restoration tooth interface in to the pulp.
or chemically.
ii. Cavity varnish is a solution of natural gum, synthetic
l A combination of the previous three mechanisms.
resins or resins dissolved in a volatile solvent, such as
Q.3. Define biocompatible materials. acetone, ether or chloroform.
iii. Functions of varnish are
Ans.
l Reduces the marginal leakage
l Glass ionomer cement l Pulp protection
l Resin-modified GIC l Reduces tooth discolouration
l Calcium hydroxide cement Q.9. Define intermediate restorative materials.

Q.4. Define hue. Ans.
Ans. l Tooth filling or prosthesis that is placed for a limited
period, from several days to months and is designed
l Hue refers to the property associated with the colour of
to seal teeth and maintain their position until a
an object.
long-term restoration is placed is called a temporary
l Example, whether it is red, green or blue.
restoration.
Q.5. Classify and describe uses of zinc phosphate cement.
Q.10. Discuss modified zinc oxide eugenol cement.
Ans.
Ans.
[Ref SE Q.4]
The modified ZOE cements are
Q.6. Define cavity sealer, liner and base. l EBA–Alumina-modified cements
l Polymer-reinforced ZOE cements

Ans.
Commercial names
i. Thin layer of cement, such as a calcium hydroxide sus- l Inter Mediate Restorative material (IRM)
pension in an aqueous or resin carrier, used for protec- l Kalzinol
tion of the pulp; certain glass ionomer cements used as These were introduced to improve the mechanical
an intermediate layer between tooth structure and com- properties of zinc oxide eugenol cement.
posite restorative material are also considered liners. Uses
ii. They provide barrier against passage of irritants from a. As luting cement
restorative materials to dentine and pulp. b. As base
iii. They reduce the penetration of oral fluids at restoration c. As temporary filling material
tooth interface and prevent marginal leakage. d. As cavity liner
iv. They provide some therapeutic benefits to pulp and re-
duce the sensitivity of freshly cut dentine. Q.11. Define dentine adhesives.
Q.7. Define Intermediate Restorative material (IRM). Ans.
Ans. [Ref SN Q.2]

Q.12. Define cavity liners. [Ref SN Q.7]

Ans. Q.14. Define interim restoration.
[Ref SN Q.6] Ans.
Q.13. Define temporary restorative materials. [Ref SN Q.9]
Ans.
Topic 7
Composite Resin Restorations
LONG ESSAYS:
1. Describe in detail the extended use of composites in aesthetic restorations.
2. Enumerate various uses of dental composite resin. Describe the restoration of class III cavity using composite
resin restoration.
3. Give indications for composite resins. Describe the procedure of restoring fractured incisal angle. Classify
composites. Describe the step-by-step procedure for an incisal build-up for a fractured incisor involving only
enamel.
4. Discuss status of composite resins as a posterior restorative material.
5. Define dentine bonding agents.
6. Describe in detail recent advances in composite resins. [Same as LE Q.1]
7. Define dental composites, classify and enumerate various indications and contraindications. [Same as LE Q.2]
8. Describe the restoration of class III cavity using composite resin restoration. [Same as LE Q.2]
9. What are the indications and contraindications for use of composite restorative material? Describe the proce-
dure for a composite restoration of an incisal one-third fracture. [Same as LE Q.3]
10. Describe the technique of restoring a fractured mesioincisal angle of 11 using composite resin. [Same as LE Q.3]
11. Discuss in detail the materials and various steps involved in placing a composite resin restoration mesioincisally
fractured upper central incisor. [Same as LE Q.3]
12. Describe the technique of restoring a fractured incisal angle with composite resin add a note on posterior com-
posite. [Same as LE Q.4]
SHORT ESSAYS:
1. Enumerate various tooth-coloured restoration materials. Describe the restoration techniques for light-cured
composite resin restoration.
2. Define composites. [Ref LE Q.2 and Q.1]
3. Give indications for composite resins.
4. Discuss posterior composites and their advantages and disadvantages. [Ref LE Q.4]
5. Define compomers. [Ref LE Q.1]
6. Discuss types of fillers used in composite resins. [Same as SE Q.2]
7. Classify composite resins. Write a note on nanocomposites. [Same as SE Q.2]
8. Define posterior composites. [Same as SE Q.4]
9. Discuss status of composite resins as a posterior restorative material. [Same as SE Q.4]
SHORT NOTES:
1. Discuss advantages and disadvantages of microfilled composites.
2. Discuss methods of curing composite.
3. Discuss microfilled composites. [Same as SN Q.1]
4. Discuss composite restorative materials.
5. Fillers and their role in composite resin.
6. Describe advantages of light-cured composite resin.
7. Define light-cured composite.
8. Define resin matrix.
9. Describe finishing and polishing of composite restorations.
10. Define failures in composite restorations.
11. Define polymerization shrinkage.
12. Define visible light-cured composites.
13. Define packable composites. [Same as SN Q.4]
14. Define filler in composites. [Same as SN Q.5]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Describe in detail the extended use of composites in ii. Packable or condensable composites
aesthetic restorations. l These are used in posterior teeth. They have a stiff
consistency, which makes them packable or condens-

Ans.
able like amalgam.
Recent advances in composite resins are as follows: l The basis for packable composite resins is a new
i. Flowable composite resins concept called PRIMM – polymeric rigid inorganic
l In flowable composite resins, the filler content was matrix material.
reduced, thus lowering the viscosity of the compos- l The fillers in packable composites consist of a continu-
ite resins. ous network of elongated fibres of alumina and silica.
l They were developed to improve the handling char- l After silanation of these ceramic fibres, the spaces
acteristics of existing composites and to extend their within this fibrous network are infiltrated with
clinical applications. BisGMA or UDMA resin.
l The resin matrix in flowable composites is l Since most of the resin is located within the fibrous
TEGDMA – triethylene glycol dimethacrylate – network and the silanation promotes good coupling
which has very low viscosity and thus contributes to between the resin and the ceramic fibres, polymer-
the flow of the material. ization shrinkage is greatly reduced.
l The fillers present are silica which are usually Properties
0.02–0.05 microns in size and 60% by weight. It has superior properties to those of conventional
l The mechanical properties of flowable composites composites.
are poorer than those of the hybrid composites, but l Greater depth of cure – Due to the light-
have a higher fracture toughness due to their lower conducting properties of the individual ce-
modulus of elasticity. ramic fibres, packable composites can be cured
l Hence, they are indicated in low-stress bearing areas to a depth of over 4 mm.
where increased flow of the composite resin is l Low polymerization shrinkage – They exhibit a
desirable. low polymerization shrinkage of 0.6%–0.9%
Clinical considerations due to the increased content of ceramic fibres
Due to their excellent flow, they are indicated in: and the incorporation of the resin matrix within
(i) Pit and fissure sealants this fibrous network.
(ii) Preventive resin restorations l Low wear rate – Packable composites show a
(iii) Small class III and class V restorations low wear rate of 3.5 m/year, which is similar to
(iv) Liners in class I and class II cavities espe- that of amalgam.
cially in the proximal box l This is also because of the high amount of ce-
(v) Repair of ceramic crown margins ramic fibres present in the material.
Radiopacity l However, they are mainly composed of a resin

There is increased radiopacity due to the presence of with minimal glass ionomer characteristics.
alumina. l Therefore, a more appropriate nomenclature
Ormocer – organically modified ceramic would be ‘polyacid-modified composite resins’.

l The ormocer matrix consists of ceramic polysi- l They are available as a single-paste, light-
loxane (silicon–oxygen chains) instead of or- curable material in a syringe or ampoule.

ganic dimethacrylate monomers like BisGMA. Composition
l It exhibits low shrinkage on polymerization i. The resin matrix contains two distinct resins:
(only 1.8%) and has high abrasion resistance (a) UDMA – Urethane dimethacrylate.
and therefore is versatile in its application in (b) TCB – A new monomer containing bu-
both anterior and posterior regions of the mouth. tane tetracarboxylic acid with polymeriz-
l This material also releases fluoride, calcium able HEMA (2-Hydroxyethyl Methacry-
and phosphate ions that protect the adjoining late) side chains.
cavity margin. ii. Strontium fluorosilicate glass – This is a reac-
Ion-releasing composite resin tive silicate glass filler containing fluoride.
l A new approach was developed with ion- iii. Photoinitiators.
releasing composite resin called Ariston pHc iv. Stabilizers.
from Vivadent Co. Setting reaction – Compomers harden through a
l This composite resin has an alkaline glass filler light-curing mechanism.
which releases fluoride, hydroxyl and calcium l There are two stages in the setting reaction:
ions based on the pH value immediately adja- (i) Initially, light-curing causes polymeriza-
cent to the restorative material. tion of the UDMA and TCB resin to form
l Whenever the pH value lowers at the margins a 3D network reinforced by filler particles.
of the restoration due to active plaque forma- (ii) After the initial set, the material absorbs
tion, the functional ions are released in large water from the mouth.
numbers. l The carboxyl group present on the TCB resin
l Thus, there is suppression of bacterial growth liberates metal cations from the silicate glass
and inhibition of secondary caries around the particles in the presence of water.
margins of these composite resin restorations. l This results in the formation of hydrogels
similar to glass ionomer cements within the set

[SE Q.2]
resin structure.
{Nanofilled composites l This additional acid–base reaction further
l Nanotechnology has led to the development of cross-links the entire matrix.

a new composite resin containing nanosized Properties
filler particles (0.005–0.05 microns). l Their strength, fracture toughness and wear
l The fillers are zirconium, silica or nanosilica resistance are similar to those of hybrid com-
particles measuring approximately 25 nm or posite resins.
nanoclusters of 75 nm. l Their colour matching and optical properties are
l The filler distribution can be as high as 79.5% very good, superior to those of glass ionomer
by weight. cements. Compomers adhere to tooth structure
l Nanofilled composites demonstrate the polish- by micromechanical means and require acid-
ing ability of microfilled composites and the etching and application of a bonding agent.
mechanical properties of hybrid composites. l They release fluoride but to a lesser extent than
l They also exhibit significantly lesser polymer- glass ionomer cements.

ization shrinkage of 1.5%–2%.} l The fluoride release falls rapidly after an initial
period and they do not possess any fluoride

[SE Q.5]
recharge capacity.
{Compomers Clinical applications
l Compomers is a new variety of tooth-coloured Indications
restorative materials. l Class III and class V cavities as an alterna-
l They were developed to combine the durability tive to composite resins or glass ionomer
of composite resins and the fluoride releasing cements.
ability of glass ionomer cements. Hence named l For deciduous restorations in anterior and
‘compomers’. posterior regions.}

Silorane composites (ii) Visible (V) light-cured composites.

l Silorane-containing composite resins are a new l Dual-cured composites – Both self-curing and
low shrinkage restorative material. light-curing mechanisms.
l In this, silorane forms the matrix phase instead of l Staged-curing composites – Initial soft-start po-
BisGMA or UDMA. lymerization followed by complete polymeriza-

Composition tion.
l Siloranematrix – 23% Based on the mode of presentation
l Fillers (quartz and yttrium fluoride) – 76% l Two-paste system
l Initiators – 0.9% l Single-paste system
l Stabilizers – 0.13% l Powder–liquid system
l Pigments – 0.005% Based on use

l The silorane resins are derived from silorane and l Anterior composites
oxirane monomers and consist of a hydrophobic l Posterior composites
siloxane backbone with oxirane rings. l Core build-up composites
l They polymerize via a photocationic ring-opening l Luting composites
reaction. This results in very minimal polymeriza- Based on their consistency

tion shrinkage of 0.9%, which is much lower than l Light body composite – Flowable composites
most other composites (2%–4%). l Medium body composites – Medium viscosity
l They are used with a specially developed self-etch composites like microfilled, hybrid and microhy-
adhesive called the silorane adhesive. brid composites
l The silorane-based composites demonstrate me- l Heavy body composites – Packable composites}
chanical properties comparable to clinically suc- Indications

cessful methacrylate-based composites. l Class I and II cavities: Indicated for pit and fissure
sealing as prevention resin restoration.

Q.2. Enumerate various uses of dental composite resin.
l Class III, class IV, class V cavities: Most of these
Describe the restoration of class III cavity using com-
cavities are restored with composite resins as they
posite resin restoration.
restore optimal aesthetics.
Ans. l Class VI: Anterior class VI cavities involving incisal
edges are restored.

[SE Q.2]
l Foundation for core build-up: Indicated for core
l {Composite resin is a 3D combination of two or more build-up in endodontically treated anterior and poste-
chemically different materials with a distinct interface rior teeth.
between them. l Aesthetic enhancement procedures: For modifying
Classification tooth contours for aesthetic results such as midline

Based on the mean particle size of the major filler diastema closure, reshaping peg laterals back to nor-
l Traditional (conventional/macrofilled) compos- mal form, modifying canine to resemble lateral inci-
ites: 8–12 microns sor in case of congenitally missing laterals.
l Small particle composites: L-Sum l Luting cements: Resin cements are indicated for ce-
l Microfilled composites: 0.04–0.4 microns mentation of indirect restorations such as ceramic or

l Any remaining caries on the axial wall can be composite inlays, onlays and crowns.
eliminated with a spoon excavator or a steel hy- l Interim restorations: In teeth with questionable
brid composites: 0.6–1 microns. pulpal status, composite resins may be employed as
Based on the filler particle size and distribution a long-term interim restoration. In these situations,
l Megafilled composites: Very large fillers pulp capping with a calcium hydroxide liner fol-
l Macrofilled composites: 10–100 microns lowed by a glass ionomer base is mandatory.
l Midifilled composites: 1–10 microns l Miscellaneous applications: Additional indications
l Minifilled composites: 0.1–1 microns for composite resins include periodontal splinting of
l Microfilled composites: 0.01–0.1 microns weakened or mobile teeth, fixing orthodontic brack-
l Nanofilled composites: 0.005–0.05 microns ets and repair of fractured ceramic crowns.
Based on the method of polymerization Class III cavity preparation for composite resins
l Self-cured, autocured or chemically cured com- Class III caries is smooth surface caries found on the
posites. proximal surfaces of anterior teeth, usually slightly gin-
l Light-cured composites: gival to the proximal contact.
(i) Ultraviolet (UV) light-cured composites. l It does not involve the incisal angle of the tooth.
l The approach for the preparation may be from the Extend the preparation similar to the conventional
l
facial or the lingual direction, but lingual ap- design, but here instead of a butt joint cavosurface
proach is preferred more because of enhancement margin, a bevel is incorporated.
of aesthetics, facial enamel is conserved. l This is prepared using a flame-shaped diamond
l Unsupported facial enamel may be preserved for point, producing a cavosurface angle of 45°.
bonding with composite resin. l The bevel may be 0.25–0.5 mm in width. It is avoided
l On final restoration, discolouration is less visible. on gingival margins and centric contact areas.
Facial approach is indicated when: Modified class III cavity preparation
l Caries is located more facially. Indications
l Irregular alignment of teeth. l For small to moderate carious lesions and is based
l Caries is extensive or a faulty old restoration on the extent of the caries.

placed from a facial approach needs re- l It is made as conservatively as possible and pref-
placement. erably from the lingual approach.

Conventional class III cavity preparation l Using a no. 1 or 2 round diamond point, approach
l Conventional class III is indicated for root surface the lesion from the lingual aspect perpendicular to
lesions. the tooth surface.
l The gingival portion of a large class III cavity prepa- l Access is opened only to the extent of caries.
ration may be prepared using the conventional de- l The preparation walls diverge externally from the
sign, as it is unusual to have entire lesion on the root axial depth in a concave manner creating a bevel
surface. or flared margin as well as conservation of inter-
Root surface lesions nal tooth structure.
l The cavity preparation is done using a no. 1 or 2 l The depth is usually limited to 0.2 mm into
round bur. The outline form is prepared on the root dentine.

surface extending the external walls perpendicular to l Bevels may be placed on the enamel margin when
the root surface. required using a flame-shaped diamond.

l The initial axial depth is maintained round bur and
Q.3. Give indications for composite resins. Describe the
the pulp should be protected with a calcium hydrox-
procedure of restoring fractured incisal angle.
ide liner or a glass ionomer base depending upon the
depth. Classify composites. Describe the step-by-step proce-
l For better retention of the composite resin on the root dure for an incisal build-up for a fractured incisor in-
surface, grooves may be placed in the axiogingival volving only enamel.
and axioincisal line angles with a no. 114 round bur
Ans.
to a depth of 0.5 mm.
l Thus, the design is like a typical box pattern with Class IV cavity preparation for composite resins
definite external walls and a 90° cavosurface angle. Although the general preoperative considerations are
Large class III lesions the same as for other composite restorations, special at-
l In the case of an extensive class III lesion extending tention should be given to the following details:
onto the root surfaces, the coronal portion is pre- i. Occlusion:
pared using a bevelled conventional design. l The amount of occlusal forces dictates the
l The root surface portion is prepared in the conven- type of cavity preparation design.
tional manner using a butt joint margin and retention In case of heavy occlusal forces increased re-
groove in dentine. sistance and retention form are necessary
Bevelled conventional class III cavity preparation while for minimal occlusal loading modified
l This design is indicated for replacing an existing old designs are adequate.
nonadhesive restoration such as silicate or acrylic ii. Shade selection:
resin with composite resin. l Selecting proper shades may be more tricky,
l It can also be done for a large carious class III lesion, especially for large class IV composite resto-
which requires increased resistance and retention. rations.
l The preparation is preferably done from the lingual l Dentinal portions should be restored with ap-
approach. propriate opaque shades, while enamel portion

l Begin the preparation using no. 1 or 2 round dia- requires translucent shades.
mond point, close to the adjacent tooth at the inciso- l Hybrid resins can be used for dentine replace-
gingival level of caries. ment, while microfilled composite resins are

l The bur is held perpendicular to the enamel surface. used on the labial surface.
Conventional class IV cavity preparation The placement of composite resins involves a sequence
The conventional design for class IV cavity preparation of steps that are:
for composite resins is used in the following clinical i. Acid etching:
situations: l The total etch technique is done using 37% phos-
l The preparation is box-like with facial and lingual phoric acid liquid or gel.
walls parallel to the long axis of the tooth. l Gel etchants are preferred as they can be con-
l The gingival floor is prepared perpendicular to the fined to the area of application.
long axis using a round abrasive bur. l It should be of a contrasting colour for easy visu-
l All weakened enamel is removed and the initial alization on the tooth surface.
axial depth is maintained at 0.5 mm into dentine. l The gel may be applied using a syringe applica-
l In case of deep caries, the remaining caries is ex- tor or a brush.

cavated later and the pulp can be protected with a l The etching time is 15 s for both enamel and
calcium hydroxide sub-base and glass ionomer dentine preparations.

base. l Following this, it has to be thoroughly rinsed
l It is recommended that additional retention can be with a water spray for 5–15 s.
provided by retention grooves placed incisally l When the preparation is only in enamel, the sur-
and gingivally in the axial wall. face can be dried with clean dry air.
l This can be done using a no. 114 round bur. l The etched enamel will appear frosty white due
Conventional class IV cavity preparation to the removal of both prism cores and peripher-
This design is employed for large class IV cavities or ies creating microscopic irregularities.
while replacing an old defective restoration placed in a l When the preparation involves both enamel and
conventional cavity preparation. dentine, the surface should be dried using cotton
l The outline form exhibits preparation walls that pellets or blotting paper, so that the dentine is left
are perpendicular or parallel to the long axis of visibly moist.
the tooth and is done using a round diamond abra- l This is because acid-etching of dentine removes
sive. the surface hydroxyapatite from the intertubular

l All weakened enamel are removed and infected and peritubular dentine, thus opening the tubules
dentine is excavated. leaving an interconnected layer of collagen fibrils.
l Finally, all enamel margins that are accessible are l If the dentine is overdried, it leads to collapse of
bevelled. the collagen network and thus a poor bond.

l The bevel is placed at a 45° angle to the external ii. Bonding:
tooth surface using a flame-shaped diamond. l The bonding agent is applied using a microbrush.
l The width of the bevel may be 0.25–2 mm de- The manufacturer’s instructions are followed re-
pending on: garding number of coats to be applied and curing
l The amount of tooth structure lost. time.
l The degree of retention required. l The bonding agent penetrates the irregularities
l When extra retention is required, a retention on enamel and bonds micromechanically by for-
groove is placed at the gingival wall using a no. 14 mation of resin tags.
round bur. l On dentine, the bonding agent penetrates the col-
Modified class IV cavity preparation lagen network and the dentinal tubules forming a
l This design is used for small class IV carious de- hybrid layer consisting of a resin-dentine inter-
fects or traumatic injuries resulting in incisal edge diffusion zone.
fractures. l The bond to dentine is also by tag formation
l The preparation involves conserving maximum tooth producing micromechanical bonding.

structure by involving only the faulty tooth structure Insertion of the composite resin
in case of carious defects. Retention is provided by l The composite resin is built incrementally using spe-
placing bevels using a flame-shaped diamond. cial hand instruments in 1–2 mm thickness.
l For traumatic injuries slightly roughen the fractured l The material is contoured before light curing.
site and place bevels using a flame-shaped diamond. l The cavity is filled and contoured using the matrix
l The width of the bevel may be 1–2 mm, which helps before final curing.
in retention by providing an increased surface area of Finishing and polishing
enamel for better etching and bonding. l After filling the entire cavity, the matrix is removed
l The bevel also helps produce a more aesthetic blend- and the restoration is finished and polished using
ing between the composite resin and enamel. finishing burs, strips and stones.
Q.4. Discuss status of composite resins as a posterior cracks in the tooth structure that leads to post-
restorative material. operative sensitivity.
iv. Reduced wear resistance:
Ans.
l Composites with lower filler content like mi-
[SE Q.4] crofilled composites exhibit greater wear,

while those with higher filler content and par-
{Recently, the demand for aesthetic restorations for ticle size of 1–3 microns exhibit lesser wear.
posterior teeth has greatly increased.
v. High coefficient of thermal expansion:
Advantages l As compared to that of the tooth structure,
Advantages of composite resin as a posterior restorative composite resins exhibit high coefficient of
material are as follows: thermal expansion. This reduces with increase
i. Aesthetics: Composite resins are available in in filler content.
several shades and tints which are aesthetically Technique sensitivity
acceptable. l There should be no room for error while placing
ii. Conservation of tooth structure: Composite composite restorations.
resins require adhesive cavity preparation and l Every step should be meticulously performed to
involve minimal cavity preparation only to re- achieve optimal results.
move caries and fragile enamel. l Hence, chair time is increased for composite resin
iii. Preparations for composite resins are narrower, restorations than for amalgam restorations.
shallow, with rounded internal line angles and do Indications for direct posterior composite restorations
not require extension for prevention. i. Incipient class I cavities which can be restored by pit
Thus, the cavity preparation is also less complex. and fissure sealants.
iv. Adhesion to tooth structure: Composite resins ii. Small carious lesions that allow conservative prepa-
can be adhesively bonded to the prepared cavity. ration and preventive resin restorations.
This provides good marginal seal and reinforce- iii. Moderate-sized class I and class II cavities which do
ment of the remaining tooth structure. not have heavy occlusal contacts.
v. Insulation: Composite resins have low thermal iv. In areas where aesthetics is highly important like in
conductivity due to which they provide good insu- premolar and first molar regions.
lation against temperature changes. v. Class I or II restorations which can be properly iso-
vi. No galvanism: Since they do not contain any lated.
metal composite resins and do not produce any vi. As a foundation or core for a full-crown restoration.
galvanism. vii. In patients with good oral hygiene and low caries
vii. Radiopacity: Composite resins have adequate rate.
radiopacity to enable their visualization in radio- Contraindications for direct posterior composite resto-
graphs. rations
Disadvantages i. In patients with poor oral hygiene and high caries
Disadvantages of composite resins as a posterior restor- activity.
ative material: ii. For posterior areas where adequate isolation is not
i. Polymerization shrinkage: possible.
l Polymerization shrinkage occurs during iii. When multiple large restorations have to be placed
setting. and contact areas are on regions of occlusal contact.
ii. Secondary caries: iv. Patients with grinding habits or bruxism.
l Marginal gaps form in composite resin resto- v. When the cavity extends subgingivally.}
rations due to polymerization shrinkage, For fractured incisal angle, the tooth is acid etch and
which can lead to secondary caries formation. restored with composite resin.
Hence, there is a need to regularly monitor The placement of composite resins involves a sequence
patients with posterior composite restorations. of steps that are
iii. Postoperative sensitivity: i. Acid etching:
l The reason for postoperative sensitivity is po- l The total etch technique is done using 37% phos-
lymerization shrinkage causing gaps, which phoric acid liquid or gel.

could result in rapid movement of dentinal l Gel etchants are preferred as they can be confined
fluid and thus sensitivity. to the area of application.
l Cuspal deformation is also possible due to l It should be of a contrasting colour for easy visu-
polymerization shrinkage, which can cause alization on the tooth surface.

l The gel may be applied using a syringe applica- l Theoretically, NPG-GMA was supposed to chelate
tor or a brush. with the calcium in dentine to form a water-resistant
l The etching time is 15 s for both enamel and chemical bond to dentine.
dentine preparations. l The bond strengths produced by this agent were very
l Following this, it has to be thoroughly rinsed low, only 2–3 MPa.

with a water spray for 5–15 s. l Clinically, this agent did not successfully bond com-
l When the preparation is only in enamel, the sur- posite resins to dentine.
face can be dried with clean dry air. Second generation dentinal adhesives
l The etched enamel will appear frosty white due to l The second generation dentine bonding agents were
the removal of both prism cores and peripheries – attempted to bond chemically to either the inorganic
creating microscopic irregularities. or the organic components of dentine.
l When the preparation involves both enamel and l They contained phosphate groups, amino acid groups,
dentine, the surface should be dried using cotton isocyanate groups or carboxylic acid groups to affect
pellets or blotting paper, so that the dentine is left the bond to the calcium or the collagen of dentine.
visibly moist. l But they produced only limited bond strengths of
l This is because acid etching of dentine removes 5–6 MPa.

the surface hydroxyapatite from the intertubular l Clinical applications did not succeed due to their lack
and peritubular dentine, thus opening the tubules of hydrolytic stability; also they primarily bonded to
leaving an interconnected layer of collagen fibrils. the smear layer and not to the underlying dentine.
l If the dentine is overdried, it leads to collapse of l For example, Clearfil bond system F (Kuraray),
the collagen network and thus a poor bond. Bondlite (Kerr/Sybron) and Scotch bond (3M).
ii. Bonding: Dentine bonding agents bonding to the inorganic com-
l The bonding agent is applied using a microbrush. ponent of dentine:
The manufacturer’s instructions are followed re- l Phosphate group
garding number of coats to be applied and curing l Amino group
time. Dentine bonding agents bonding to the organic compo-

l The bonding agent penetrates the irregularities nent of dentine:
on enamel and bonds micromechanically by for- l Isocyanate group
mation of resin tags. l Carboxylic acid group
l On dentine, the bonding agent penetrates the col- Third generation dentinal adhesives
lagen network and the dentinal tubules forming a l The third generation dentinal adhesives attempted to
hybrid layer consisting of a resin–dentine inter- deal with the smear layer as well as the dentinal fluid.
diffusion zone. They employed two approaches:
l The bond to dentine is also by tag formation pro- l Modification of the smear layer to improve its
ducing micromechanical bonding. properties and

iii. Insertion of the composite resin: l Removal of the smear layer without disturbing the
l The composite resin is built incrementally using smear plugs that occlude the dentinal tubules.
special-hand instruments in 1–2 mm thickness. l This was to avoid aggressive etching of dentine be-
l The material is contoured before light curing. cause of concerns that acid etching of dentine can
l The cavity is filled and contoured using the ma- cause pulpal inflammation.
trix before final curing. l Third generation dentinal adhesives used milder ac-
iv. Finishing and polishing: ids like 2% nitric acid, 2.5% maleic acid with
l After filling the entire cavity, the matrix is re- HEMA, 10% citric acid with 3% ferric chloride and
moved and the restoration is finished and pol- 10% phosphoric acid.
ished using finishing burs, strips and stones. l These dentinal adhesives continued to involve M-R-
X chemistries for the most part.

Q.5. Define dentine bonding agents. l For example, Tenure (Den-Mat), Scotch bond II
(3M), GLUMA (Kulzer) and C&B metabond (Sun

Ans.
Medical).
First generation dentinal adhesives Fourth generation dentinal adhesives
l The development of NPG-GMA (N-phenyl glycine- l Fourth generation dentinal adhesives are based on mul-
glycidylmethacrylate), a surface-active comonomer tistep treatment of dentine. They are based on the total-
was the basis of the first commercially available etch concept where both enamel and dentine are simul-
dentine-bonding agent, Cervident (SS White). taneously etched with 37% phosphoric acid for 15 s.
Following this, the tooth is washed and gently dried

l Seventh generation dentinal adhesives
to leave the dentine surface moist, so as to prevent l These are simple to use but have many drawbacks.
collapse of the exposed collagen network. l Seventh generation dentinal adhesive are ‘all-in-one
l Next a primer is applied. These are hydrophilic adhesives’.

monomers like HEMA (2-Hydroxyethyl Methacry- l They combine the etchant, primer and adhesive in
late), NPG-GMA (N-Phenylglycine glycidyl methac- one bottle.

rylate), PMDM (Pyromellitic acid diethyl methacry- l Before application on the tooth surface, these do not
late), BPDM (Biphenyl dimethacrylate), and PENTA require mixing.

(Dipentaerythritol penta acrylate monophosphate), l Primarily, these agents are intricate mixes of hydro-
dissolved in organic solvents like acetone or ethanol. philic and hydrophobic components in one bottle.
l Due to their volatile nature, the solvents displace For example, Clearfil 53 Bond (Kuraray), G-Bond
water from the collagen network and allow penetra- (GC) and Xeno IV (Dentsply).
tion of the primers.
Q.6. Describe in detail recent advances in composite
l Following this, application of the adhesive resin may
resins.
be BisGMA or UDMA with TEGDMA and HEMA.
l For example, Scotch bond multipurpose (3M), All Ans.
bond 2 (Bisco) and Panavia 21.
[Same as LE Q.1]
Mechanism of dentine bonding
l The concept of ‘hybrid layer’ formation was put Q.7. Define dental composites, classify and enumerate
forth as the mechanism of bonding to dentine. various indications and contraindications.
l This layer is formed by the interdiffusion of the low
Ans.
viscosity monomers into the exposed collagen net-
work and the intertubular dentine to form a microme- [Same as LE Q.2]
chanical bond with dentine. The hybrid layer is a
Q.8. Describe the restoration of class III cavity using
‘resin-dentine interdiffusion zone’.
composite resin restoration.
l Bond strengths of these adhesives range from 17 to
24 MPa. Ans.
Fifth generation dentinal adhesives
[Same as LE Q.2]
l The primer and adhesive are present in the same
bottle. Q.9. What are the indications and contraindications for

l These agents are inferior to the fourth generation use of composite restorative material? Describe the pro-
bonding agents in terms of their bond strengths. cedure for a composite restoration of an incisal one-
l For example, Single Bond (3M), One-Step (Bisco), third fracture.
Gluma Comfort Bond (HeraeusKulzer) and Opti-
Ans.
bond Solo (Kerr).
Sixth generation dentinal adhesives [Same as LE Q.3]
Sixth generation dentinal adhesives do not require a Q.10. Describe the technique of restoring a fractured
separate etching and rinsing step. They are of two types: mesioincisal angle of 11 using composite resin.
(i) Self-etching primers
l The etchant and primer are in one bottle, while Ans.
the adhesive is in a separate bottle. [Same as LE Q.3]
l The etchant and primer are applied on the
tooth surface, which is followed by the appli- Q.11. Discuss in detail the materials and various steps
cation of the adhesive agent and the bonding involved in placing a composite resin restoration mesio-
agent is light cured. For example, Clearfil SE incisally fractured upper central incisor.
bond (Kuraray) and Xeno (Dentsply). Ans.
(ii) Self-etching adhesives
l The etchant, primer and adhesive are all in one
[Same as LE Q.3]
package. Q.12. Describe the technique of restoring a fractured
l It requires mixing before application on the incisal angle with composite resin add a note on poste-
tooth surface. For example, Prompt-L-Pop rior composite.
(3M).
Ans.
l The bond strength to enamel is poor for sixth
generation bonding agent. [Same as LE Q.4]

SHORT ESSAYS: Q.3. Give indications for composite resins.

Q.1. Enumerate various tooth-coloured restoration ma- Ans.
terials. Describe the restoration techniques for light- Indications of composite resins
cured composite resin restoration. Class I and II cavities
Ans. l Indicated for pit and fissure sealing as prevention
resin restoration.
Tooth-coloured restorative materials recently in use are
Class III, class IV and class V cavities
i. Composite
Class VI
ii. Glass ionomer cement
l Anterior class VI cavities involving incisal edges are
iii. Ceramics
restored.
Technique for light-curing composite resin Foundation for core build-up
Polymerization of composite resins Aesthetic enhancement procedures
l Composite resins are most commonly cured using Luting cements
quartz–tungsten–halogen (QTH) light sources. l Resin cements are indicated for cementation of
l It uses visible light in the wavelength of 410–500 nm indirect restorations such as ceramic or com-
which is within the absorption of the camphorqui- posite inlays, onlays and crowns.
none photoinitiator. Interim restorations
l On excitation of the photoinitiator, it combines with l In teeth with questionable pulpal status, com-
the amine accelerator to release free radicals that posite resins may be employed as a long-term
start the polymerization. interim restoration. In these situations, pulp
l Composite resins require a curing time of 20–60 s of capping with a calcium hydroxide liner fol-
exposure to this light. lowed by a glass ionomer base is mandatory.
They have certain drawbacks such as: Miscellaneous applications
l Limited life of the halogen light (not over l Additional indications for composite resins
50 h) include periodontal splinting of weakened or
l Bulb intensity decreases over time mobile teeth, fixing orthodontic brackets and
l Filter degrades with time repair of fractured ceramic crowns.
High-intensity quartz–tungsten–halogen (QTH) lights
Q.4. Discuss posterior composites and their advantages
l These have an increased light output (over 1200
and disadvantages.
mW/cm2) to produce faster curing of composite res-
ins, but faster curing may result in lesser conversion Ans.
of the monomers in the resin matrix to polymers.
l Rapid polymerization also affects the mechanical
[Ref LE Q.4]
properties of the polymer network that is forming. Q.5. Define compomers.
l Polymerization shrinkage can be high enough to
cause failure of the bond to tooth structure. Ans.

l Hence, high-intensity QTH lights are currently avail-
[Ref LE Q.1]
able as variable intensity QTH lights. They produce
a ‘soft start’ polymerization, which gradually in- Q.6. Discuss types of fillers used in composite resins.
creases to maximum intensity through a ‘ramped’
program. Ans.
l At the start of the curing cycle, the light emits a low
[Same as SE Q.2]
power density (100 mW/cm2) which gradually in-
creases to the maximum intensity over 10 s, after which Q.7. Classify composite resins. Write a note on nano-
it remains constant for the duration of the exposure. composites.
l This technique produces lesser polymerization
stresses at the initial stages and maximum degree of Ans.

cure and physical properties at the end of the curing [Same as SE Q.2]
cycle.
Q.8. Define posterior composites.
Q.2. Define composites.
Ans. Ans.
[Ref LE Q.2 and LE Q.1] [Same as SE Q.4]
Q.9. Discuss status of composite resins as a posterior l These are used in posterior teeth. They have a stiff con-
restorative material. sistency which makes them packable or condensable
like amalgam.
Ans. l The basis for packable composite resins is a new con-
[Same as SE Q.4] cept called PRIMM – polymeric rigid inorganic matrix

material.
l The fillers in packable composites consist of a continu-
SHORT NOTES: ous network of elongated fibres of alumina and silica.
Q.1. Discuss advantages and disadvantages of micro- l After silanation of these ceramic fibres, the spaces
filled composites. within this fibrous network are infiltrated with BisGMA
or UDMA resin.
Ans. l Since most of the resin is located within the fibrous
l Microfilled composite resins were developed to over- network and the silanation promotes good coupling be-
come the surface roughness and low translucency of the tween the resin and the ceramic fibres, polymerization
traditional and small particle composite. shrinkage is greatly reduced.
l The fillers used are colloidal silica with a particle size l It has superior properties to those of conventional com-
of 0.04–0.4 microns. posites.

l Since these particles are very small, they tend to ag-
Q.5. Fillers and their role in composite resin.
glomerate and form long chains.
l The chains of silica act similar to resin polymer chain and Ans.
greatly increase the viscosity of the microfilled resins.
l Fillers in composite resins are usually a type of glass
l The filler content is thus kept low at 50% by weight or
such as quartz, silica, barium glass.
30%–40% by volume.
l They are added to improve the physical, mechanical and
Advantage
optical properties of the resin matrix.
l Provide the smoothest surface finish among all com-
l The types of fillers used include quartz, silica, borosili-
posite resins.
cate glass, barium, strontium, zinc, zirconium or yt-
Disadvantages
trium-modified silicate glasses.
l Due to increase matrix content, they exhibit inferior
The addition of fillers improves the following properties
property than traditional composites.
of the resin matrix:
l Greater water sorption.
(a) Lower polymerization shrinkage
l Higher coefficient of thermal expansion.
(b) Increase compressive, tensile strengths and mod-
l Decreased elastic modulus.
ulus of elasticity
l Lower tensile strength.
(c) Increase abrasion resistance
l Increased wear due to poor bond between the pro-
(d) Lower water sorption
cured composite particles and the clinically cured
(e) Lower coefficient of thermal expansion
matrix.
(f) Improve translucency
Q.2. Discuss methods of curing composite.
Q.6. Describe advantages of light-cured composite resin.
Ans.
Ans.
Recently, various alternatives techniques and devices
are used for effective curing of light-cured composite res- l Command setting occurs which is under operator’s
ins. These are: control.
l Adequate working time is possible due to command set.
i. High-intensity quartz–tungsten–halogen (QTH) lights
l No voids as there is no mixing, so less porosity.
ii. Plasma arc curing (PAC) light
l Colour stability.
iii. Light-emitting diode (LED) light
iv. Argon laser curing light Q.7. Define light-cured composite.
Q.3. Discuss microfilled composites. Ans.
Ans. l Polymerization is towards light source.
[Same as SN Q.1] l Incremental placement is recommended.
l Command setting occurs which is under operator’s
Q.4. Discuss composite restorative materials. control.
Ans.
l No voids as there is no mixing so less porosity. Q.10. Define failures in composite restorations.
l Colour stability due to the aliphatic amine initiator.
Ans.
Q.8. Define resin matrix.
Failures in composite restoration occur due to:
Ans. l Improper isolation
l Contamination with blood and saliva

Resin matrix
l Improper cavity preparation
l The resin matrix is the continuous phase to which the
l Improper bonding technique
other ingredients are incorporated.
l Improper technique of composite restoration
l Basically, the resin matrix is composed of monomers
which are aromatic or aliphatic diacrylates. Q.11. Define polymerization shrinkage.

Most composite resins contain the following resin ma- Ans.
trices:
l Composite resins undergo shrinkage during polymer-
(i) BisGMA – Bisphenol-A-glycidylmethacrylate
ization, because of presence of resin matrix.
(ii) UDMA – Urethane dimethacrylate
l This shrinkage causes stresses between the composite
(iii) Combination of BisGMA and UDMA
resin and the tooth structure leading to marginal gaps
l Both these have reactive carbon double bonds at each
and enamel fractures.
end that can undergo addition polymerization
l Polymerization shrinkage is countered by the addition
l Since these resin matrices are viscous, a diluent such
of fillers.
as TEGDMA (triethylene glycol dimethacrylate) is
l Thus, hybrid composites shrink only 0.6%–1.4%, while
added to lower the viscosity and produces a working
microfilled composites shrink 2%–3%.
consistency
l It can also be reduced by incremental placement of
Q.9. Describe finishing and polishing of composite resto- composite resins, which allows for some contraction
rations. within each increment before the next increment is
placed.
Ans.
Q.12. Define visible light-cured composites.
l Gross interproximal flash should be removed by no. 12
scalpel blade. Ans.
l This should be followed by gross finishing using finish-
Visible light-curing composites
ing diamonds, fluted carbide burs and coarse abrasive
l Polymerization is towards light source.
discs. Use coolant during gross finishing.
l Incremental placement is recommended.
l Next, using successively, finer grit of polishing points,
l Command setting occurs, which is under operator’s
cups or discs the composite material can be blended to
control.
the tooth.
l Aluminium oxide discs, used in series from coarse to
l No voids as there is no mixing, so less porosity.
ultrafine, produce the best surface finish to composite
l Colour stability due to the aliphatic amine initiator.
resins.
l These are especially useful for facial and proximal sur- Q.13. Define packable composites.
faces of anterior and posterior teeth.
Ans.
l For occlusal surfaces of posterior teeth, finishing dia-
monds, multifluted carbide burs or silicon carbide points [Same as SN Q.4]

of various sizes, shapes and grits are useful.
Q.14. Define filler in composites.
l Interproximal areas can be finished and polished using
aluminium oxide finishing strips. Ans.

l A final high point can be provided using a rubber cup
[Same as SN Q.5]
with aluminium oxide pastes.
Topic 8
Glass Ionomer Restorations
LONG ESSAYS:
1 . Give the composition, manipulation and uses of glass ionomer cement.
2. Describe the procedure of restoring abrasive defect (class V restoration). Add a note on advantages and disad-
vantages of glass ionomer cement.
3. Classify cements depending on their uses in restorative dentistry. Write down the composition, classification,
manipulation and properties of conventional glass ionomer cement. [Same as LE Q1]
4. Discuss the various treatment modality of a cervically eroded lesions in a lower first permanent molar. [Same as LE Q.2]
5. Describe the techniques of restoring erosion lesions in a maxillary first premolar with glass ionomer cement.
[Same as LE Q.2]
6. What are the clinical indications for glass ionomer cements? What do you understand by ‘sandwich technique’?
Write in detail tooth preparation and restoration of class V erosion lesion in a posterior tooth. [Same as LE Q.2]
7. Describe merits and demerits of glass ionomer cement (GIC) diagnosis applications in restorative dentistry.
[Same as LE Q.2]
SHORT ESSAYS:
1 . Describe classification of glass ionomer cement. [Ref LE Q.1 and Q.2]
2. Describe type II glass ionomer cement. [Ref LE Q.1]
3. Define bilayered technique. [Ref LE Q.2]
4. Define glass cermet cements.
5. Mention the uses of glass ionomer cement and add a note on its biocompatibility. [Same as SE Q.1]
6. Define bilayered restoration. [Same as SE Q.3]
7. Define resin-modified GIC. [Same as SE Q.4]
SHORT NOTES:
1. Define glass ionomer cement (GIC).
2. Describe composition of glass ionomer cement. [Ref LE Q.1]
3. Discuss resin-modified glass ionomers. [Ref SE Q.4]
4. Discuss reinforced glass ionomer. [Ref SE Q.4]
5. Describe pulp responses to glass ionomer cements.
6. Discuss recent advances in glass ionomer cements.
7. Define hybrid glass ionomer cement. [Same as SN Q.4]
8. Describe metal-modified glass ionomer cement.
9. Define miracle mixtures.
10. Discuss biocompatibility of glass ionomer cements. [Same as SN Q.1]
11. Describe resin-reinforced glass ionomer cement. [Same as SN Q.4]
SOLVED ANSWERS
LONG ESSAYS:
l Glass ionomer cements were developed as a replace-
Q.1. Give the composition, manipulation and uses of
ment of silicate cements by combination of aluminosili-
glass ionomer cement.
cate glass powder with polyacrylic acid, hence known
Ans. as ASPA – aluminosilicate polyacrylate cements.
l They are used because of their better mechanical When used as a base or dentine substitute, the ce-
l
strength, increased translucency, faster setting and ment is mixed with a high powder/liquid ratio, so
resin-modified version. that the physical properties are improved.
l The lining or base glass ionomer cement is also
available as autocured or resin-modified versions.

{SN Q.4} Mount’s classification of glass ionomer cements
Composition of glass ionomer cement Type I – Luting
l Uses – Cementation of crowns, bridges, inlays
Powder and orthodontic appliances
Silica 29% l Powder/liquid ratio – 1.5:1
Alumina 16.6% l Film thickness – ,20 microns}
Calcium fluoride 34.3% [SE Q.1 and SE Q.2]

Aluminium fluoride 5.3% {Type II – Restorative
Sodium aluminium fluoride 5% Type II.1 – Restorative aesthetic
l Uses – Class III, class V and tunnel restora-
Aluminium phosphate
tions
Lanthanum, barium and Traces l Powder/liquid ratio – 3:1 or greater
strontium
l Autocured or resin-modified
Liquid Type II.2 – Restorative reinforced
Polyacrylic acid 40%–45% l Uses – Core build-up, root caries, tunnel resto-
rations, deciduous restorations

Itaconic acid
l Powder/liquid ratio – 3:1 or greater}
Maleic acid
[SE Q.1]
Tartaric acid 5%–15%
Water 30%
{Type III – Lining or base
l Uses – In low powder–liquid ratio as lining; in
high powder–liquid ratio as base beneath amal-
gam, composite restorations
l Powder/liquid ratio – 1.5:1 (lining)
[SE Q.1]
3:1 or greater (base)
{Classification is based on the composition, powder/ l Autocured or resin-modified}
liquid ratio and clinical applications of the material: Dispensing and manipulation
Type I – Luting glass ionomer cement l Glass ionomer cements are available as powder–
l This has a fine powder particle size and uses a low liquid, paste–paste systems and as preproportioned
powder/liquid ratio. capsules.
l Used for luting crowns, bridges, inlays and orth- l They can be manipulated by hand mixing on a paper
odontic appliances. pad or by mechanical mixing in an amalgamator.
Type II.1 – Restorative glass ionomer cement i. Hand mixing:
l This is used for aesthetic restorations. l Mixing may be done on a cool, dry glass slab or
l This cement uses a high powder/liquid ratio and has a paper pad using a thin-bladed plastic spatula.
superior physical properties and good translucency. l For restorative purposes, the powder is divided
l According to its setting mechanism, these cements into two halves. The first half is rapidly incor-
may be either autocured or resin-modified cements. porated into the liquid within 10 s by gently
Type II.2 – Restorative reinforced glass ionomer cement but rapidly rolling the powder into the liquid.
l These cements have metallic inclusions for rein- l The second half is then incorporated and
forcement. mixed within 15 s.
l They have superior strength but lack aesthetics. l Mixing should be completed within 25–30 s
l Used where improved physical properties are re- and the finished mix should be glossy wet on
quired but aesthetics is not important. the surface.
Type III – Lining or base glass ionomer cement l The working time for the mixed cement is
l When used as a lining cement, the powder content is 1–2 min.
low, so that the cement flows readily, but it has lower l The paste–paste dispensing system is devel-
physical properties. oped recently.
l To achieve a paste–paste consistency, a spe- l Pulpal response to resin-modified glass ionomer

cially designed cartridge delivery pastes on cements is similar to that of conventional ce-
the paper pad, which can then be mixed using ments. But a slight rise in temperature during
a plastic spatula. polymerization may be a cause for concern.
l This dispensing system provides optimum ra- iii. Fluoride release:
tio as well as easy mixing and placement of l Glass ionomer cement contains fluoride and dur-
the cement. ing the mixing of the glass powder with the poly-
ii. Mechanical mixing: alkenoic acid, fluoride ions are released by the
l Preproportioned capsules containing premea- initial attack of the acid on the surface of the
sured glass ionomer powder and liquid can be glass particles.
mechanically mixed in an amalgamator. l The fluoride ions do not take part in the setting
l This ensures standardized mixing, optimal reaction but remain within the matrix of the set
properties and predictable setting time. cement and are continuously released into the
l The capsules have an angled nozzle to syringe oral cavity.
and the cement directly into the cavity prepa- l The initial release is high but declines rapidly
ration. after the first 3 months. But after this period also
Properties of glass ionomer cements fluoride release continues for a long time ensur-
i. Adhesion to enamel and dentine: ing caries protection for the surrounding tooth
l The important properties of glass ionomer cement structure.
are to adhere chemically to enamel and dentine. l Glass ionomer cement is also able to absorb fluo-
l This is because of the polyacrylic acid which rides from the mouth when topical fluorides are
when contacts the tooth surface, attacks the applied. Thus, a glass ionomer restoration serves
enamel and dentine displacing calcium and phos- as a fluoride reservoir.
phate ions which migrates into cement and forms iv. Colour and translucency:
an ion-enriched layer which is firmly attached to l Conventional and resin-modified glass ionomer
the tooth surface. cements are available in various shades and

l The chemical bonding is achieved by a calcium provide acceptable colour matching and trans-
phosphate-polyacrylate crystalline structure lucency.
formed at the interface between enamel or den- l Conventional glass ionomer cements are highly
tine and the set cement. This is called ‘diffusion- sensitive to moisture contamination, which can
based adhesion’. be overcome by applying a sealant and finishing
l Glass ionomer cements also exhibit adhesion to the restoration after 24 h.
the collagen of dentine through hydrogen bond- l Resin-modified glass ionomer cements show ex-
ing or metallic ion bridging between the carboxyl cellent colour match and translucency soon after
groups of the polyacid and the collagen mole- light curing and are less sensitive to moisture
cules of dentine. contamination.
l Resin-modified glass ionomers demonstrate sim- v. Radiopacity:
ilar or better bond strengths to tooth structure l Conventional glass ionomer cements are radiolu-
than the conventional glass ionomers. cent but resin-modified and lining glass ionomer
ii. Biocompatibility: cements are radiopaque due to the presence of
l The freshly mixed cement has a pH of 1–2, but lanthanum, barium or strontium in the powder.
this rises rapidly within the first hour after setting. l Metal-modified glass ionomers are more radi-
l Glass ionomer cements cause a mild pulp inflam- opaque due to the presence of silver particles.
mation, which resolves soon. vi. Strength and fracture resistance:
There are two factors responsible for this: l The compressive strength of glass ionomer ce-
(i) High buffering capacity of the hydroxy- ments is similar to that of zinc phosphate cement,
apatite as its diametral strength is slightly higher.
(ii) Large molecular weight of the polyacrylic l The modulus of elasticity of glass ionomer ce-
acid, which does not travel through the ments ranges from 7 to 13 GPa.
narrow dentinal tubules. l Glass ionomer cements are weak and lack frac-
l In deep carious lesions where the remaining denture resistance when compared to composite res-
tine thickness is less than 0.5 mm, pulp capping ins and amalgams.
with calcium hydroxide is preferred before plac- l Resin-modified glass ionomer cements are twice
ing a glass ionomer lining. as strong as conventional glass ionomer cements,

almost comparable to that of microfilled compos- v. Glass ionomer placement:

ite resins. l Glass ionomer cement is mixed and placed according
vii. Abrasion resistance: to manufacturer’s instructions.
l Glass ionomer cements are less resistant to abra- vi. Matrix placement:
sion than composite resins but abrasion resis- l For chemically cured glass ionomer cements, pre-
tance improves as the cement matures. countoured cervical matrix is used.
l Cermet ionomers have improved abrasion resis- l For resin-modified glass ionomer cements, a trans-
tance due to the presence of silver particles. parent plastic matrix is placed.
viii. Solubility and disintegration: vii. Finishing:
l Properly set glass ionomer cements exhibit low l For chemically cured glass ionomer, the excess ma-
solubility in the oral environment, but use of terial is contoured using a scalpel.
topical fluorides with low pH like Acidulated l Final finishing is done after 24 h.
Phosphate Fluoride (APF) gel can roughen the l For resin-modified glass ionomer cements, final con-
cement surface. touring can be done using finishing diamonds and
l Resin-modified glass ionomers are more resistant carbide burs soon after light curing followed by sur-
to solubility and disintegration than conventional face protection.
glass ionomer cements, because of the initial set-
[SE Q.1]
ting by polymerization which reduces the disrup-
tion of the ionomeric component. {Indications of glass ionomer cement
ix. Thermal expansion and diffusivity: As a pit and fissure sealant:
l Glass ionomer cements have a linear coefficient of l Glass ionomer cement is an effective sealant for
thermal expansion similar to that of tooth structure. open fissures especially in children who are at
l Their thermal diffusivity is also close to that of high risk for dental caries.
tooth structure. Class I restorations:
l Indicated for restoration of buccal and lingual pits
Q.2. Describe the procedure of restoring abrasive defect
in molars and lingual pits in anterior teeth.
(class V restoration). Add a note on advantages and
Tunnel restorations:
disadvantages of glass ionomer cement.
l Indicated for restoring initial proximal caries in
Ans. posterior teeth when a tunnel restoration is planned.
Restoration of noncarious cervical lesion is indicated in Class III restorations:
following clinical situations: l For class III cavities which can be approached
i. Considerable loss of enamel and dentine from the lingual aspect, glass ionomer restora-
ii. Where aesthetics is compromised tions are the preferred choice.
iii. Deep lesion affecting the strength of the tooth and Class V restorations:
pulpal integrity l Glass ionomer cements are the preferred materials
iv. Carious lesion in cervical region for carious and noncarious class V cavities.
v. Significant sensitivity in cervical region Root caries:
l For caries involving root surfaces, glass ionomer
Chemically cured glass ionomer cements are excellent
cement is the material of choice because of its
in restoring class V lesions.
adhesive potential and fluoride-releasing capacity.
Steps involved in restoring class V lesions are As a liner/base:
i. Pumice prophylaxis: l Glass ionomer cement is preferred as a liner/base
l This is done first after which shade selection is done. beneath composite resins, amalgam and cast res-
ii. Isolation: torations because of its adhesive nature and bio-
l This is done with rubber dam or cotton rolls. compatibility.
l If lesion extends subgingivally, retraction is required. l This is popular as the ‘sandwich technique’.
iii. Tooth preparation: Restoration of deciduous teeth:
l Tooth preparation is not needed because glass iono- l Glass ionomer cements are indicated for restora-
mer cement (GIC) is adhesive material. tion of class I, II, III and V cavities in deciduous
iv. Surface conditioning: teeth because of their ease of handling.
l This is necessary as it removes the smear layer and As a core build-up material:
improves adhesion. l In anterior and posterior teeth, glass ionomer ce-
l This is done with 10% polyacrylic acid applied for 15 s ments are used as a core build-up material prior to
followed by washing it off and gently drying the tooth. a full coverage restoration.
Luting cement: Low wear resistance:

l Glass ionomer cements are employed for luting l Glass ionomer cements exhibit low resistance to
inlays, onlays, crowns, orthodontic bands, posts wear when compared to composite resins.
and fixed partial dentures. Colour:
As an interim restoration: l Autocured glass ionomer cements are not as aes-
l Glass ionomer cement can be used as a long-term thetic as composite resins.

temporary restoration in teeth with deep caries Sensitivity to moisture soon after setting:
and questionable pulpal status. l Glass ionomer cements are sensitive to water
As a repair material: uptake and loss soon after placement and it affects
l For defective restoration margins such as mar- the physical properties and aesthetics of the
ginal gaps in inlays and crowns, glass ionomer cement.
cement can be employed as a repair material.
In endodontics: [SE Q.3]

l
Glass ionomer cements can be employed as an {Sandwich technique
endodontic access filling material, root canal seal- l It is also known as laminate or bilayered technique.
ers and repair material for root perforations and as l Clinically, this technique can be used for restoring class
a retrograde filling material.} I, II cavities with composite resin.
Advantages of glass ionomer cements Procedure
Adhesion to enamel and dentine: l First cavity preparation is done.
l Glass ionomer is the only restorative material l Following this, conditioning of the cavity for good
available that is capable of producing chemical adhesion with GIC.
adhesion to both enamel and dentine through ion l To replace the lost dentine, a fast setting type III GIC
exchange. is used in sufficient bulk.
Anticariogenic effect: l GIC can also be used in cavities extending subgin-
l The cement contains fluoride which is released givally. As it sets, cut back the expose enamel
into the surrounding tooth structure after place- margins to allow the sufficient bulk for composite
ment and prevents recurrent caries and plaque resins.
accumulation. The fluoride content can also be l Etch the enamel surface for 20 s, followed by proper
‘recharged’ from topical applications. washing and drying of the tooth.
Acceptable aesthetics: l Etching is not necessary for GIC.
l Both chemically cured and light-cured restorative l Now, apply a thin coat of enamel bonding agent on
glass ionomer cements exhibit good colour match- enamel and GIC and light cure for 20 s.
ing and translucency as they are available in vari- l Build-up with composite resin.
ous shades. Advantages
Low solubility: l Biocompatible.
l In the oral environment, glass ionomer cements l Ion-exchange adhesion of glass ionomer to dentine
are less soluble than most other cements. Resin- prevents microleakage.
modified glass ionomer cements are more resis- l Fluoride release from glass ionomers minimizes
tant to solubility and disintegration than autocure recurrent caries.
cements. l Good subgingival response.
Biocompatibility: l By minimizing the bulk of the composite resin, po-
l Pulpal response to glass ionomer cements is favour- lymerization shrinkage of the resin is reduced.
able. Though the freshly mixed cement is acidic in l Better strength, finish and aesthetics of the overlying
nature, dentine itself is an excellent buffer. Also the composite resin.
large size of the polyacrylic acid molecules prevents Disadvantage
the acid from producing a pulpal response. l Time-consuming and technique sensitive.}
Less technique sensitivity:
l Glass ionomer cements are less technique sensi- Q.3. Classify cements depending on their uses in restor-
tive than composite resins. ative dentistry. Write down the composition, classifica-
l Simple and easy to handle. tion, manipulation and properties of conventional glass
Disadvantages of glass ionomer cements ionomer cement.
Low fracture resistance: Ans.
l They are weak and lack rigidity and have low
modulus of elasticity. [Same as LE Q.1]

Q.4. Discuss the various treatment modality of a cervi-

{SN Q.4}
cally eroded lesions in a lower first permanent molar.
Metal-reinforced glass ionomer cement
Ans.
l Metal powders or fibres are added to the glass pow-
[Same as LE Q2.] der to reinforce glass ionomer cements.
l There are two types of metal-reinforced glass iono-
Q.5. Describe the techniques of restoring erosion lesions
mer cements:
in a maxillary first premolar with glass ionomer cement.
(i) Silver alloy admix glass ionomer cement
Ans. l Silver alloy admix consists of physically blend-
ing silver alloy powder with the glass powder in

[Same as LE Q.2]
the ratio of 1:7.
Q.6. What are the clinical indications for glass ionomer l Mix it with glass ionomer liquid.
cements? What do you understand by ‘sandwich tech- l This blending increases the strength and abrasion
nique’? Write in detail tooth preparation and restora- resistance to some extent. For example, Miracle
tion of class V erosion lesion in a posterior tooth. Mix (GIC).
Composition of silver alloy admix glass ionomer
Ans.
cement
[Same as LE Q.2] Powder – Physical blend of silver alloy and glass
powder in a 1:7 ratio.
Q.7. Describe merits and demerits of glass ionomer
Liquid – Glass ionomer cement liquid.
cement (GIC) diagnosis applications in restorative den-
(ii) Cermet cement
tistry.
l Cermet cement is formed by fusing equal volume
Ans. of glass powder to fine metal powders like silver
or gold through sintering.
[Same as LE Q.2]
l The pelletizing chamber is then evacuated at 100
MPa pressure following which the compressed

SHORT ESSAYS: pellets are fused at 800°C.
l This produces a sintered glass–silver composite –
Q.1. Describe classification of glass ionomer cement.
a ‘cermet’ (ceramic metal), which is then ground
Ans. to a fine powder.
l 5% (by weight) of titanium oxide powder is
[Ref LE Q.1 and Q.2]
added to this powder to make it more aesthetic.
Q.2. Describe type II glass ionomer cement. l The liquid for cermet ionomer cements is the
regular glass ionomer cement liquid. For exam-

Ans.
ple, Ketac silver (3M) and Chelon silver.
[Ref LE Q.1] Composition of cermet ionomer cement
Powder – Sintered glass-pure silver powder.
Q.3. Define bilayered technique.
5% titanium oxide.
Ans. Liquid – Glass ionomer cement liquid.
[Ref LE Q.2] Condensable/high viscosity glass ionomer cements
l The high viscosity of these cements is due to the incor-
Q.4. Define glass cermet cements.
poration of freeze-dried polyacrylic acid to the powder
Ans. and the finer grain size of the powder particles.
l These cements set more rapidly and exhibit higher
Resin-modified glass ionomer cements
strength and better physical properties.
l Supplied as powder and liquid systems.
l They show early resistance to water uptake. For exam-
Powder
ple, Ketac Molar (3M), Fuji IX and Fuji IX GP (GC).
l It has ion-leachable fluoroaluminosilicate glass par-
ticles along with initiators for light curing or chemi- Indications

cal curing. l Restoration of deciduous teeth
Liquid l Long-term temporary restorations
l Water and polyacrylic acid modified with pendant l Liner/base applications
methacrylate groups and HEMA monomers. l ART technique
l Resin component is between 15% and 25%.
(ii) Large molecular weight of the polyacrylic acid

Another condensable glass ionomer cement has been
which does not travel through the narrow den-
developed, which is reinforced with resin.
tinal tubules.
Uses l In deep carious lesions where the remaining dentine
l For restoring anterior teeth for ART. thickness is less than 0.5 mm, pulp capping with cal-
cium hydroxide is preferred before placing a glass iono-
Advantage
mer lining.
l Provide better translucency and higher flexural
l Pulpal response to resin-modified glass ionomer ce-
strength. For example, Fuji VIII (GC).
ments is similar to that of conventional cements. But a
slight rise in temperature during polymerization may be
a cause for concern.
{SN Q.3 and SN Q.4}
Q.2. Describe composition of glass ionomer cement.
Resin-modified glass ionomer cements
Ans.
l Supplied as powder and liquid systems.
Powder [Ref LE Q.1]

l It has ion-leachable fluoroaluminosilicate glass
Q.3. Discuss resin-modified glass ionomers.
particles along with initiators for light curing
or chemical curing. Ans.
Liquid [Ref SE Q.4]
l Water and polyacrylic acid modified with
Q.4. Discuss reinforced glass ionomer.
pendant methacrylate groups and HEMA
monomers. Ans.
l Resin component is between 15% and 25%.
[Ref SE Q.4]
Q.5. Describe pulp responses to glass ionomer cements.
Ans.
Q.5. Mention the uses of glass ionomer cement and add
l The freshly mixed cement has a pH of 1–2, but this rises
a note on its biocompatibility.
rapidly within the first hour after setting.
Ans. l Glass ionomer cements cause a mild pulp inflammation,
which resolves soon.

[Same as SE Q.1]
There are two factors responsible for this:
Q.6. Define bilayered restoration. (i) High buffering capacity of the hydroxyapatite
(ii) Large molecular weight of the polyacrylic acid
Ans.
which does not travel through the narrow den-
[Same as SE Q.3] tinal tubules
l In deep carious lesions where the remaining dentine
Q.7. Define resin-modified GIC.
thickness is less than 0.5 mm, pulp capping with cal-
Ans. cium hydroxide is preferred before placing a glass iono-
mer lining.
[Same as SE Q.4]
l Pulpal response to resin-modified glass ionomer ce-
ments is similar to that of conventional cements. But a

SHORT NOTES: slight rise in temperature during polymerization may be
a cause for concern.
Q.1. Define glass ionomer cement (GIC).
Q.6. Discuss recent advances in glass ionomer cements.
Ans.
Ans.
Biocompatibility of GIC
l The freshly mixed cement has a pH of 1–2, but this rises Recent advances in glass ionomer cements
rapidly within the first hour after setting. i. Giomers:
l Glass ionomer cements cause a mild pulp inflammation, l Giomer is a combination of glass ionomers and com-
which resolves soon. posite resins to achieve the best from both the materials.
There are two factors responsible for this: l It consists of prereacted glass ionomer particles
(i) High buffering capacity of the hydroxyapatite within a resin matrix.
l It can be subdivided into two distinct groups: l There are two types of metal-reinforced glass ionomer
(i) S-PRG (surface prereacted giomers) can be cements:
used in all situations where composite resins (i) Silver alloy admix glass ionomer cement:
are used. l Silver alloy admix consists of physically blend-
(ii) F-PRG (fully prereacted giomers) can be used ing silver alloy powder with the glass powder in
as dentine bonding agents, pit and fissure seal- the ratio of 1:7.
ants and as restorative material for cervical (ii) Cermet cement:
lesions. l Cermet cement is formed by fusing equal vol-
l Giomers also have the property of fluoride release ume of glass powder to fine metal powders like
and uptake like other glass ionomer cements. For silver or gold through sintering.
example, Beautiful (Shofu). l This produces a sintered glass–silver composite –
ii. Glass ionomer stabilization and protection material: a ‘cermet’ (ceramic metal), which is then ground
l It is a temporary restorative material used for sealing to a fine powder.
active carious lesions. l 5% (by weight) of titanium oxide powder is
l It protects susceptible tooth surfaces in patients with added to this powder to make it more aesthetic.
high risk for caries. l The liquid for cermet ionomer cements is the
l It is pink in colour for easy identification of its mar- regular glass ionomer cement liquid. For exam-
gins. ple, Ketac silver (3M) and Chelon silver.
l It has a high release of fluoride that offers greater
Q.9. Define miracle mixtures.
protection to the surrounding tooth surfaces. For ex-
ample, Fuji VII (GC). Ans.
iii. Amino acid-modified glass ionomer cements:
l Silver alloy admix glass ionomer cement – also known
l To improve the fracture toughness of glass ionomer
as Miracle Mix.
cements, polyacrylic acid copolymers with pendant
l Silver alloy admix consists of physically blending silver
amino acid residues (N-methacryloylamino acid,
alloy powder with the glass powder in the ratio of 1:7.
N-vinylpyrrolidinone) have been combined for both
l Mix it with glass ionomer liquid.
autocure and resin-modified versions of glass iono-
l This blending increases the strength and abrasion resis-
mer cements.
tance to some extent. For example, Miracle Mix (GC).
Q.7. Define hybrid glass ionomer cement.
Q.10. Discuss biocompatibility of glass ionomer
Ans. cements.
[Same as SN Q.4] Ans.
Q.8. Describe metal-modified glass ionomer cement. [Same as SN Q.1]
Ans. Q.11. Describe resin-reinforced glass ionomer cement.
Metal-reinforced glass ionomer cements Ans.
l Metal powders or fibres are added to the glass powder
[Same as SN Q.4]
to reinforce glass ionomer cements.
Topic 9
Dental Ceramic Restorations
LONG ESSAYS:
1. Describe the types, composition, role of ingredients, methods of firing and shrinking of ceramics.
SHORT ESSAYS:
1 . Describe CAD–CAM.
2. Discuss porcelain bonded to metal.
3. What are the advantages and disadvantages of porcelain?
4. Discuss direct composite veneers.
5. Describe incisal lapping preparation for veneers.
6. Describe porcelain fused to metal (PFM) teeth. [Same as SE Q.2]
7. Define veneers. [Same as SE Q.4]
8. Describe veneering materials. [Same as SE Q.4]
9. Define laminates and veneers. [Same as SE Q.4]
SHORT NOTES:
1 . Define aluminous porcelain.
2. Define castable ceramics.
3. Describe advantages of porcelain veneers. [Ref SE Q.4]
4. Define cerestore. [Same as SN Q.2]
5. Define Dicor. [Same as SN Q.2]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Describe the types, composition, role of ingredients, C. Fabrication technique
methods of firing and shrinking of ceramics. According to their fabrication technique, ceramics may be:
Ans. i. Sintered – Metal ceramics
ii. Castable ceramics – Dicor
Dental ceramics are nonmetallic, inorganic structures, iii. Pressable ceramics – IPS Empress 1 and IPS
containing compounds of oxygen with one or more metallic Empress 2
or semimetallic elements like aluminium, calcium, lithium, iv. Infiltrated/slip-cast ceramics – In-Ceram, In-
magnesium, phosphorus, potassium, silicon, sodium and Ceram spinel and In-Ceram Zirconia
zirconium. v. Machinable – Cerec vitablocs Mark I and II,
Dicor MGC and Zirconia blocks
Classification D. Crystalline phase
Dental ceramics can be classified based on: According to the crystalline phase present in ceramics,
. Fusion temperatures
A they may be:
B. Applications i. Alumina-based – Optec HSP
C. Fabrication techniques ii. Feldspar-based – Conventional ceramics
D. Crystalline phases iii. Leucite-based – IPS Empress
A. Fusion temperatures iv. Spinel-based – In-Ceram spinel
According to their fusion temperatures, dental ceramics Composition
may be classified as: . High-fusing ceramics
A
i. High-fusing ceramics, .1300°C High-fusing ceramics have three major ingredients:
ii. Medium-fusing ceramics, 1101–1300°C i. Feldspar
iii. Low-fusing ceramics, 850–1100°C ii. Kaolin
iv. Ultra low-fusing ceramics, ,850°C iii. Quartz
B. Applications Feldspar
Dental ceramics have three major applications: l It is primary a constituent present in concentra-
i. Ceramics as veneers over metal crowns and tions of 75%–85%.
fixed partial dentures. l Natural feldspars can be either sodium feldspar
ii. All-ceramic crowns, inlays, onlays and veneers. (albite) or potassium feldspar (orthoclase/
iii. Ceramic denture teeth. microcline).
l These minerals are composed of potash (KCl), Pigments

soda (NaHCO3), alumina (Al2O3) and silica l Colouring pigments are added to obtain various shades
(SiO2). needed to mimic natural tooth colour.

Kaolin/clay l These are made by fusing metallic oxides with fine glass
l It is present in concentrations of 4%–5%. and feldspar and then regrinding to a powder.

l It serves as a binder.
Stains or colour modifiers
l It consists of Al2O3, 2SiO2 and 2H2O.
l Stains are surface colourants used to create check lines,
l Kaolin is opaque and can lower the translu-
decalcification spots, etc. in the body porcelain.
cency of porcelain.
l Colour modifiers are used to produce gingival effects or
Quartz
to highlight body colours.
l Quartz is present in concentrations of 13%–14%.
l Its main role is to provide strength, firmness Fluorescing agents

and improve the translucency of porcelain. l Due to radiation hazards of uranium, samarium is used
l On heating, it remains unchanged. nowadays.

l It provides stability by serving as a framework
Glazes and add-on porcelains
for other ingredients.
l Glazes are uncoloured glass powders and mature at
B. Low-fusing ceramics
lower temperatures than that of the restoration and their
l Low-fusing ceramics have the same basic ingredients
thermal expansion coefficient should be slightly smaller
as that of high-fusing ceramics; in addition, it con-
than the ceramic body.
tains glass modifiers.
l They can be used for simple corrections of tooth con-
Glass modifiers tour and contact points.

l These modify the properties of ceramics by interrupting
Firing or sintering of porcelain
the glass network.
Porcelain restorations are fired in a special ceramic
l They serve as fluxes and help reduce the softening tem-
furnace.
perature of the glass.
(i) Temperature control method: The furnace temperature
l Potassium, sodium and calcium oxides are the com-
is raised at a constant rate until a specified temperature
monly used glass modifiers and their concentration
is reached.
should be less.
(ii) Temperature–time control method: The furnace tem-
l Glass modifiers also lower the viscosity of the glass and
perature is raised at a given rate until the preset tem-
increase the thermal expansion.
perature is reached, after which the temperature is
l If they are too much in concentration, it would result in
maintained for a specific time till the reactions are
reduced chemical durability and crystallization of the
completed. This method is usually preferred as it pro-
glass during porcelain firing.
duces a uniform restoration.
Intermediate oxides l Vacuum firing of porcelain is preferred.
l To overcome this problem, intermediate oxides like alu-

Stages of maturity of porcelain during firing
minium oxide (Al2O3) are added to overcome the action
1. Low bisque stage: The surface of the porcelain is very
of glass modifier, which lowers the viscosity of glass
porous and will easily absorb water. Grains would have
and makes it more flowable.
started lensing at the contact points. Shrinkage is mini-
l These take part in the glass network and help increase
mal but the porcelain is very weak.
the viscosity of the ceramic.
2. Medium bisque: The surface is still porous but the flow
Boric oxide of the glass grains is increased and entrapped air will
l This serves as a glass former and a glass modifier and become sphere-shaped. A definite shrinkage would have
forms a separate network, which interrupts the silica taken place.
network. 3. High bisque: The surface is completely sealed and pres-
l It lowers the fusion temperature of the glass and reduces ents a smooth texture. At the end of the high bisque stage,
its viscosity while increasing its expansion. the porcelain is very strong but grinding is possible.
Opacifying agents Glazing
l To improve hue and chroma, opacifying agents such as l After the firing is completed, the porcelain is cleaned
cerium oxide, zirconium oxide, titanium oxide or tin and returned to the furnace for final glaze firing. Glaz-
oxide are used. ing reduces surface flaws, seals surface porosities and
l These agents are blended with the unpigmented porce- increases the strength of the porcelain by preventing
lain powder to achieve proper hue and chroma. crack propagation.
l If the glaze is removed by grinding, the porcelain is ii. CAD – computer-aided design:
weakened and is prone to fracture. Using the appropriate software, the computer analyses
the optical impression and designs a virtual 3D model
Glazing may be of two types:
of the cavity preparation and a virtual 3D model of the
(i) Self-glazing.
restoration is created.
(ii) Add-on or overglazing.
iii. CAM – computer-assisted manufacture
l In self-glazing, the complete restoration is heated and an
l The restoration is then fabricated in a milling cham-
external glaze is not applied to the glazing temperature.
ber, which has two motors fitted with diamond-cut-
l This produces a thin glassy film by viscous flow on the
ting tools.
porcelain surface.
l Based on the calculated 3D model of the restoration,
l Add-on or overglazing uses uncoloured glasses with fu-
the computer directs the milling machine to process
sion temperatures lower than the porcelain restoration to
the restoration from prefabricated ceramic blocks.
form an external glaze layer.
l The ceramic blocks may be Dicor MGC (Fluor-
l Usually, self-glazing is preferred as add-on glazing has
mica), Vita Mark II (Feldspathic porcelain), Pro-
several drawbacks.
CAD (Leucite-reinforced), etc.
Drawbacks of add-on or overglazing l It takes 10–20 min to machine the restoration.
l Low chemical durability
l Difficult to apply
CAD/CAM systems may be either chairside or labora-
l Produces an unnatural shiny appearance
tory systems
l Causes shade modification
i. Chairside system:
l The dentist can design and manufacture the restora-
Cooling tion at the chairside in a single appointment without
l Cooling is a very important step in the processing of a
the need for conventional impression, model or
metal ceramic restoration. laboratory support. For example, CEREC 3 system.
l Cooling is done slowly, but too slow and too fast cool-
ii. Laboratory systems:
ing results in cracking. l The clinician either scans the preparation and sends
l This is done by removing the fired metal ceramic resto-
the optical impression to the laboratory or records a
ration from the furnace soon after firing is completed conventional impression and sends the stone model
and placing it under a glass cover to protect it from air to the laboratory.
currents and contamination by dirt. l In the laboratory, the CAD/CAM system designs
and mills the restoration. For example, ProCAD,

SHORT ESSAYS: Lava and Procera.
Q.1. Describe CAD–CAM. Q.2. Discuss porcelain bonded to metal.
Ans. Ans.
CAD/CAM (computer-assisted design/computer-assisted l PFM teeth consist of a cast metallic frame work or core
machining) over which the ceramic is fired.
l CAD/CAM uses computer technology to produce the l They are most widely used in fixed prosthodontics for
restoration in one visit. fabrication of crowns and bridges.

l After the tooth is prepared, the preparation is optically l They provide excellent aesthetics and good strength
scanned and the image is computerized. because of the alloy framework.

l The restoration is designed with the aid of a computer
Metal ceramic alloys
and machined from the machinable ceramic blocks by a
1. Noble metal alloys
computer-assisted milling machine.
l High gold alloys
CAD/CAM systems have three functional components l Gold–platinum–palladium alloys
i. Scanning device: 2. Low gold alloys

l Intraoral camera l Gold–palladium–silver alloys
l Laser l Gold–palladium alloys
ii. CAD system 3. Silver palladium alloys

iii. CAM system l Silver–palladium alloys
i. Scanning device: l Palladium–tin–gallium alloys
Is an intraoral camera or a laser that records an optical 4. Base metal alloys

impression of the prepared tooth, adjacent tooth and l Nickel–chromium alloys
occluding tooth geometry. l Cobalt–chromium alloys

Requirements for metal ceramic restorations v. Can be formed into precise shapes:
l High fusion temperature of the alloy (at least 100°C l A skilled technician can accurately reproduce the
greater than the firing temperature of the ceramic). anatomy of both the occlusal and proximal surfaces
l Low fusion temperature of the ceramic, so that no dis- using ceramics.
tortion of the metal coping occurs. vi. Can be bonded to tooth structure:
l Good wetting of the alloy by the ceramic and good l All ceramic systems can be bonded micromechani-
bonding between the ceramic and metal. cally to tooth structure by acid etching and resin
l Compatible coefficient of thermal expansion of the ce- bonding.
ramic and metal to prevent the ceramic from cracking l The bond is durable and increases the longevity of
during fabrication. ceramic restorations.
l Adequate stiffness, strength and sag resistance of the
alloy. Disadvantages of dental ceramics

l Appropriate design of the tooth preparation so as to al- i. Brittleness:
low enough thickness of the alloy, adequate space for l The fracture resistance of ceramics is not high and
ceramic build-up, etc. ceramic restorations can undergo cracking and
chipping, especially if occlusion is not correctly
Metal-ceramic bond
adjusted.
The bond between the metal and the ceramic is due to:
ii. Technique sensitive:
l Chemical bonding
l Good skill and accuracy is needed for ceramic res-
l Mechanical interlocking
toration as there are several steps in processing of
l Residual compressive stresses
ceramic restoration.
l Chemical bond is mainly due to diffusion between
iii. High cost:
the surface oxides on the alloy and in the ceramic.
l Fabricating ceramic restoration costs very high.
l Mechanical interlocking occurs due to surface irreg-
iv. Wear of natural teeth:
ularity of the alloy.
l Ceramic causes wearing of the opposite tooth, espe-
l Air abrasion with aluminium oxide produces a rough
cially when it has lost its surface glaze.
surface to increase bonding.
v. Difficult to repair intraorally:
l Residual compressive forces are created when an al-
l In case of chipping or cracks in ceramic restoration,
loy with a slightly higher coefficient of thermal ex-
generally complete reconstruction is required as in-
pansion than that of the porcelain are used.
traoral repair is difficult.
l This causes the porcelain to draw towards the coping
when the restoration cools after firing and thus con-

Q.4. Discuss direct composite veneers.
tributes to the bond between the metal and the ce-
ramic due to residual compressive forces. Ans.
Q.3. What are the advantages and disadvantages of por- l Ceramic veneer can be used to modify a tooth’s colour,
celain? shape, length, alignment and to close diastema.
Ans. Indications for ceramic veneers
i. To mask discolourations due to fluorosis, tetracycline
Advantages of dental ceramics
stains, etc.
i. Aesthetics:
ii. To correct enamel hypoplasias and hypocalcifications.
l Porcelain matches the adjacent tooth in colour, trans-
iii. To close diastema between teeth.
lucency and texture and exhibits long-term colour
iv. To correct malocclusion and malpositions of anterior
stability.
teeth.
ii. Biocompatibility:
v. To improve aesthetics in case of several unaesthetic fill-
l Ceramics are chemically inert.
ings in anterior teeth.
l They do not release any harmful substances and their
vi. To mask colour changes due to ageing process.
smooth surface prevents bacterial adhesion.
vii. To correct progressive wear or fracture of anterior
iii. Insulation:
teeth.
l Dental ceramics have low thermal conductivity, ther-
mal diffusivity and electrical conductivity, and are Contraindications for ceramic veneers
therefore excellent electrical and thermal insulators. i. When more of dentine and cementum is exposed and
iv. Wear resistance: there is inadequate enamel left.
l Ceramics have high abrasion resistance due to their ii. In extensive fluorosis, poor enamel quality.
hardness and are not prone to wear. iii. Patients having abnormal oral habits with bruxism.
{SN Q.3} iv. Incisal overlap

l Here, the preparation extends on to lingual side ter-
Advantages minating in a butt joint.
l Aesthetic Advantages
l Good bonding to enamel l Provides a positive seat for luting the veneer.
l Biocompatible with periodontium Disadvantages
l Good abrasion resistance l More extensive tooth preparation.
l Resists fluid absorption
Q.6. Describe porcelain fused to metal (PFM) teeth.
Ans.
Disadvantages
l Technique sensitive and time-consuming
[Same as SE Q.2]
l Ceramic veneers are very fragile Q.7. Define veneers.
l Precise tooth preparation to avoid overcountering
l Expensive
Ans.
l Difficult to repair or modify the colour after cementa- [Same as SE Q.4]
tion
Q.8. Describe veneering materials.
Q.5. Describe incisal lapping preparation for veneers.
Ans.
Ans.
[Same as SE Q.4]
There are four types of incisal preparations in veneers:
i. Window Q.9. Define laminates and veneers.
ii. Feather Ans.
iii. Bevel
iv. Incisal overlap [Same as SE Q.4]
These incisal preparations are described in detail below:

i. Window SHORT NOTES:
l It is also known as intraenamel preparation. Q.1. Define aluminous porcelain.
l Preparation is taken close to but not up to incisal
edge. Ans.
Advantage Alumina-reinforced ceramic:
l Retains natural enamel over the incisal edge. l For example, Hi-Ceram
Disadvantages
l The preparation weakens incisal edge.
Advantages
l Increased tensile and shear strength
l Aesthetically unpleasing as the margins are
l High fracture resistance
obvious.
ii. Feather Disadvantage
l In this preparation even though veneer margin ex- l Increased opacity
tends up to incisal edge, there is no reduction.
Advantage Uses
l As core for crowns and inlays
l Guidance on the natural tooth.
Disadvantages Q.2. Define castable ceramics.

l Veneer is fragile at the incisal edge and can get
dislodged during protrusive movements. Ans.

iii. Bevel l Castable ceramics are supplied as ceramic ingots which
l There is reduction of incisal length and a bevel is are used to fabricate the restoration using a lost-wax and
placed along the entire incisal edge. centrifugal casting technique.
Advantage l The commercially available castable ceramic material
l More control over incisal aesthetics. for dental use is, for example, Dicor.
l Provides a positive seat for veneer placement. l This has a glassy matrix and a crystalline phase and is
Disadvantages composed of 55% tetrasilic fluormica crystals and 45%
l More extensive tooth reduction. glass ceramic.
The material is fabricated as follows: Q.3. Describe advantages of porcelain veneers.

l First a wax pattern in made and invested in a refractory
Ans.
investment.
l After that dewaxing is done and molten glass is cast into [Ref SE Q.4]
the mould using a centrifugal casting machine.
Q.4. Define cerestore.
l Next the cast glass core is recovered and covered by a
protective ‘embedment’ material. It is then subjected to Ans.

a heat treatment process called ‘ceramming’.
[Same as SN Q.2]
l During ‘ceramming’, microscopic plate-like crystals of
crystalline material (mica) grow within the glass matrix. Q.5. Define Dicor.
l After ceramming, the glass core is placed on the refrac-
Ans.
tory die and veneered using feldspathic ceramics like
Dicor Plus. [Same as SN Q.2]
Topic 10
Amalgam Restorations
LONG ESSAYS:
1. Define dental amalgam. Mention the advantages and disadvantages of dental amalgam. Add a note on high
copper amalgam.
2. Classify silver alloys. Discuss the manipulation of amalgam.
3. Describe the causes of failure of amalgam restorations.
4. Write causes of failures of amalgam restoration and how will you manage them? [Same as LE Q.3]
SHORT ESSAYS:
1. Describe trituration of silver amalgam.
2. Discuss condensation of amalgam.
3. Describe metallurgy of silver amalgam.
4. Define mercuroscopic expansion.
5. Define delayed expansion of amalgam.
6. Define mercury toxicity.
7. Describe finishing and polishing of amalgam restoration.
8. Discuss tarnish and corrosion.
9. Discuss delayed expansion. [Same as SE Q.5]
10. Define corrosion. [Same as SE Q.8]
SHORT NOTES:
1 . Define mercury hygiene.
2. Define mulling of amalgam.
3. Define trituration.
4. Describe non-g phase.
5. Define hygroscopic expansion. [Ref SE Q.5]
6. Define marginal leakage of restorations.
7. Describe Eames’ technique.
8. Define mercury hygiene. [Same as SN Q.1]

9. Define polishing of silver amalgam.
10. Define tarnish and corrosion. [Ref SE Q.8]
11. Define zinc-free amalgam.
12. Define original g phase. [Same as SN Q.4]
13. Define delayed expansion.
14. Define microleakage around restoration. [Same as SN Q.6]
15. Define tarnish and corrosion in amalgam. [Same as SE Q.8]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Define dental amalgam. Mention the advantages Advantages of amalgam restorations
and disadvantages of dental amalgam. Add a note on 1 . Ease of use:
high copper amalgam. l Simple and easy to manipulate. Minimal amount of
Ans. time is required and least technique sensitive.

2. High compressive strength:
l Dental amalgam is an alloy of mercury with silver, tin l Amalgam exhibits good compressive strength.
and varying amounts of copper, zinc and other minor 3. Excellent wear resistance:
ingredients. l Good wear resistance and hence are used in patients
Classification of dental amalgam alloys with moderate-to-heavy occlusal stresses.

There are several ways of classifying amalgam alloys. 4. Favourable long-term clinical results:
These include: l Well-placed amalgam restorations are durable and
(1) According to the number of alloyed metals last for several years.
(a) Binary alloys – contain silver and tin. 5. Economic:
(b) Ternary alloys – contain silver, tin and copper. l The cost of silver amalgam is lesser than composite,
(c) Quaternary alloys – contain silver, tin, copper and ceramic or cast restorations.
zinc or indium. 6. Can be bonded to tooth structure:
(2) According to the shape of the particles l Amalgam restorations can also be bonded to tooth
(a) Irregular – alloy particles are irregular in shape in structure which affords better bonding and strength-
the form of spindles or shavings. ening of the remaining tooth structure.
(b) Spherical – alloy particles have a smooth spherical 7. Self-sealing ability:
shape. l Corrosion products formed at the interface of the
(c) Spheroidal – alloy particles are spherical with ir- amalgam restoration and the tooth tend to seal the
regular surfaces. amalgam against leakage and bacterial invasion.
(3) According to the copper content of the alloy Disadvantages of amalgam restorations
(a) Low copper alloys – contain copper in the range of 1. Lack of aesthetics:
2%–6%. l Amalgam is silvery grey in colour and hence aes-
(b) High copper alloys – contain copper in the range of thetically not acceptable.
12%–30%. 2. Less conservative:
(4) According to zinc content l Cavity preparation for amalgam requires removal of
(a) Zinc-containing alloys – contain zinc in the range more tooth structure, for retention feature.
of 0.01%–1%. 3. Noninsulating:
(b) Zinc-free alloys – contain less than 0.01%. l Being a metallic restoration, amalgam conducts ther-
(c) Single-composition or unicompositional alloys – each mal sensations to the underlying tooth structure and
particle of the alloy has the same chemical composition. hence is noninsulating.
(d) Admixed restorative – these alloys are a physic 4. Corrosion and galvanism:
blend of lathe cut and spherical particles. l Amalgams are susceptible to tarnish and corrosion.
(5) According to the presence of noble metals l Corrosion causes discolouration of the surrounding
(a) Noble metal alloys – contain small amounts of pal- tooth structure.
ladium or gold. l Silver amalgam is also prone to galvanic corrosion
(b) Non-noble metal alloys – do not contain any noble when placed adjacent to or opposing a gold
metals. restoration.
5. Lack of reinforcement of weakened tooth structure: Final set material consists of:
l Amalgam is not strong enough to support and rein- Core
force weakened tooth structure unless bonded. l Unreacted Ag3Sn (g phase)
6. Difficulty in restoring proper anatomy: l Unreacted Ag–Cu surrounded by Cu6Sn5(h)
l In complex situations, it is difficult to restore proper Matrix

anatomy using amalgam. l g1 phase is (Ag2Hg3).
Where (g) phase is Ag3Sn; (g1) phase is Ag2Hg3; (h) is

High copper alloy
Cu6Sn5 and Ag–Cu is eutectic.
Admixed alloy powder
Single-composition alloys
i. The overall composition of admixed alloy powder is
In single-composition alloy, each particle of the alloy
powder has the same composition. Therefore, they are
Silver 69% called single-composition or ‘unicompositional alloys’.
Tin 17% Composition
Copper 13%
Silver 40%–60%
Zinc 1%
Tin 22%–30%
Copper 13%–30%
ii. The total copper content ranges from 9 to 20 weight% Zinc 0%–4%
in admixed alloy powders which usually contain 30 –55
Indium or palladium Small amounts
weight% spherical high copper powder.
iii. Setting reaction:
l Silver enters the mercury from the silver–copper Setting reaction
eutectic alloy particles, and both silver and tin en- When triturated, silver and tin from Ag–Sn phases
ter the mercury from the silver–tin alloy particles. dissolve in mercury. Very little copper dissolves in mer-
The mercury dissolved in the silver–tin particles cury. The Ag2Hg3 (gl) crystals grow forming a matrix that
will react like low copper alloys and will form the binds together the partially dissolved alloy particles.
gl and g2 phases, leaving some silver–tin particles Later, h (Cu6Sn5) crystals are formed at the surface of
unreacted. alloy particles.
l The newly formed g2 phase (Sn8Hg) will react with The overall reaction is as below:
silver–copper particles forming Cu6Sn5 (h or eta)
phase. Some g1 phase (Ag2Hg3) will also form AgSnCu Hg → Cu 6 Sn 5 Ag2 Hg3 AgSnCu
around the silver–copper particles. ( E ) () (1 ) ( unreacted)
l The reaction may be shown as follows:
The difference between the elimination of the g2 phase

Ag3Sn Ag-Cu Hg → Ag2 Hg3 Sn8 Hg in an admixed and unicompositional alloy is that in the
admixed type, the g2 forms around the silver–tin (lathe cut)
() (eutecctic) (1 ) (2 ) particles and is eliminated around the silver–copper (spher-
Ag3Sn unreacted Ag-Cu unnreacted ical) particles. In unicompositional alloy, the particles at the
() (eutectic) beginning of the reaction function like silver–tin particles
of the admixed type, and later the same particles function
and later ,
like the silver–copper particles of the admixed type, elimi-
Sn 6 Hg Ag-Cu → Cu 6 Sn 5 Ag2 Hg3 nating g2 phase.
( 2 ) (eutectic) ( ) (1 )
Microstructure of set amalgam
Final set material consists of:
In the above reaction, g2 has been eliminated and is re- Core
placed by h-phase. To accomplish this, it is necessary to l Unreacted Ag3Sn (g phase)
have a net copper content of at least 12% in the alloy l Unreacted Ag–Cu (E)
powder. Matrix
l g1 (Ag2Hg3 ).
Microstructure of set amalgam
The Cu6Sn5 is present surrounding as a ‘halo’ around Cu6Sn5 (h) is present in the g1 matrix rather than as a
the Ag–Cu particles. halo surrounding Ag–Cu.
Applications (uses) ii. Dimensional change:

i. As a permanent filling material in: l Amalgam may expand or contract, depending on its
Class I, class II and class V cavities where aesthetics is manipulation. Ideally, dimensional change should
not important be small.
ii. In combination with retentive pins to restore a crown l Measurement of dimensional change: American
iii. For making dies Dental Association (ADA) specification no. 1 re-
iv. In retrograde root canal fillings quires that amalgam should not expand or contract
v. As a core material . 20 microns/cm at 37°C, between 5 min and 24 h
Q.2. Classify silver alloys. Discuss the manipulation of from the beginning of trituration.
amalgam. iii. Strength:
Hardened amalgams have good compressive strength.
Ans.
Types of amalgam alloys Compressive
A. Based on copper content strength 1h 7 days
Low copper 145 MPa 343 MPa
Low copper alloys High copper alloys
Admixed 137 MPa 431 MPa
Contain less than 6% copper l Contain more than 6%
(conventional alloys) copper Single composition 262 MPa 510 MPa
l Single composition or uni-

compositional alloys Tensile strength:
l Amalgam cannot withstand high tensile or bending
l Admixed or dispersion or
blended alloys stresses.
l The cavity design should be such that the restora-
B. Based on zinc content tion will receive compression forces and minimize
tension or shear forces in service.
Zinc-containing alloys Zinc-free alloys l The tensile strength is 48–70 MPa.
Contain more than 0.01% Contain less than 0.01% zinc iv. Creep:
zinc l Creep is defined as a time-dependent plastic defor-
mation.
C. Based on shape of the alloy particle l Creep of dental amalgam is a slow progressive per-
manent deformation of set amalgam, which occurs

Lathe cut alloys Spherical alloys Spheroidal alloys
under constant stress (static creep) or intermittent
Irregular shape stress (dynamic creep).
D. Based on number of alloyed metals Creep values:
Binary alloys Ternary alloys Quaternary alloys Low copper amalgam 0.8%–8.0%
Silver–tin Silver–tin–copper Silver–tin–copper– High copper amalgam 0.4%–0.1%
indium
v. Retention of amalgam:
E. Based on size of alloy
l Amalgam does not adhere to tooth structure.
Microcut alloy Macrocut alloy l Rather retention of the amalgam filling is obtained
through mechanical locking. This is achieved by

proper cavity design.
Properties of amalgam
l Additional retention if needed can be obtained by
i. Microleakage:
placing pins within the cavity.
l Dental amalgam has tendency to minimize mar-
vi. Tarnish and corrosion:
ginal leakage.
Amalgam restorations often tarnish, and corrode in the
l It is a self-sealing material. The small amount of
mouth.
leakage under amalgam restorations is unique. The
leakage decreases as the restoration ages in the Manipulation of amalgam
mouth due to the corrosion products that form in the Stages of manipulation of amalgam alloy
tooth-restoration interface. These products over a i. Selection of materials:
period of time seal the interface and thereby prevent l Alloys for amalgam should be selected from prod-
leakage. Thus, amalgam is a self-sealing restoration. ucts certified to meet or exceed the properties listed
in ADA specification no. 1 for dental amalgam l Amalgam should be carved using sharp instruments
alloys. with strokes proceeding from tooth surface to amal-
l There is only one requisite for selection of dental gam surface.
mercury, that is its purity. vii. Burnishing:
l The delivery system provided by the manufacturer l After the carving, the restoration should be smooth-
is convenient, expedient and capable of reducing ened by burnishing the surface and the margins of
human errors or variables. the restoration.
l Preproportioned capsules containing alloy parti- l Burnishing of the occlusal anatomy can be done by
cles and mercury in compartments separated by a using a ball burnisher with light-stroke proceeding
membrane are available; before use, the mem- from the amalgam surface to the tooth surface.
brane is ruptured by compression of the capsule, l More pressure should not be applied and heat gen-
and the capsule is then placed in a mechanical eration should be avoided during burnishing.
amalgamator. l If the temperature rises above 60°C, it causes re-
ii. Mercury:alloy ratio (proportioning): lease of mercury, which will accelerate corrosion
l The better method of reducing the mercury content and fracture at margins. Final smoothing can be
is to reduce the original mercury:alloy ratio. This done by rubbing the surface with a moist cotton
method is known as the minimal mercury or the pellet or by a rubber-polishing cup and polishing
Eames technique (mercury:alloy – 1:1). paste.
iii. Trituration: viii. Polishing:
l The main objective of trituration is to wet all of the l The objective of finishing and polishing is the re-
surfaces of the alloy particles with mercury. moval of superficial scratches and irregularities.
l Trituration is achieved either by hand or more com- l This minimizes corrosion and prevents adherence
monly by mechanical amalgamators. of plaque.

A. Hand mixing: a glass mortar and the pestle are l The polishing should be delayed for at least 24 h
used. after condensation, or preferably longer.

B. Mechanical trituration: mechanical amalgam- l Wet polishing is advised, so a wet abrasive in a
ators are used to triturate. paste form is used. Dry polishing powders and
l With a mechanical amalgamator, the mixing time is discs can raise the temperature above 60°C.
reduced and the procedure is more readily stan- Q.3. Describe the causes of failure of amalgam resto-
dardized. The amalgamators have automatic timer rations.
and speed control device.
iv. Mulling: Ans.
l Mulling is actually continuation of trituration. It is Failures of amalgam restorations
done to improve the homogeneity of the mass and Improper preparation of the cavity is considered to be
get a consistent mix. the most common cause of tile failure of silver amalgam
v. Condensation: restoration. The factors that govern the quality of the amal-
l The amalgam is placed in the cavity after tritura- gam restoration are broadly divided into:
tion, and force is applied to the amalgam using A. Factors controlled by manufactures:
suitable instruments in order to adapt it to the cav- These include:
ity wall. a. Composition of the silver alloy
l Removes excess mercury. b. Manufacturing process of alloy
l Enhances packing of amalgam and reduces the B. Factors controlled by the dentist and his auxiliary
risk of void formation. This increases the include:
strength and decreases the creep of the amal- a. Improper cavity preparation
gam. Condensation can be effected manually or b. Improper in lining
mechanically. c. Manipulation of dental amalgam
vi. Trimming and carving: d. Defects in filling
l After the amalgam is overfilled into the prepared e. Defects in carving
cavity, the mercury-rich layer can be trimmed away f. Defects in burnishing
and filling is carved to reproduce the proper tooth g. Defects in finishing and polishing
anatomy. A. Factors controlled by manufactures
l The carving should not be started until the amal- Composition of silver alloy
gam is hard enough to offer resistance to the carv- l Excess silver: Minimum quality of silver in alloy
ing instrument. powder should be 65%. This decreases the rate of

setting of amalgam, but in above 70% will result 4. Presence of g2 phase:

in higher expansion of the amalgam restoration. l g2 phase is the weakest phase in amalgam,
l Excess tin: Tin produces contraction compensat- formed by hexagonal tin–mercury compound
ing the expansion produced by silver and having (Sn8Hg). The hardness of g2 phase is approxi-
greater affinity for mercury, speeds up the amal- mately 10% of gamma-1 and the g-phase
gamation. But, it also reduces the compressive hardness is somewhat higher than that of
strength and increases the flow of the amalgam. gamma-1.
l Copper content: Copper minimizes the flow of l The g2 phase is also the least stable in a cor-
the restoration and increases the crushing strength rosive environment, and consequently the g2
and setting expansion. phase may suffer corrosion attack, especially
l Nowadays, with the advent of high copper alloys in crevices of restorations.
which contain a minimum of 10% copper, amal- Hence, all measures must be taken to reduce the
gam restorations with more strength and increased g2 phase as much as possible to get a stronger and
resistance to corrosion can be obtained. more corrosion resistant amalgam restoration.
l Presence of zinc: Alloys with zinc have a slightly This can be achieved by addition of copper, in-
higher compressive strength and the resultant res- dium, platinum, etc.
toration is less apt for tarnish and corrosion and 5. Presence of g1 phase:
will take a better polish. l The g1 phase, i.e. alloy mercury (Ag2Hg3) is
l But when contaminated with moisture, it causes one of the amalgamation products that forms
delayed expansion of the amalgam restoration part of the matrix, joining the original Ag3Sn
that can be seen only after 3 days of placing the (g phase) particles. Comparatively, it is the
restoration. noblest phase, i.e. the most resistant to tarnish
l Recently, alloys containing very little or no zinc and corrosion and every effort is made to al-
have come into the market. When zinc content is low this phase to occupy the maximum avail-
0.01% or less they are plastic and less workable, able space in the bonding matrix of the final
it is more susceptible to oxidation. product.
Manufacturing process of the alloy 6. The original g phase:
1. Heat treatment of the alloy: l The g phase (Ag 3Sn) is the one which has
l Due to the rapid cast cooling conditions, the not been completely dissolved in mercury.
ingot of a silver–tin alloy has a cored structure Mechanically, this is the strongest phase and
and contains nonhomogeneous grains of vary- for this reason, it should occupy the maxi-
ing composition. mum available space in the volume of the
l In order to re-establish the equilibrium phase restoration.
relationship, a homogenizing heat treatment is 7. The mercury phase:
performed. l This is the unreacted, residual mercury present
2. Ageing: in isolated areas within the amalgam mass.

l The microstresses induced into the particle Though it will continue to diffuse and react
during cutting and ball milling must be re- with the g phase or any other present or future
lieved. If not, they will slowly release over a phases, this reaction rate is very low and in-
period of time, causing a change in the alloy; complete.
particularly in the rate at which amalgamation Mechanically, this is the weakest phase in the
will occur and the dimensional change that produced mass and when it exceeds a certain vol-
will occur during hardening. The process is ume limit, there will be a drastic drop in the
called ageing and involves an annealing cycle strength and hardness properties of the amalgam
at a moderate temperature. Usually, ageing is in addition to an increase in the flow and creep of
done several hours at approximately 100°C. the restoration.
3. Surface treatment of particles: B. Factors controlled by the dentist and his auxiliary
l The exact function of this treatment is still not I. Cavity preparation
entirely understood, but it is probably related (i). Too shallow cavity:
to preferential dissolution of specific compo- The optimum depth of the cavity for amal-
nents from the alloy. gam restoration should be at least 1.5 mm.
Amalgams made from acid washed powder tend If the depth is less than this, the amalgam
to be more reactive than those made from un- restoration cannot withstand the mastica-
washed powders. tory forces as it is very weak when not in
minimum bulk and results in fracture and (ix). Absence of undercuts:

pitting of the restoration. Absence of undercuts results in loss of re-
(ii). Too deep cavity: tention leading to easy dislodgement of the
If the depth of the cavity is too deep, the amalgam restoration.
width of the cement base should be suffi- (x). Dovetail with only one cornu:
cient to inhibit the thermal conductivity Only one cornu of dovetail may lead to loos
through amalgam restoration, otherwise re- of retention and resistance to dislodgement
sulting in hyperaemia of pulp and other resulting in proximal creep of restoration or
complications. loss of restoration.
(iii). Sharp axiopulpal line angle: (xi). Cavosurface angle is more or less than 90°:
Axiopulpal line angle is the joining part of Cavosurface angle more than 90° will result
the proximal and occlusal preparations of a in week amalgam margin and as edge
class II cavity. It is very significant with re- strength of amalgam is very less, it leads to
gard to life of amalgam restoration. fracture of the margin.
A sharp axiopulpal line angle means that the When the angle is less than 90°, this will
surface area is very less and there is every lead to weak enamel margin resulting in
chance for it to fracture during mastication fracture or detaching of the enamel margins.
as a small area has to withstand all the oc- (xii). Reverse curve:
clusal forces acting on isthmus. This is a reverse ‘S’-shaped curve seen in
Hence, it is advised to round off the ax- class II cavity preparations on molar teeth.
iopulpal line angle always during cavity It is more prominent on buccoproximal sur-
preparation. This increases the surface area face than the linguoproximal surface.
and can withstand the occlusal forces. It gives more bulk to the amalgam restora-
(iv). Gingival step not horizontal: tion, making it stronger. The curve is ob-
The gingival step in the proximal box tained at the junction of buccoocclusal and
should always be horizontal to provide buccoproximal interface.
proper resistance form. If it is not horizon- Absence of reverse curve results in less bulk
tal and is sloping towards proximal, the of amalgam restoration leading to fracture
amalgam restoration might fractures right of the restoration.
through the isthmus. II. Manipulation of dental amalgam
(v). Narrow isthmus: (i). Excess alloy powder:
Isthmus is the joining portion between the Presence of silver alloy in higher amounts in
occlusal and proximal preparation of cavity. set product will result in a grainy restoration
The optimum width of the bathmus should and the restoration is more prone for corro-
be at least the intercuspal distance. If it is sion. The amalgam restoration is weak and
too narrow, there will be inadequate bulk of porous and difficult to condense.
amalgam restoration resulting in fracture of (ii). Excess mercury:
the restoration. This results in low compressive strength and
(vi). Wide isthmus: high creep values leading to failure of amal-
A wider isthmus will result in loss of reten- gam restoration.
tion and the amalgam restoration is prone (iii). Overtrituration:
for fracture. Overtrituration of amalgam material will
(vii). Sharp angles in the outline form: lead to contraction of the restoration upon
Sharp angles result in stress concentration, setting. The optimum time for trituration of
thereby fracture of restoration or the tooth amalgam should be 45–60 s.
occurs. Hence, all angles should be (iv). Undertrituration:
rounded so as to increase the surface area, An undertriturated amalgam is more grainy.
so that the stresses will be distributed all The restoration made from this mix will be
over. weak and also the rough surface left after
(viii). Excessive removal of tooth structure: the carving of the granular amalgam will
Excess removal of tooth structure leads to decrease the tarnish resistance.
undermining of enamel and weakens the (v). Excessive pressure on pestle while mixing:
tooth and later resulting in fracture of the Excess pressure on pestle during mixing
tooth. will result in comminution of the alloy
grains and subsequent contraction of the (x). Cusps restored in amalgam to inadequate depth:
amalgam. When cusps are not restored to the adequate
(vi). Condensation of amalgam with sweat from height, there will be insufficient depth for
fingers: strength and may result in fracture of the
When contaminated with sweat, the restora- amalgam cusp.
tion becomes porous and may also exhibit (xi). Surface left high in bite:
delayed expansion, if the alloy contains zinc. If amalgam is high in bite, it will result ei-
III. Condensation of amalgam ther in the fracture of amalgam restoration
(i). Inserting large amounts of amalgam: or severe postoperative pain to the patient.
Small increments should be used to con- Patient will be unable to eat or chew.
dense the amalgam into the cavity prepara- (xii). No wedges used:
tion. Inserting large amounts to condense If wedge is not used during condensation of
thoroughly is very difficult and has a ten- dental amalgam in a class II cavity preparation,
dency to porosity and deficient margins. the pressure of condensation may force amal-
(ii). Initiating condensation with large condensers: gam into the gingival crevices, resulting in
If large condensers are used in the begin- gingival overhangs, which irritates the gingiva
ning of the condensation, undercuts and and later might lead to periodontal problems.
margins will not be filled thoroughly with Hence, a wedge should always be applied
amalgam resulting in inadequate retention. during class II cavity filling to prevent gin-
(iii). Condensing amalgam which is too rich in gival overhang.
mercury: (xiii). Improper placement of matrix band:
Amalgam too rich in mercury is difficult to Matrix band should be placed properly for
condense and hence the restoration tends to condensation of amalgam to provide for the
be weak and porous. missing wall of the cavity preparation. Inad-
(iv). Amalgam squeezed too dry: equate placement of matrix band will result
Too dry amalgam mix is again difficult to in gingival overhangs, defective embrasures,
condense and look of cohesion of layers etc., leading to periodontal problems.
leads to bridging and a weak restoration. (xiv). Failure to ensure proximal contact:
(v). Condensation of partly crystallized amalgam: The proximal contact with the neighbouring
Condensing the partly crystallized amalgam tooth should be restored properly; other-
will result in a weak and porous restoration wise, excess space between the two teeth
which is prone for fracture and corrosion. will result in food lodgement, fracture of the
(vi). Failure to condense amalgam towards margins: restoration and later periodontal problems.
Failure to condense the amalgam mix to- (xv). Contamination of zinc-containing amalgam
wards the margins of cavosurface triangles with saliva:
will result in marginal deficiencies and de- Zinc-containing amalgam alloys when con-
taching of the material. taminated with saliva or moisture may result in
(vii). Insufficient amalgam mixed: delayed expansion of the amalgam restoration.
If the amalgam mix is not sufficient and the The delayed expansion is related with the
surface not over built before carving, the sur- zinc in the amalgam. This is not seen in non-
face layers will become too rich in mercury zinc amalgams. One of the products of the
resulting in a weak and porous restoration. reaction of water and zinc is hydrogen. It is
(viii). Excess amalgam left beyond cavosurface produced by the electrolytic action between
margins: the zinc and the electrolyte elements present.
No excess amalgam should be left beyond This hydrogen does not combine with the
the cavosurface margins. Otherwise, this amalgam constituents but rather collects
excess amalgam will fracture leaving rough within the restoration. The internal pressure
and deficient margins. of the hydrogen may build up to levels high
(ix). Condensing amalgam with serrated plug- enough to cause the amalgam to creep, thus
gers with set amalgam in serrations: producing the observed expansion.
The set amalgam in serrations, if not re- Delayed expansion usually stains after 3–5
moved and the same plugger is used to days and may continue for months reaching
condense a new amalgam restoration, may values greater than 400 microns (4%). This
contaminate the restoration and weaken it. is also known as secondary expansion.
The contamination must occur during tritu- Q.4. Write causes of failures of amalgam restoration
ration or condensation. and how will you manage them?
This expansion may also cause postopera-
tive pain, 10–12 days after the insertion of Ans.
the restoration. [Same as LE Q.3]
(xvi). Voids in amalgam:
Voids occur in amalgam restoration as the
process of building of amalgam restoration SHORT ESSAYS:
traps air bubbles despite the most meticu- Q.1. Describe trituration of silver amalgam.
lous procedures to avoid. Such voids act as
nidi not only for internal corrosion but also Ans.
for stress concentration and propagation. Trituration
Both lead to early failure of the structure of l Trituration is the process of combining or mixing of
the restoration. liquid mercury with dry amalgam alloy powder.
(xvii). Failure to support proximal part of restora- l Trituration can be performed with hand or mechanical
tion when removing matrix: amalgamators.
This may cause immediate or delayed frac-
l Objective is to wet all the surfaces of the alloy particles
ture of the marginal ridge.
with mercury.
IV. Carving i. Trituration is the mixing procedure to remove the
The object of carving is to simulate the anatomy. It oxide film by friction and enhance the amalgamation
should not be started until the amalgam is suffi- reactions.
ciently hard to offer resistance to the carving instru- Trituration can be carried out by either of two
ment. A scraping or ringing sound should be heard. methods:
(i). Fissures carved too deep: a. Hand trituration using glass mortar and pestle
If development fissures are carved too deep, b. Mechanical trituration by using amalgamators
it weakens the restoration and diminishes
functional efficiency. It also results in food Hand mixing
stagnation leading to tarnish and corrosion. l A glass mortar and pestle are used.
(ii). Restoration carved from amalgam to enamel: l The mortar has its inner surface roughened to increase
If carving is done from restoration towards the friction between amalgam and glass surface.
enamel, it might produce marginal deficien- l A rough surface can be maintained by occasional grind-
cies leading to food lodgement, tarnish and ing with carborundum paste.
corrosion. l The three factors to obtain a well-mixed amalgam
V. Burnishing mass are

Burnishing of slow setting alloys can damage the i. The number of rotations
margins of the restoration. Hence, when such an ii. The speed of rotation
alloy is used, burnishing should not be done. iii. The magnitude of pressure placed on the pestle
Undue pressure should not be exerted and heat
Typically, a 25–45 s period is sufficient.
generation should be avoided. Any temperature
above 60°C (140°F) causes release of mercury. Mechanical trituration
This mercury at the margins results in accelerated Mechanical amalgamators are more commonly used to
corrosion and fracture of the restoration. triturate amalgam alloy and mercury.
VI. Polishing l The disposable capsule serves as a mortar.
(i). Failure to polish: l A cylindrical metal or plastic piston is placed in the
Failure to polish the amalgam restoration capsule, which serves as the pestle.
leaves rough surface leading to tarnish and l The capsule is inserted between the arms on top of the
corrosion. machines.
(ii). Overheating when polishing: l When put on, the arms holding the capsule oscillate at
Excess heat during polishing releases mer- high speed, thus triturating the amalgam.
cury and causes porosity. l Reusable capsules are available with friction fit or
(iii). Failure to polish the proximal surface: screw-type lids. At one time, not more than two pellets
If the proximal surface of the restoration is alloy should be mixed in a capsule.
not polished, it will result in food stagnation, l With either type, the lid should fit the capsule tightly,
tarnish and corrosion. otherwise, the mercury will spray out from the capsule,
and the inhalation of fine mist of mercury droplets is a l The remainder will assist bonding with the next incre-
health hazard. ment. Modern amalgams are fast setting, and so work-
l The amalgamators have automatic timer and speed coning time is short.
trol device. The speed used is recommended by the manu- l Therefore, condensation should be as rapid as possible.
facturer. High copper alloys require higher mixing speeds. l A fresh mix of amalgam should be ready, if condensa-
l Spherical alloys usually require less amalgamation tion takes more than 3–4 min.
time than do lathe cut alloys. A large mix requires l Long delay between mixing and condensation results in
slightly longer mixing time than a smaller one. weaker amalgam and increased mercury content and creep.
l Spherical alloys have little ‘body’ and thus offers only
Advantages of mechanical trituration
mild resistance to the condensation force. When condens-
i. Shorter mixing time
ing these alloys large condensation force can be used.
ii. More standardized procedure
iii. Requires less mercury when compared to hand mixing Q.3. Describe metallurgy of silver amalgam.
technique
Ans.
Q.2. Discuss condensation of amalgam. l The recommended mercury/alloy ratios for most mod-
ern lathe cut alloys are approximately 1:1 or 50% mer-
Ans.
cury according to Eames’ minimum mercury technique.
Condensation l The mercury/alloy ratio by volume is 1:1.5 as the density
The amalgam is placed in the cavity after trituration, of mercury is 1.5 times the powder. The volume dispens-
and packed (condensed) using suitable instruments. ers are now incorporated in the amalgamator itself.
I. The composition of low copper amalgam alloys
Aims (lathe cut or spherical):
1. To adapt it to the cavity wall
2. Remove excess mercury Silver 63%–70%
3. Reduce voids
Tin 26%–28%
l This increases the strength and decreases the creep of
the amalgam. Copper 2%–5% (,6%)

l Condensation must always be accomplished within Zinc 0%–2%
the four walls and floor.
l If one or more walls of the cavity are missing, a stain- II. The composition of high copper amalgam alloys:
less steel matrix may be used to compensate for it. a. Admix or disperse alloy:
Condensers Silver 50%–60%

l Condensers are instruments with serrated tips of differ-
Tin 20%–25%
ent shapes and sizes.
Copper 13%–30%
l The shapes are oval, crescent, trapezoidal, triangular,
circular or square. Zinc 0%–2%

l The condenser type is selected as per the area and shape
of the cavity. b. Single-composition alloy:

l Smaller the condenser, greater is the pressure exerted on
Silver 40%–60%
the amalgam.
Tin 22%–30%
l Condensation can be done manually or mechanically.
Copper 13%–30%
Manual condensation
l The mixed material is packed in increments. Zinc 0%–4%
l Each increment is carried to the prepared cavity by
means of small forceps or an amalgam carrier. Q.4. Define mercuroscopic expansion.

l Once inserted, it should be condensed immediately with
Ans.
sufficient pressure (approximately 3–4 pounds).
l Condensation is started at the centre, and the condenser Mercuroscopic expansion
point is stepped little by little towards the cavity walls. l During electrochemical corrosion of low copper amal-
l As the mix is condensed, some mercury-rich material gams, the thinner curve phase (Sn7Hg) oxidizes into tin
rises to the surface. oxide and/or tin oxychloride.
l Some of this can be removed to reduce the final mercury l Electrochemical corrosion of the g2 phase does not ap-
content and improve the mechanical properties. pear to release mercury into the oral environment.
l Rather, the mercury immediately reacts with the locally Precautions

available silver and tin from residual amalgam alloy l The clinic should be well ventilated.
particles and is reconsumed to form more reaction prod- l All excess mercury and amalgam waste should be
ucts, which produces further expansion of the amalgam. stored in well-sealed containers.
l This mechanism is explained as mercuroscopic expan- l To avoid environmental pollution, proper disposal sys-
sion by Jorgensen and is seen only in low copper amal- tem should be followed.
gam. l Amalgam scrap and materials contaminated with mercury
l This is responsible for extrusion of amalgam at the mar- or amalgam should not be subjected to heat sterilization.
gins followed by marginal fracture or ditching. l Spilled mercury is cleaned as soon as possible as it is
extremely difficult to clean it from carpets.

Q.5. Define delayed expansion of amalgam.
l Vacuum cleaners should not be used because they dis-
Ans. perse the mercury further through the exhaust.

l Mercury suppressant powders are helpful but are tem-
porary measures.
{SN Q.5} l Skin contacted with mercury should be washed with
soap and water.

l If a zinc-containing low copper or high copper amal-
l The alloy mercury capsules should have a tightly fitting
gam is contaminated by moisture during trituration
cap to avoid leakage. While removing old fillings, a
or condensation, a large expansion can take place
water spray, mouth mask and suction should be used.
which starts after 3–5 days and may continue for
l The use of ultrasonic amalgam condenser is not recom-
months, reaching values greater than 400 urn (4%).
mended as a spray of small mercury droplets is observed
l This is known as delayed expansion or secondary
surrounding condenser point during condensation.
expansion:
l Annually, a program for handling toxic materials should
l This hydrogen gas does not combine with the amal-
be monitored for actual exposure levels.
gam, but collects within the restoration, which cre-
ates extreme internal pressure and expansion of the Q.7. Describe finishing and polishing of amalgam
mass. restoration.
l This causes protrusion of the restoration out of the Ans.
cavity, increased creep, increased microleakage, pit- Finishing and polishing
ted surfaces and corrosion.
Burnishing
l Dental pain, recurrence of caries and fracture of the
l The restoration should be smoothened after the carving by
restoration are seen as a result of these poorly in-
burnishing the surface and the margins of the restoration.
serted restorations.
l Burnishing of the occlusal anatomy can be done by us-
ing a ball burnisher with light-stroke proceeding from

the amalgam surface to the tooth surface.
Q.6. Define mercury toxicity. l More pressure should not be applied and heat genera-
tion should be avoided during burnishing.
Ans.
l If the temperature rises above 60°C, it causes release of
Mercury toxicity mercury, which will accelerate corrosion and fracture at
l Mercury is toxic. Free mercury should not be sprayed or margins. Final smoothing can be done by rubbing the
exposed to the atmosphere. This hazard can arise during surface with a moist cotton pellet or by a rubber-polishing
trituration, condensation and finishing of the restora- cup and polishing paste.
tion, and during the removal of old restorations at high l Polishing should be done in order to produce a smooth
speed. and shiny surface for the restoration.
l Skin contact with mercury should be avoided as it can l Polishing is done using the amalgam-polishing kit.
be absorbed. l Polishing is done 24 h after restoration is placed, when
l Any excess mercury should not be allowed to get into the amalgam would have gained most of its strength.
the sink, as it reacts with some of the alloys used in l The removal of superficial scratches and irregularities is
plumbing. the objective of finishing and polishing.
l It also reacts with gold ornaments. l This minimizes corrosion and prevents adherence of
l Mercury has a cumulative toxic effect. plaque.
l Dentists and dental assistants are at high risk. l Wet polishing is advised, so a wet abrasive in a paste
l Though it can be absorbed by the skin or by ingestion, form is used. Dry polishing powders and discs can raise
the primary risk is from inhalation. the temperature above 60°C.
Steps l Wear professional clothing only, with protective

1. Inspect for ‘high spots’ on the shiny area of the restora- masks, gloves and safety glasses to prevents inhalation
tion which is burnished. or direct skin contact with mercury or freshly mixed
2. Reduce high spots carefully with a steel finishing bur amalgam.
run lightly over the surface. l Store mercury in unbreakable containers and avoid bulk
3. Use a series of finishing abrasive points run with a light mercury spill.
uniform touch and constant movement over the amal- l Area should be well-ventilated.
gam surface. Take care not to damage the carving or l Scrape amalgam should be stored in a radiographic fixer
overheating the amalgam. solution covered container. Water and glycerine can also
l When the surface appears satiny, polishing can be done. be used.
l This can be done using a soft rubber cup and an abra- l Monitor the mercury vapour level in the dental office
sive paste like pumice slurry. from time to time using dosimeter badges.
l Use of tin oxide mixed with water produces a high shine. l Monitor dental office personnel periodically. Average
mercury level permissible in urine is 16.1 microgram/L.

Q.8. Discuss tarnish and corrosion.
l Know the various possible symptoms of mercury
Ans. exposure.
Tarnish and corrosion
Q.2. Define mulling of amalgam.
{SN Q.10} Ans.
Factors related to excess tarnish and corrosion l Mulling of amalgam is a step done after trituration.
l High residual mercury l To make the mix homogenous and cohesive.
l Surface texture – small scratches and exposed voids l In hand mixing using a mortar and pestle, mulling is
l Contact of dissimilar metals, e.g. gold and amalgam achieved by collecting the amalgam in a dry piece of
l Patients on a high sulphur diet rubber dam or chamois skin and rubbing it vigorously
l Moisture contamination during condensation between the thumb and forefinger for 2–5 s.
l Type of alloy – low copper amalgam is more suscep- l While mixing in an amalgamator, mulling is done by
tible to corrosion (due to greater y2 content) than continuing the trituration for an additional 2–3 s.
high copper. Also h(Cu6Sn5) phase of high copper is
less susceptible to corrosion. Q.3. Define trituration.
l A high copper amalgam is cathodic in respect to a
Ans.
low copper amalgam. So, mixed high copper and low
copper restorations should be avoided. l Trituration is the process of combining or mixing of
Corrosion of amalgam can be reduced by: liquid mercury with dry amalgam alloy powder.
l Trituration can be performed with hand or mechanical
l smoothing and polishing the restoration
l correct Hg/alloy ratio and proper manipulation

amalgamators. The objective of trituration is to remove
l avoid dissimilar metals including mixing of high and
the oxide coating and wet each alloy particle with mer-
low copper amalgams cury, thus starting the reaction between the two to pro-
duce a solid mass.
Mechanical amalgamators are referred for trituration
Q.9. Discuss delayed expansion.
for the following reasons:
Ans. l They produce a uniform mix.
l They require less mixing time.

[Same as SE Q.5]
l The alloy and mercury can be properly proportioned.
Q.10. Define corrosion. l They reduce the possibility of mercury spills in the of-
fice.
Ans.
Trituration can produce different types of mixes:
[Same as SE Q.8]
( a) Normal mix – this is plastic in consistency, convenient
to handle, shiny and homogenous.
SHORT NOTES: (b) Undertriturated mix – this mix is dry and crumbly,
dull in appearance and cannot be manipulated.
Q.1. Define mercury hygiene.
(c) Overtriturated mix – this mix is warm, too hard due
Ans. to premature setting of the amalgam and is not easy to
condense. The normal mix is preferred as it is plastic The usual Hg/alloy ratio used are
enough to be condensed well. l Hg/alloy ratio for high copper – 1:1
l Hg/alloy ratio for low copper – 40%:60%.
Q.4. Describe non-g phase.
Q.8. Define mercury hygiene.
Ans.
Ans.
l The stoichiometric formula of g2 phase in amalgam
alloys and set dental amalgams is Sn8Hg. [Same as SN Q.1]
l The g2 phase is the weakest component.
Q.9. Define polishing of silver amalgam.
l The hardness of g2 is approximately 10% of the hard-
ness of g1, whereas the g phase hardness is somewhat Ans.

higher than that of 1.
l The objective of finishing and polishing of amalgam
l The g2 phase is also the least stable in a corrosive environ-
is for the removal of superficial scratches and irregu-
ment and may suffer corrosion attack, especially in ‘crev-
larities.
ices’ of the restorations. In general, g (Ag3Sn) and pure g1
l This minimizes corrosion and prevents adherence of
(Ag2Hg3) phases are stable in an oral environment.
plaque.
Q.5. Define hygroscopic expansion. l The polishing should be delayed for at least 24 h after
condensation or preferably longer.

Ans.
l Wet polishing is advised, so a wet abrasive in a paste
[Ref SE Q.6] form is used. Dry polishing powders and discs can raise
the temperature above 60°C.
Q.6. Define marginal leakage of restorations.
Q.10. Define tarnish and corrosion.
Ans.
Ans.
l The materials used in the restoration of the carious le-
sion are that they do not provide adhesion to tooth [Ref SE Q.8]
structure and seal the cavity preparation except those
Q.11. Define zinc-free amalgam.
systems based upon polyacrylic acid and certain dentine
bonding agent. Ans.
l Thus, a microscopic space always exists between the
l Zinc-free alloy contains less than 0.01% zinc.
restoration and the prepared cavity.
l Zinc-free alloy does not show delayed expansion, when
l The use of radioisotope tracers, dyes, the scanning elec-
contaminated with water, but with moisture will result
tron microscope and other techniques has demonstrated
in some inferior property.
that fluids, microorganisms and oral debris from the
l Zinc-free alloy tends to less plastic and less workable.
mouth can penetrate freely along the interface between
l So they are used only where it is clinically impossible
the restoration and the tooth, and progress down the
for the patient to control moisture like in patient having
walls of the cavity preparation.
excessive salivation, retrograde root canal filling, etc.
l The seepage of acid and microorganism could initiate
caries around the margins of the restoration. Q.12. Define original g phase.
l Microleakage in some situation causes the tooth to re-
Ans.
main sensitive following placement of the restoration.
l If leakage is severe, bacterial growth occurs between the [Same as SN Q.4]
restoration and the cavity and even into the dentinal tu- Q.13. Define delayed expansion.
bules. Toxic products released by these organisms irri-
tate the pulp. Ans.
Ref to SE Q .5
Q.7. Describe Eames’ technique.
Q.14. Define microleakage around restoration.
Ans.
Ans.
Eames’ technique
l Method of reducing mercury content is to reduce the [Same as SN Q.6]
original mercury:alloy ratio. This is known as the mini- Q.15. Define tarnish and corrosion in amalgam.
mal mercury or Eames’ technique (mercury:alloy 1:1).
l This technique contains 50% or less mercury in the final
Ans.
restoration, with obvious advantages. [Same as SE Q.8]
Topic 11
Pin-Retained Restorations
LONG ESSAYS:
1 . Give indications for pins in restorations. Briefly describe the technique.
2. Classify pins. Write in detail self-threaded pins.
3. Describe indications, contraindications, advantages and disadvantages of pin-retained amalgam restoration.
[Same as LE Q.1]
4. Discuss pins in restorative dentistry. [Same as LE Q.2]
5. Classify pins. What factors will you consider before using pins for an amalgam restoration in a badly mutilated
tooth? Describe procedure of fixing threaded pin. [Same as LE Q.2]
SHORT ESSAYS:
1 . Describe pins in amalgam restoration.
2. Describe retentive pins. [Ref LE Q.2]
3. Discuss in detail the causes of failure of pin-retained amalgam restorations. [Same as SE Q.1]
SHORT NOTES:
1 . Define pin-retained restoration and give its two indications. [Ref LE Q.1]
2. Define self-shearing pin. [Ref LE Q.2]
3. Define TMS pins. [Ref LE Q.2]
4. Define friction lock pins. [Ref LE Q.2]
5. Discuss classifications of pins. [Ref SE Q.1]
6. Define retention pins. [Ref LE Q.2]
7. Define self-threading pins. [Same as SN Q.2]
8. Discuss types of pins in amalgam restoration. [Same as SN Q.5]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Give indications for pins in restorations. Briefly
ii. Questionable prognosis:
describe the technique.
Pin-retained restorations are placed as interim resto-
Ans. rations, when the pulpal and periodontal prognoses
are established.
{SN Q.1} iii. As a foundation:
Pin-retained restorations may be used as foundation
l A pin-retained restoration is defined as any restora-
for crowns and onlays.
tion which requires the placement of one or more
pins in the dentine, so as to provide adequate resis-
tance and retention form to the restoration. i. Economics:
They serve as cheaper alternatives for complex resto-
Indications for pins in restorations rations.
i. Extensive tooth loss: ii. Age and health of patient:
Pins are indicated in teeth with extensive caries where For old and debilitated patients, pin-retained restora-
conventional retention features are not sufficient. tions are preferred over cast restorations.
Contraindications for pins in restorations l The aluminium shank helps to absorb the heat gen-
i. Occlusal problems: When the patient has significant erated by the twist drill.
occlusal problems, pin-retained restorations are not in- l Twist drills are colour-coded and matched with the
dicated. Here, cast restorations are more suitable to appropriate pin size, so that they can be correctly
correct the occlusion. selected for a specific pin.
ii. Aesthetics: Pin amalgams are avoided in areas where l There are two types of twist drills:
aesthetics is important. (i) Standard drill:

iii. Access difficulties: In posterior areas where access and Standard drills have a length of 4–5 mm.
isolation for pin placement are difficult, pins are contra- (ii) Depth-limiting drill:
indicated. Depth limiting drills create a pin channel of
2 mm depth into dentine.
Technique l The twist drill is attached to a contra-angle micro-
(i) Pin size: motor handpiece and runs at very low speeds of
l In the Thread Mate System (TMS) system, minikin 300–500 rpm.
and minim pins are usually the sizes selected for pos- l Pinholes are prepared in one or two thrusts.
terior teeth because they provide maximum retention l The drill should be removed, while it is still
without the risk of dentinal crazing or perforation. rotating.

(ii) Number of pins: l The position of the drill should be parallel to the
Factors that help to decide the number of pins for a tooth to prevent perforation.
given situation are l A twist drill should be discarded after 20 pin holes
(i) Amount of missing tooth structure to prevent risk of heat and dentine cracks.
(ii) Amount of dentine available (v) Insertion of pins:
(iii) Size of the pin Pins can be placed into the prepared channels using
(iv) Amount of retention needed two devices:
Fewer pins should be used that is one pin per missing i. Conventional latch-type contra-angle micromo-
axial line angle. This is because placing more pins can tor handpiece – for disposable latch-head pins.
weaken both the tooth and the amalgam restoration. ii. TMS hand wrenches – for standard pins.
(iii) Location of pins: l Disposable latch head pins like link series,
l For proper placement of pins, it is important to once the pin reaches the desirable depth it
know the pulpal anatomy and external contours of shears off by itself.
the tooth to be treated. l Standard pins are rotated clockwise to reach
l Pinholes are usually placed in the cervical one-third the desired depth then made to turn quarter
of posteriors near the line angles of the teeth. These counter clockwise to reduce dentinal stress
holes should be 1 mm away from the Dentini and then slowly disengaged.
Enamel Junction (DEJ) or 1.5 mm away from the (vi) Length control:
external surface of the tooth. The pin should be placed in such a way that it is placed
l The pinhole should be parallel to the adjacent ex- 2 mm in the dentine and 2 mm into the restoration. If
ternal surface of the tooth. the pin length is more, it is either cut off using a no.
l Pinholes should be located at least 0.5 mm away 169L bur or pin bender such as TMS bending tool.
from a vertical wall of the tooth to allow ease of
condensation of amalgam. Advantages of pin amalgams
l Pinholes should be located on a flat surface to pre- i. Conservation of tooth structure: the preparation of
vent the drill from slipping. tooth structure for pin-retained restorations is less ex-
l Interpin distance should be 3–5 mm to lower tensive than cast restorations or mechanically retained
stresses in the dentine. preparations like slot or lock. Pins provide retention
l Avoid fluted and furcated areas as they may cause without extensive cavity preparation.
perforation during pin placement. ii. Appointment time: pin-retained restorations can be
(iv) Preparation of pinholes: completed in a single appointment, while cast restora-
l First use a no. 1/4 round bur to prepare a pilot hole tions require multiple appointments.
or a dimple to accurately position the twist drill iii. Resistance and retention form: Pins increase the re-
used to prepare the pinhole. This prevents ‘crawl- sistance and retention form of the restoration to some
ing’ of the twist drill. extent.
l Twist drills are made of steel swaged onto an alu- iv. Economics: Pins are comparatively less expensive than
minium shank. cast restorations for restoring a grossly damaged tooth.
Disadvantages of pin amalgam

l Enough dentine must be present around the pins
i. Dentinal microfractures – internal stresses, cracks or
as they generate greater stresses in dentine caus-
craze lines may develop during the pin placement that
ing craze lines or cracks.
can cause tooth fracture in future.
ii. Lowered fracture resistance – fracture resistance of pin
amalgams is lower than that of cast onlays and crowns. ii. Self-threaded pins
iii. Strength of amalgam restoration is reduced – pins l These are available as stainless steel or titanium pins
lower the tensile and compressive strength of the with threads and may be gold plated for increased
amalgam. passivity.
iv. Microleakage – microleakage is usually seen at the pin l The pins are 0.0015" to 0.004" larger than the pin
dentine interface. channels and are therefore retained by the elasticity
v. Perforations – there is always a risk or pulpal or peri- of dentine.
odontal perforation chance. l The threads actively engage the dentine providing
vi. Difficult to achieve proper contours – in complex situ- maximum retention among the different pin types.
ations, it is difficult to achieve proper contours and l Self-threaded pins also induce stresses in dentine
contacts. resulting in craze lines.
l They are used in vital teeth where enough dentine is
Q.2. Classify pins. Write in detail self-threaded pins.
available surrounding the pin.
Ans. l There are several styles of self-threaded pins like the
TMS pins.)}
(SE Q.2 and SN Q.6)
{(Types of pins
There are three categories of pins as follows: {SN Q.3}
i. Cemented pins
TMS pins:
ii. Friction-locked pins
The thread mate pins are made of stainless steel or tita-
iii. Self-threaded pins
nium plated with gold.
i. Cemented pins
l Cemented pins are made of stainless steel and have The pins are available in four sizes:
threads or serrations for better retention. i. Regular 0.030", 0.031"
l The pin diameters may be of various sizes – 0.018" ii. Minim 0.024", 0.025"
to 0.030". iii. Minikin 0.019", 0.020"
l The pin channels are 0.001" to 0.002" larger than iv. Minuta 0.014", 0.015"
the pins.
l This allows easy cementation of the pins into the pin
i. Regular – These are the largest diameter pins. They
channel. cause considerable stress and maximum dentinal craz-
l Zinc phosphate or zinc polycarboxylate cements
ing during placement. Due to these reasons, regular
may be used for luting these pins. pins are rarely used.
It causes less internal stresses and is least retentive. ii. Minim – These are the next smaller diameter pins. They
cause lesser stresses and dentinal crazing, while provid-
ing good retention.
iii. Minikin – Since their diameter is lesser than that of
{SN Q.4}
minim pins. These pins cause very less risk of dentinal
i. Friction-locked pins crazing. At the same time, they afford good retention.
l They are made of stainless steel and have threads. iv. Minim and minikin pins are the commonly used sizes
The pins are 0.001" larger than the pin channels. of TMS pins.
l Friction-locked pins are tapped into the prepared v. Minuta – These are the smallest size of pins. Minuta
channels with a mallet. pins are too small to provide adequate retention. Hence,
l Since they are larger than the pin holes, they uti- they are not used often.
lize the resiliency of dentine for retention. These
Each of these sizes of pins is available in several
pins are two- to three-times more retentive than
designs:
cemented pins.
a. Standard
l Friction-locked pins are used in vital teeth with
b. Self-shearing
good access for ease of tapping the pins.
c. Two-in-one
d. Link series SHORT ESSAYS:

e. Link plus
a. Standard design – The standard design pins are 7 mm Q.1. Describe pins in amalgam restoration.
long with a flattened head to fit into a hand wrench or a Ans.
handpiece chuck. After placement, this pin can be re-
versed one-fourth turn to reduce dentinal stresses and
{SN Q.5}
the pin height can also be cut to the appropriate length
after placement. A pin-retained restoration is defined as any restoration
which requires the placement of one or more pins in the
{SN Q.2} dentine so as to provide adequate resistance and reten-
tion form to the restoration
b. Self-shearing design – In the self-shearing design,
Types of pins
the pins are available in varying lengths with a flat-
tened head to fit into the hand wrench or handpiece There are three categories of pins. They are
chuck. They are designed in such a way that when i. Cemented pins
the pin reaches the bottom of the pinhole, the head ii. Friction-locked pins
automatically shears off. This leaves a portion of the iii. Self-threaded pins
pin projecting from the dentine.
Complications of pin-retained restorations
I. Failure of pin-retained restorations
c. Two-in-one design – This design consists of two pins This can occur at any of the following five different
connected by means of a joint which serves as the shear locations:
line for the peripheral pin. They are 9 mm long and (i) Within the restoration – This is mainly be-
provide two pins each about 4 mm long. These pins also cause of improper matricing or premature
have a flattened head to fit into a hand wrench or a matrix removal. Another reason could be a
handpiece chuck. They work the same way as the self- high point in the restoration.
shearing pin except that the handpiece need not be re- (ii) At the pin/restoration interface – This is
loaded during insertion of more than one pin. caused by corrosion products at the interface.
d. Link series design – Link series design pins have a (iii) Within the pin – This is due to improper tech-
plastic sleeve that fits into a latch-type contra-angle nique during pin placement.
handpiece. They are also self-shearing and after the pin (iv) At the pin dentine interface – This is because
engages the dentine the plastic sleeve can be discarded. of improper pin engagement of dentine.
e. Link plus design – This design is similar to the link (v) Within the dentine – This occurs due to in-
series design. These pins are also self-shearing and may creased internal stresses and incorrect selection
be available as single or two-in-one pins. The major of site for pin placement. Of these, most often
difference in this pin design is that the pins have failure occurs at the pin dentine interface. By
sharper threads and a tapered tip in order to reduce applying the proper principles of pin place-
dentinal stresses while seating. ment, the dentist can minimize these failures.
Q.3. Describe indications, contraindications, advantages II. Broken drills and broken pins
and disadvantages of pin-retained amalgam restoration. l Twist drills may break, if they are stressed laterally
or allowed to stop rotating before removing them

Ans.
from the pin hole.
[Same as LE Q.1] III. Loose pins
l If the pin hole is larger than the self-threaded.
Q.4. Discuss pins in restorative dentistry.
Ans. Q.2. Describe retentive pins.
[Same as LE Q.2] Ans.

[Ref LE Q.2]
Q.5. Classify pins. What factors will you consider before
using pins for an amalgam restoration in a badly muti- Q.3. Discuss in detail the causes of failure of pin-
lated tooth? Describe procedure of fixing threaded pin. retained amalgam restorations.
Ans. Ans.
[Same as LE Q.2] [Same as SE Q.1]
SHORT NOTES: Q.5. Discuss classifications of pins.

Q.1. Define pin-retained restoration and give its two in- Ans.
dications. [Ref SE Q.1]
Ans. Q.6. Define retention pins.
[Ref LE Q.1] Ans.
Q.2. Define self-shearing pin. [Ref LE Q.2]
Ans. Q.7. Define self-threading pins.
[Ref LE Q.2] Ans.
Q.3. Define TMS pins. [Same as SN Q.2]
Ans. Q.8. Discuss types of pins in amalgam restoration.
[Ref LE Q.2] Ans.
Q.4. Define friction lock pins. [Same as SN Q.5]
Ans.
[Ref LE Q.2]
Topic 12
Cast Metal Restorations
LONG ESSAYS:
1 . Discuss classification of cast gold alloys and indications for class II gold inlays and onlays.
2. Discuss the cavity designs for class II cast gold restorations.
3. Define inlay. Mention indications, contraindications, advantages and disadvantages of a cast gold restorations.
4. Describe class II cavity preparation for gold inlay in a molar tooth.
5. Describe the preparation of direct wax pattern for a cast gold inlay.
6. Classify dental investments. Write in detail about failures of casting or casting defects.
7. Discuss in detail the differences between cast gold inlay preparation and amalgam preparation. [Same as LE Q.2]
8. Write briefly about class II cavity for silver amalgam and gold inlay. [Same as LE Q.2]
9. Write in detail how you proceed to take direct wax pattern for a cast gold inlay or onlay. [Same as LE Q.5]
SHORT ESSAYS:
1 . Electroforming of dies.
2. Gypsum-bonded investment material.
3. Indications for the gold inlay. [Ref LE Q.3]
4. Disadvantages of cast restorations. [Ref LE Q.3]
5. Types of flares in inlay preparation.
6. Advantages of cast gold inlay. [Ref LE Q.3]
7. Investment material.
8. Finishing and polishing procedures for posterior restorations.
9. Indications for cast gold restoration. [Same as SE Q.3]
10. Die materials. [Same as SE Q.7]
SHORT NOTES:
1 . Onlay.
2. Types of cast gold alloys. [Ref LE Q.2]
3. Phosphate-bonded investment.
4. Dies. [Ref SE Q.7]
5. Define and name bevels in inlay.
6. Gypsum-bonded investment. [Ref SE Q.2]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Discuss classification of cast gold alloys and indica- Specific indications are:
tions for class II gold inlays and onlays. i. When the width of the cavity does not exceed one-third
Ans. of the intercuspal distance.
ii. Proximal caries extensively involving the buccal and
Classification of cast gold alloys:
lingual line angles of the tooth.
The ADA specification for cast gold alloys classifies them
iii. When the proximal margins extend subgingivally as the
into four types. They are
polished gold alloys are compatible with the periodon-
Type I alloys – Soft
tium.
Type II alloys – Medium
iv. The mesiodistal dimension of cast gold inlays can be
Type III alloys – Hard
extended to establish good contact, for achieving ideal
Type IV alloys – Extra hard.
contact, contours and embrasures.
Type I alloys: They have gold content ranging from 75% to v. In a grossly decayed tooth where one or more but not
83%. These are used for fabrication of small inlays as they all cusps need coverage.
are subjected to low stress. They are soft, have low strength vi. In patients exhibiting good oral hygiene and low caries
and can be easily burnished. incidence.
Type II alloys: Their gold content ranges from 70%–75%. vii. When other gold castings are present in the mouth.
They are used in moderate stress cases for fabrication of
Indications for class II gold onlays
inlays and onlays. They possess medium strength and can
i. When the facial and lingual surfaces are intact and there
also be readily burnished.
is extensive weakening by caries or a larger failing res-
Type I and II alloys are not capable of being heat-
toration, the onlay can protect the underlying tooth
treated.
structure and distribute the occlusal loads without caus-
Type III alloys: Their gold content ranges from 65% to
ing tooth fracture.
70%. They are used during high stress conditions such as
ii. As a post endodontic restoration, the cast gold onlay is
fabrication of onlays and crowns. They can be heat-treated
the simplest option to protect and strengthen the re-
but cannot be burnished easily.
maining tooth structure.
Type IV alloys: These alloys contain 60% gold. They are
iii. In extensive restorations exhibiting craze lines due to
used for crowns, bridges and removable partial dentures.
excessive occlusal stresses in order to prevent tooth
They have high strength, increased hardness and can be
fracture.
heat-treated.
iv. When there are other cast restorations in the adjacent or
Indications for class II gold inlays opposing teeth.
Class II gold inlays are indicated primarily in case of v. To establish contact with the adjacent tooth when the
extensive proximal caries that cannot be restored satisfac- mesiodistal diameter is less.
torily with silver amalgam. vi. To correct the occlusal plane of a tooth with slight tilting.
vii. Onlays may be employed as abutment for a removable l Proximal walls usually have only a primary flare.
partial denture. l Internal line angles are rounded.
l Reverse curve may be present in the proximal outline.
Q.2. Discuss the cavity designs for class II cast gold
l Unsupported enamel is removed from the cavosurface
restorations.
margin by giving a bevel.
Ans.
Class II cast gold inlay
l Outline form is wider as there is more of surface in-
{SN Q.2} volvement and the cavity walls diverge occlusally.
l The width of the cavity may increase up to one-third the
The ADA specification for cast gold alloys classifies
intercuspal distance.
them into four types. They are:
l The cavity walls diverge occlusally and the burs used
Type I alloys – Soft
are no. 271, 169L.
Type II alloys – Medium
l The occlusal cavosurface angle is 135–145°. This helps
Type III alloys – Hard
to achieve a lap, sliding fit with the inlay.
Type IV alloys – Extra hard
l The cement line is prevented by giving a steeper gingi-
val bevel in the range of 20–30°.

Type I alloys: They have gold content ranging from 75% to l There should no undercuts present in the preparation.
83%. These are used for fabrication of small inlays as they l Proximally, more clearance may be acceptable.
are subjected to low stress. They are soft, have low strength l Subgingival extension of gingival seat is indicated
and can be easily burnished. sometimes.
Type II alloys: Their gold content ranges from 70% to 75%. l Secondary retention is provided by grooves, slots, inter-
They are used in moderate stress cases for fabrication of nal boxes, skirts, collars and reverse bevel.
inlays and onlays. They possess medium strength and can l The proximal margins may show a primary and a sec-
also be readily burnished. ondary flare.
Type I and II alloys are not capable of being heat- l Internal angles are well defined.
treated. l There is no reverse curve provided in the proximal
Type III alloys: Their gold content ranges from 65%–70%. outline.
They are used during high stress conditions such as fabrica- l Bevels are placed at the occlusal and gingival cavosur-
tion of onlays and crowns. They can be heat-treated but face margins to provide frictional retention.
cannot be burnished easily.
Type IV alloys: These alloys contain 60% gold. They are Q.3. Define inlay. Mention indications, contraindica-
used for crowns, bridges and removable partial dentures. tions, advantages and disadvantages of a cast gold
They have high strength, increased hardness and can be restorations.
heat-treated.
Ans.
Silver amalgam
l The outline form of this type of cavity is narrow as there
[SE Q.6]
is no surface involvement and the walls converge oc- {An inlay is an indirect intracoronal restoration fabri-
clusally. cated using the lost wax technique.
l The width of the cavity should be one-fourth of the in- Class II inlay:
tercuspal distance. This is an indirect restoration that caps one or more
l The no. 245 and 330 burs are used to make the cavity cusps of a posterior tooth but not all the cusps.
walls converge occlusally. Advantages of cast gold restorations
l The occlusal cavosurface angle is 90°. This forms a butt i. Strength – Cast gold alloys are strong enough to
joint with amalgam. replace and reinforce areas of high stress even in
l Gingival bevel should be given ranging from 15° to 20°. thin sections of l mm or so. Hence cast gold alloys
l Undercuts are provided in the preparation so as to im- are ideally suited for inlays, onlays and crowns.
prove retention of the restoration. Their tensile strength is high.
l Minimal clearance that is provided is not more than 0.5 ii. Accurate reproduction of contacts and contours –
mm from the adjacent tooth proximally. They are fabricated by the indirect technique, cast
l The gingival seat should be located supra gingivally in gold restorations can accurately reproduce precise
an ideal cavity preparation. form and minute detail and maintain them under
l The secondary retention is provided by grooves, slots, function. Thus, they can create nearly ideal occlusal
pins and amalgam pins. and axial contours and contacts.
iii. Noble and inert cast gold alloys are inert in the iv. The mesiodistal dimension of cast gold inlays
oral environment – Hence, they are biocompatible can be extended to establish good contact for
and exhibit excellent durability and longevity. achieving ideal contact, contours and embrasures.
iv. Abrasion resistance – Gold wears at a rate similar v. In a grossly carious tooth where one or more
to that of enamel. So it does not cause accelerated but not all cusps need coverage.
wear of the opposing teeth. vi. In patients with good oral hygiene and low car-
v. Reduced internal stresses – There are fewer inter- ies incidence.
nal stresses and voids as cast gold restorations are vii. When other gold castings are present in the
built in bulk and not in increments like amalgam or mouth.}
composite restorations. Contraindications for class II gold inlays
vi. Extraoral finishing and polishing – Excellent fin- i. Class II gold inlays are not used as an abutment for
ishing and polishing can be done since cast gold a fixed or removable prosthesis as they are not strong
restorations are finished and polished outside the enough.
oral cavity, excellent finish and polish can be created ii. In postendodontic restorations, class II inlays are
without endangering the pulp.} contraindicated because they can wedge and fracture
the remaining tooth structure.
[SE Q.4] iii. In young permanent teeth, class II gold inlays are
{Disadvantages of cast gold restorations avoided as there are increased chances for iatrogenic
i. Microleakage – Since they are indirect restorations pulp exposure due to the presence of high pulp horns.
that are cemented into the prepared cavity using lut- iv. In patients with high plaque and caries incidence,
ing cements, cast restorations are prone to microle- class II gold inlays should be avoided as there may
akage at the tooth–cement–casting junction due to be a greater tendency for recurrent caries.
the several interphases present. v. When the adjacent or opposing teeth have dissimilar
ii. More number of appointments – Cast gold resto- metallic restorations, class II cast gold inlays should
rations requires at least two appointments; more be avoided in order to prevent galvanism.
chair time is also necessary due to the need for im- vi. When cost is a major factor for the patient.
pressions. vii. Class II gold inlays are contraindicated in case of
iii. Need for temporary restorations – Temporary grossly destroyed teeth with weak cusps.
restorations must be placed between appointments Q.4. Describe class II cavity preparation for gold inlay
before cementing the cast restoration. in a molar tooth.
iv. Cost – The cost of the gold alloys and laboratory ex-
penses make cast gold restorations much more expen- Ans.
sive than amalgam or composite resin restorations. Cavity preparation for class II gold inlays
v. Technique sensitivity – Fabrication of cast gold
restorations requires meticulous attention. Errors Occlusal step
during fabrication can produce unacceptable restora- l Enter the pit or the fossa closest to the marginal ridge
tions. with the no. 271 bur held parallel to the long axis of the
vi. Aesthetics – Cast gold restorations are aesthetically crown. Initial depth of the pulpal floor should be done
unacceptable in anterior teeth and facial surfaces of using a punch cut to a depth of 1.5 mm.
posterior teeth.} l Extend the preparation mesially and provide adequate
Indications for class II gold inlays width for the preparation. Circumvent the cusps by
Class II gold inlays are indicated primarily in case of curving the facial and lingual walls of the preparation
extensive proximal caries that cannot be restored satis- around the cusps. The facial and lingual extension in the
factorily with silver amalgam. mesial pit region should provide dovetail retention form
to resist distal displacement of the final restoration.
[SE Q.3]
l The mesial marginal ridge should be conserved. Any
{Specific indications are shallow fissure on the mesial marginal ridge should be
i. When the width of the cavity does not exceed included in the outline by means of a cavosurface bevel.
one-third of the intercuspal distance. Otherwise it may be eliminated by enameloplasty. Both
ii. Proximal caries involving the buccal and lingual preparations can be done by means of the finishing dia-
line angles of the tooth that has become extensive. mond point.
iii. When the proximal margins extend subgingi- l Now using the 271 bur continues at the initial depth and
vally as the polished gold alloys are compatible extend the occlusal step distally into the distal marginal
with the periodontium. ridge to expose the junction of the proximal enamel and
of pit dentine extend the faciolingual dimensions de- l There should be uninterrupted blending of the occlu-
pending on the dimensions. sal bevels, secondary flares and the gingival bevel so
as to prevent open margins and leakage in the final
Proximal box preparations
restoration.
l With the no. 271 bur isolate the distal enamel by means
l The diamond instrument is also used to slightly bevel
of the proximal ditch cut. The occlusal and gingival
the axiopulpal line angle so as to create a thicker and
cavosurface margin while approximately two-thirds at
stronger wax pattern at this critical area.
the expense of dentine (0.5 mm) and one-third at the
expense of enamel (0.3 mm). Q.5. Describe the preparation of direct wax pattern for
l Now proceed gingivally and extend the proximal ditch a cast gold inlay.
facially and lingually beyond the caries to the desired
position of the facioaxial and linguoaxial line angles. Ans.
l The gingival extension should eliminate caries on the
Fabrication of the wax pattern
gingival floor as well as provide 0.5 mm clearance from
There are two methods of making the wax pattern for a
the adjacent tooth, the axial wall should follow the fa-
cast gold inlay or onlay:
ciolingual contour of the tooth. At this stage any re-
i. Direct method
maining caries on the axial wall is not removed.
ii. Indirect method
l To break the proximal contact use the no. 271 bur to
make two cuts, one on the facial limit and another at the Direct wax pattern
lingual limit of the proximal ditch; extend these cuts In this method, the wax pattern is formed directly on the
gingivally till the bur is nearly through the marginal prepared tooth.
ridge enamel; the inside of the bur may emerge slightly It is indicated for:
through the surface at the level of the gingival floor. l Small inlay cavities with primary flares and minimal
l The remaining enamel wall either breaks away or can be proximal extensions.
removed by fracturing using a spoon excavator; the ragged l When access and visibility to the tooth are adequate.
enamel edges at the proximal surface may be planed using

Manipulation of the inlay wax:
an enamel hatchet or a binangle chisel; the flame shape
l The stick of inlay wax can be softened directly over a
finishing diamond may also be used to smoothen the
Bunsen burner flame.
enamel walls.
l The wax is rotated to heat it uniformly till it is shiny,
Removing remaining carious dentine and pulp pro- soft and can be compressed between the fingers.
tection l Another method for softening the wax is to use a wax an-
l Isolate the prepared cavity. In case infected dentine is nealer which maintains a constant temperature of 65°C.
present on the pulpal floor or axial wall after the initial l Once the wax is adequately softened, the plastic mass is
preparation, a round bur at slow speed or a spoon exca- shaped into a cone between the thumb and forefinger. It
vator may be used to remove the remaining carious is then ready for insertion into the prepared cavity.
dentine. (a) Wax pattern formed with a matrix band
l Following this, a suitable base such as glass ionomer l The tooth is isolated using cotton rolls and gently
cement should be placed over the deeper areas to protect dried.

the pulp and to block out undercuts in the preparation. l A separating medium such as Vaseline is uniformly
applied over the prepared tooth and the adjoining

Treatment of retention grooves
contact areas and soft tissues.
l If additional retention is required such as in short teeth,
l A Tofflemire band and retainer is carefully applied.
shallow retention grooves are placed in the axiofacial
The internal surfaces of the band are also coated with
and axiolingual line angles using the no. 169L carbide
the separating medium.
bur. The bur is held parallel to the line of draw.
l A cone of the softened inlay wax is pressed into the
Preparation of bevels and flares cavity under firm finger pressure till the wax cools.
l These are placed using the slender, flame-shaped, Excess wax is trimmed by a warm carver.
finishing diamond. Bevels are placed at the occlusal l Occlusal carving is done with a slightly warmed
and gingival cavosurface margin and the distolingual carving instrument.

walls. l Now the matrix retainer is separated, followed by
l They create a cavosurface angle of 140°–150° which careful removal of the band without disturbing the
produces strong enamel margins and helps to seal and wax pattern.
protect the margins. They also create a 30°–40° mar- l Occlusion is checked for any high points. Warm
ginal metal which is most amenable to burnishing. carvers are used to remove any excess wax.
The occlusal surface of the pattern is polished by us-

l 2 . Surface roughness and irregularities
ing a warm cotton pellet. Proximally, dental floss is (a) Surface roughness
used to check the contact and to polish the proximal l Coarse silica particles in the investment cause
surface. surface roughness of the casting.

l Finally a suitable sprue pin is attached to the wax l Mixing the investment powder with inadequate
pattern at an angle of 45° to the thickest portion of or excess water.

the wax pattern to carefully remove the pattern from l Too rapid heating of the investment as it leads to
the tooth. flaking of the investment.

l The details of the pattern are checked. l Prolonged heating of the investment also disinte-
(b) Wax pattern fabricated without a matrix band grates the gypsum-bonded investment.
The steps in this technique are similar to the fabrication l Casting pressure being too high.
of the wax pattern with a matrix band except that after (b) Surface irregularities – These are isolated imper-
carving the occlusal portion, dental floss is used to clear fections like nodules or fins.
proximal excess of wax and produce proper proximal Causes:
contour and contact. l Air bubbles becoming attached to the pattern
Advantages: during investing.

l Less laboratory work l Water film formed on the wax pattern during
l Less chances for discrepancies due to impression investing result in minute ridges on the surface
and cast inaccuracies of the casting.
l Saves time for the overall procedure l Too rapid heating of the investment as it causes
Disadvantages: flaking of the investment.

l More skill is required. l Careless removal of the sprue former can carry
l May have contact and gingival margin discrepancies. bits of investment into the mould leading to
l Finishing and polishing should be done on the surface irregularities.
prepared tooth. l Molten alloy impacting a weak portion of the
mould surface can cause a depression in the mould

Q.6. Classify dental investments. Write in detail about which is results in a raised area on the casting.
failures of casting or casting defects. l Many patterns placed close together in the
casting ring can cause breakdown of the invest-

Ans.
ment leading to surface irregularities.
l A ‘die’ is a positive replica of the prepared tooth that is 3. Discolouration of the casting
employed for fabrication of the indirect wax pattern. After separation from the investment the casting usually
l Dies may be made of different materials. appears dark due to coating of oxides or defects in casting
procedures. This surface discolouration can be removed
The commonly used die materials are:
by a process called pickling. Casting defect discoloura-
i. Dental stone Type IV and Type V
tion is due to following reasons:
ii. Electroformed dies
l Under heating – Inadequate heating of the in-
iii. Epoxy resins
vestment leaves wax residues. These carbon resi-
iv. Divestment
dues may form a tenacious carbon coating on the
Casting defects are of many types and may be classified as: casting thereby discolouring the casting.
1 . Distortion l Prolonged heating – Heating the investment for
2. Surface roughness and irregularities too long decomposes the sulphur compound in the
3. Discolouration investment which can discolour the casting and
4. Porosity make it brittle.
5. Incomplete casting l High content of sulphur in the torch flame can
1. Distortion also discolour the casting.
l This occurs due to distortion of the wax pattern l Carbon inclusion – Carbon from the crucible,
during fabrication. torch flame or investment may form carbides on
l If it is not handled properly, the high coefficient of the casting surface causing it to discolour.
thermal expansion of the inlay wax is responsible for l Use of mixtures of different casting alloys – In
warp age of the pattern. this case, discolouration is due to corrosion.
l The warp age gets worse with increase in the ambi- 4. Porosity
ent temperature and time lag between fabrications of Porosity can occur both on the internal aspect and on the
the pattern and investing. external surface of the casting. Porosity weakens the
cast restoration. The various types of porosities affect- process is called ‘metallizing’. Aqueous solutions of
ing cast gold alloys are: silver powder or bronzing powder can be deposited on
A. Solidification defects the surface of the impression with a camel-hair brush.
(a) Localized shrinkage porosity l The impression is placed in an electrolytic bath where
(b) Microporosity the anode is a bar of pure metal, supplying metal cations
B. Trapped gases continuously. The metallized impression serves as the
(a) Pinhole porosity cathode and allows electrodeposition of the cations on
(b) Gas inclusion porosity its surface.
(c) Subsurface porosity l Copper-plating can be done for compound impressions
5. Incomplete casting and addition silicone impressions. The electrolytic solu-
This occurs if the molten alloy has been prevented from tion for this consists of copper sulphate solution.
filling the mould space completely. l For silver-plating, a solution of silver cyanide or silver
Causes: nitrate is the electrolytic bath. Silver-plating can be
l Improper venting of air from the mould due to done for polysulphide, polyether and addition silicone
back pressure of air in the mould. If air is not impressions.
vented quickly and promptly, the molten alloy l Finally, the impression containing the electroformed die
does not fill the mould before it solidifies. surface is filled with dental stone. On setting, the stone
l Improper burnout leaves wax residues that create is mechanically locked into the rough interior of the
rounded margins. electroformed metal shell. Thus the model has improved
l This can also be due to lower liquid/powder ratio surface hardness and abrasion resistance. It can be pre-
which reduces the porosity of the investment. pared in the usual manner.
l In adequate heating of the alloy which increases
Advantages
the viscosity of the alloy and prevents it from fill-
l Better reproduction of details than gypsum dies.
ing the mould space completely.
l Good strength, hardness and abrasion resistance.
Q.7. Discuss in detail the differences between cast gold Disadvantages

inlay preparation and amalgam preparation. l Increased time consumption for die fabrication (up to
Ans. 12 h).
l Expensive technique.
[Same as LE Q.2] l Silver cyanide is poisonous and requires extreme care.
l Irregular electroplating.
Q.8. Write briefly about class II cavity for silver amal-
l Problems of faulty conduction leading to very slow
gam and gold inlay.
electrodeposition.
Ans. l Overconcentrated solution preventing proper electro-
plating as well as softening the surface of the rubber

[Same as LE Q.2]
base impression.
Q.9. Write in detail how you proceed to take direct wax Q.2. Gypsum-bonded investment material.
pattern for a cast gold inlay or onlay.
Ans.
Ans.
[Same as LE Q.5]
{SN Q.6}
SHORT ESSAYS: l Divestment is a combination of die stone and invest-

ment. It is a gypsum-based material which can be used
Q.1. Electroforming of dies. as the die material as well as the investing medium.
l The gypsum-bonded material is mixed with colloidal
Ans.
silica liquid and poured into the impression to form
l Electroforming of dies are a result of electrolysis. These a model. From this the die is made over which the
are made by electroplating impressions with certain wax pattern can be fabricated.
metals, so as to impart high strength and abrasion resis- l The entire assembly (die and pattern) can be invested
tance to the die. Copper-plated or silver-plated dies are in a mixture of divestment and water.
commonly used. l This eliminates the chances for distortion of the wax
l The surface of the impression material is treated with a pattern on removal from the die or during the setting
metallizing agent to make it conduct electricity. This
Q.6. Advantages of cast gold inlay.

of the investment. Divestment is a gypsum-based
material and is therefore useful for cast gold alloys. Ans.
[Ref LE Q.3]
Q.7. Investment material.
Advantages:
Ans.
l Good reproduction of details.
l Highly accurate for cast gold alloys.
l Ease of use.
l Compatible with most impression materials.

{SN Q.4}
Disadvantages: A ‘die’ is a positive replica of the prepared tooth. This is

l Lack of abrasion resistance.
employed for fabrication of the indirect wax pattern.
l Not suitable for high fusing alloys.
Dies may be made of different materials. The commonly
used die materials are:
Q.3. Indications for the gold inlay. i. Type IV and Type V dental stones
Ans. ii. Electroformed dies
iii. Epoxy resins
[Ref LE Q.3] iv. Divestment
Q.4. Disadvantages of cast restorations.
Ans.
i. Type IV and type V dental stone
[Ref LE Q.3] The most commonly used die materials are Type IV
dental stone (high strength) and Type V.
Q.5. Types of flares in inlay preparation.
Dental stone (high strength, high expansion).
Ans. The setting expansion of Type IV dental stone is 0.1
% and is used in fabrication of wax patterns for cast
Flares: Flares are the flat or concave peripheral portions of
gold restorations. The setting expansion of Type V
the facial or lingual proximal walls.
dental stone is 0.3% which is useful to compensate
They are placed on the facial and lingual proximal mar- for the larger solidification shrinkage of base metal
gins of the cavity preparation. They may be of two types: alloys.
a. Primary flare – This is similar to the primary flare pro- Desirable qualities of die materials
vided in an amalgam cavity preparation. It is on the wall l Accurate reproduction of impression details.
of the proximal portion is at 45°. l Dimensional stability.
The primary flare is indicated in case of normal contacts l Have a smooth, hard surface resistant to
and when there is minimal extension of caries in the abrasion.
buccolingual dimension. l Have adequate strength.
b. Secondary flare – This is a flat plane superimposed l Have a contrasting colour to that of inlay wax.
peripheral to the primary flare and is usually prepared in l Fabrication should be easy and quick.
enamel. This may have different angulations and extent. l Compatibility with most impression materials.
The secondary flare is indicated in the following situa- To improve their abrasion resistance they may be
tions: silver-plated, coated with cyanoacrylate or treated
(i). In case of broad contact areas, the secondary with a die hardener. But these additions can increase
flare brings the facial and lingual margins to the die dimensions slightly, thus reducing their
finishable and cleansable areas without the accuracy.
need to sacrifice more tooth structure. ii. Electroformed dies
(ii). When caries is widely extended in the bucco- l These are made by electroplating impressions with
lingual dimension, the secondary flare is nec- certain metals so as to impart high strength and
essary. abrasion resistance to the die. Most commonly
(iii). To include surface defects on the facial and copper-plated or silver-plated dies are used.
lingual aspect beyond the primary flare. iii. Epoxy resins
(iv). To overcome undercuts that may be present at l These were supplied as a paste and liquid activator.
the cervical aspect of the facial and lingual On mixing, the viscous paste should be introduced
proximal walls. into the details
iv. Divestment Indications:

l Divestment is a combination of die stone and invest- When the tooth is extensively weakened due to caries.
ment. It is a gypsum-based material which can be l As postendodontic restoration.
used as the die material as well as the investing l Teeth undergoing excessive occlusal stress.
medium. l In cases where there are other cast restorations in the
l The gypsum-bonded material is mixed with colloi- opposing arch.
dal silica liquid and poured into the impression to l When the mesiodistal dimension needs to be extended
form a model. From this the die is made over which to establish contact.
the wax pattern can be fabricated. l Used to correct occlusal plane.
l They are used as abutment for removable of partial
Q.8. Finishing and polishing procedures for posterior
denture.
restorations.
Q.2. Types of cast gold alloys.
Ans.
Ans.
Steps in finishing and polishing of posterior restorations
are: [Ref LE Q.2]
l First examine the fitting surface of the inlay for any Q.3. Phosphate-bonded investment.
projections or defects. Round burs are used to remove
any kind of projections. Ans.
l The casting should be tried with the sprue button. An l The phosphate-bonded investments contain refractory
accurate casting will seat easily without pressure. fillers and binder.
l A carborundum separating disc is used to separate the l The filler is silica in the form of cristobalite, quartz or a
sprue close to the inlay. mixture of the two.
l Burnish the inlay margins on the die with a ball or bea- l Filler provides high temperature thermal shock resis-
ver tail burnisher. tance and high thermal expansion.
l Refine the grooves using a dull round bur run at slow l The binder consists of magnesium oxide and a phos-
speed. phate that is acidic in nature.
l Use a knife-edge rubber polishing wheel to smoothen l Carbon is often added to produce clean castings and
all accessible surfaces including contact areas. facilitate investing.
l Check the occlusion and remove any prematurities.
l Perform initial polishing with a smaller knife-edge rub-

Q.4. Dies.
ber wheel on occlusal surfaces. Polish the grooves with Ans.
rubber abrasive points (brownie and greenie points).
[Ref SE Q.7]
l Finally, polish using tripoli or rouge with felt wheel to
produce the final lustre. Q.5. Define and name bevels in inlay.
Q.9. Indications for cast gold restoration. Ans.
Ans. l Bevels refer to a plane of a cavity wall or floor which is
directed away from the cavity preparation.
[Same as SE Q.3] l Bevels are placed on the occlusal and gingival cavosur-
Q.10. Die materials. face margins of the cavity preparation.

l According to their shape and extent of tissue involve-
Ans. ment, bevels are of six types:
[Same as SE Q.7] (a) Partial bevel
(b) Short bevel
(c) Long bevel
SHORT NOTES: (d) Full bevel
Q.1. Onlay. (e) Counter bevel
(f) Hollow-ground bevel
Ans.
Q.6. Gypsum-bonded investment.
Onlay is defined as an indirect restoration, which is
Ans.
partly intracoronal and partly extracoronal that covers all
the cusps of a posterior tooth. [Ref SE Q.2]
Topic 13
Dental Casting Procedures
LONG ESSAYS:
1 . Enumerate the casting defects and discuss in detail.
2. Enumerate casting defects and measures to overcome them. [Same as LE Q.1]
3. Enumerate and describe casting defects. [Same as LE Q.1]
4. Describe various casting defects in cast restorations and measures to prevent the same. [Same as LE Q.1]
5. Discuss the causes of casting defects and their prevention. [Same as LE Q.1]
SHORT ESSAYS:
1 . Sprue and sprue former.
2. Casting machines.
3. Porosities in castings. [Ref LE Q.1]
4. Write briefly on casting defects. [Ref LE Q.1]
5. Suck back porosity.
6. Pickling.
7. Sprue former. [Same as SE Q.1]
8. Porosities in dental castings. [Same as SE Q.3]
9. Casting defects. [Same as SE Q.4]
SHORT NOTES:
1. Reservoir.
2. Casting defects. [Ref LE Q.1]
3. Localized shrinkage porosity.
4. Back pressure porosity.
5. Pickling. [Ref SE Q.6]
6. Sprue and sprue former.
7. Pinhole porosity.
8. Significance of reservoir. [Same as SN Q.1]
9. Enumerate casting defect. [Same as SN Q.2]
10. Back pressure porosity in gold. [Same as SN Q.4]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Enumerate the casting defects and discuss in detail. (SE Q.4 and SN Q.2)
Ans. {(Casting defects are of many types and may be classi-
fied as:
{SN Q.2} 1. Distortion
Casting defects
2. Surface roughness and irregularities
If all the steps are followed carefully any defects in the 3. Discolouration
casting produce inaccuracies leading to poor fit or mar- 4. Porosity
ginal discrepancies can be avoided. 5. Incomplete casting)}
[SE Q.4] Too many patterns placed close together in

the casting ring can cause breakdown of
{1. Distortion the investment leading to surface irregu-
l This occurs due to distortion of the wax pattern dur- larities.}
ing fabrication. Prevention
l If it is not handled properly the high coefficient of
l Investment should be mixed in the correct ratio
thermal expansion of the inlay wax is responsible for with water.
warpage of the pattern. l Air bubbles can be avoided by use of a mechani-
l The warpage gets worse with increase in the ambient
cal mixer with vibration to mix the investment.
temperature and time lag between fabrications of the l A wetting agent should be used on the pattern to
pattern and investing.} avoid water films.
Prevention: l The invested pattern should not be heated rapidly
(a) Proper manipulation of the wax – Uniform heat- or for a prolonged time.
ing up to 50°C for at least 15 min before use and l Neither the temperature of the alloy nor the cast-
softening by kneading. ing pressure should be too high.
l Use of warm carvers.
l Too many patterns should not be placed close
l Adding wax to the die in small amounts.
together in the same casting ring.
l Use of a solid wax sprue or hollow metal sprue
filled with sticky wax during attachment of the [SE Q.4]

sprue to the pattern can reduce wax distortion.
(b) Avoiding stresses on the wax pattern during
{3. Discolouration of the casting
After separation from the investment the casting
removal.
usually appears dark due to coating of oxides or
(c) Immediate investment of the wax pattern on
defects in casting procedures. This surface discolou-
removal from the die.
ration can be removed by a process called pickling.
[SE Q.4] Casting defect discolouration occurs due to follow-
ing reasons:
{2. Surface roughness and irregularities l Under heating – Inadequate heating of the in-
(a) Surface roughness vestment leaves wax residues. These carbon resi-
l Coarse silica particles in the investment cause dues may form a tenacious carbon coating on the
surface roughness of the casting. casting thereby discolouring the casting.
l Mixing the investment powder with inadequate l Prolonged heating – Heating the investment for
or excess water. too long decomposes the sulphur compound in
l Too rapid heating of the investment as it leads to the investment which can discolour the casting
flaking of the investment. and make it brittle.
l Prolonged heating of the investment also disin- l High sulphur content of the torch flame can
tegrates the gypsum-bonded investment. also discolour the casting.
l Casting pressure being too high. l Carbon inclusion – Carbon from the crucible,
(b) Surface irregularities: These are isolated imper- torch flame or investment may form carbides on
fections like nodules or fins. the casting surface causing it to discolour.
Causes: Use of mixtures of different casting alloys – In
l Air bubbles becoming attached to the pattern this case, discolouration occurs due to corrosion.
during investing.
[SE Q.3]
l Water film formed on the wax pattern during
investing results in minute ridges or veins on {Porosity can occur both on the internal aspect and on
the surface of the casting. the external surface of the casting. Porosity weakens the
l Too rapid heating of the investment as it cast restoration. The different types of porosities affect-
causes flaking of the investment. ing cast gold alloys are:
l Careless removal of the sprue former can A. Solidification defects
carry bits of investment into the mould lead- l Localized shrinkage porosity
ing to surface irregularities. l Microporosity
l Molten alloy impacting a weak portion of the B. Trapped gases
mould surface can cause a depression in the l Pinhole porosity
mould which is reflected as a raised area on l Gas inclusion porosity
the casting. l Subsurface porosity}
[SE Q.3] Prevention: Controlling the rate at which the

molten alloy enters the mould.
{A. Solidification defects C. Residual air
(a) Localized shrinkage porosity – This occurs if Back pressure porosity – This occurs due to the
the molten alloy prematurely solidifies in the inability of the air in the mould to escape through
sprue before the solidification of the alloy in the pores in the investment. It is seen as concave
the mould space. depressions on the inner surface of the casting.
Causes: Causes:
l The diameter of the sprue former is too l Use of dense modern investments which
small. are less porous.
l Lack of a reservoir in the sprue former. l Vacuum investing which causes fewer
l Improper sprue attachment – Attachment voids.
at 900 to a broad flat surface causes a ‘hot l Improper wax elimination.
spot’ where the metal first impinges lead- l Low casting temperature.
ing to solidification of this area after the l Short sprue resulting in more invest-
alloy solidifies in the sprue. ment thickness between the pattern and
This produces a ‘suck back’ porosity. the open end of the ring.
Prevention: This can be prevented by selecting a l Inadequate casting pressure.
sprue of sufficient length and diameter. Prevention:
(b) Microporosity – This is seen in fine grain alloy l Use of porous investments.
castings when the solidification is too rapid l Proper powder/liquid ratio.
for the microvoids to segregate to the liquid l Enough mould and casting temperature.
pool. It occurs as small, irregular voids. It is l Proper wax burnout.
not a serious defect and can be avoided by: l Adequate casting pressure.
(i) Increasing the casting temperature
l Use of vents.}
(ii) Increasing the melt temperature 4. Porosity
B. Trapped gases
(a) Pinhole porosity – These are tiny spherical [SE Q.4]
voids. Any metals in the cast gold alloy, espe- {5. Incomplete casting
cially silver, copper, palladium and platinum This occurs if the molten alloy has been prevented
are prone to dissolve oxygen or hydrogen from filling the mould space completely.
when they are in the molten state. As the al- Causes:
loy solidifies, these gases are released caus- l Improper venting of air from the mould due to
ing pinhole porosity. back pressure of air in the mould. If air is not
(b) Gas inclusion porosity – Gas inclusions are vented quickly, the molten alloy does not fill the
also spherical voids, much larger than Pin- mould before it solidifies.
hole Porosity. This occurs due to mechanical l Improper burnout leaves wax residues that create
entrapment of gas by the molten metal or due rounded margins.
to gas inclusion during the casting procedure. l This can also be due to lower liquid/powder ratio
Causes: which reduces the porosity of the investment.
l Poorly adjusted torch flame.
l Inadequate heating of the alloy which increases
l Use of oxidizing zone instead of the reduc-
the viscosity of the alloy and prevents it from
ing zone of the flame. filling the mould space completely.}
Prevention: Prevention:
l Use of graphite crucible for heating the
l Use of a porous investment
alloy. l Proper venting of air from the mould
l Correct adjustment and positioning of the
l Proper burnout of the wax
torch flame during melting. l Adequate heating of the alloy
(c) Subsurface porosity – This type of porosity l Proper casting pressure
also occurs due to entrapped gases in the
Q.2. Enumerate casting defects and measures to over-
molten alloy.
come them.
Causes: Simultaneous nucleation of solid
grains and gas bubbles when the alloy freezes Ans.
at the mould walls. [Same as LE Q.1]
Q.3. Enumerate and describe casting defects. the casting ring. This will allow the investment to
withstand the impact of the molten metal as well as
Ans.
allow the mould gases to escape.
[Same as LE Q.1] Site of the attachment of the sprue former to the wax
pattern
Q.4. Describe various casting defects in cast restorations
The sprue former should be attached to the bulkiest
and measures to prevent the same.
portion of the wax pattern due to the following
Ans. reasons:
l This will reduce the residual stresses in the
[Same as LE Q.1]
wax during attachment of the sprue former.
Q.5. Discuss the causes of casting defects and their l It will ensure supply of the molten metal to fill
prevention. all thinner sections of the mould.

l The usually preferred site for attaching the
Ans.
sprue former is the proximal surface. Since this
[Same as LE Q.1] may not be possible always, the marginal ridge
area is the site of attachment.
Angulation of the sprue former
SHORT ESSAYS: l The sprue former should always be attached at an
Q.1. Sprue and sprue former. angle of 45 degrees to the bulkiest portion of the
pattern. This will allow easy and efficient flow of
Ans.
the molten alloy.
l The sprue former provides a channel for the molten l Avoid attaching the sprue at 90 degrees angula-
metal to flow into the mould space in an invested casting tion to a flat floor or thin areas of the pattern as
ring after the wax pattern has been eliminated. this can cause:
l The sprue former is attached to the wax pattern when it l A ‘hot spot’ at the first site of impact of the
is still on the tooth or the die and facilitates removal of molten metal leading to ‘suck back’ porosity in
the pattern for investing it. the casting.
l Types of sprue formers are wax, resin or metal. l A concavity on the mould wall opposite to the
Wax and resin sprue formers point of sprue attachment leading to convexity
l Can be burnt during wax elimination so do not in the casting preventing its proper seating.
require removal. Q.2. Casting machines.
l Low thermal conductivity so they do not stress the
Ans.
wax pattern.
l Lack rigidity. l There are different types of casting machines available
Metal sprue formers to cast gold alloys:
l Require removal after wax elimination. Basically they are of two types:
l High thermal conductivity which can stress and (i) Centrifugal casting machines
distort the wax pattern. (ii) Air pressure casting machines
l Have good rigidity. (i) Centrifugal casting machines
l Can loosen some investment during removal lead- l Here centrifugal force is used to accelerate the flow
ing to voids or incomplete details in the casting. of the molten alloy into the mould space.
Sprue diameter Many designs of centrifugal casting machines are
l The diameter of the sprue former depends upon available. They are
the size of the wax pattern, the casting machine a. The alloy is melted in a separate crucible by
used and the type of alloy used. a torch flame and cast into the mould by
l As a rule the sprue diameter should be greater centrifugal force.
than the thickest portion of the wax pattern. The b. The alloy is melted electrically by a resis-
sprue former diameter ranges from 8 to 18 gauge tance heating or induction furnace and then
(8 gauge – 3 mm, 18 gauge is almost 1 mm in cast into the mould centrifugally by motor or
diameter). spring action.
Sprue former length l Centrifugal casting machines are more popular as
The length of the sprue former should be such that they have many advantages.
the end of the wax pattern is one-eighth to one-fourth Advantages of centrifugal casting machines:
of an inch (3.25–6.5 mm) away from the open end of i. Simple in design and operation.
ii. Useful for casting both small and large

l After pickling, the acid is poured off and the casting
castings.
is removed and washed.
(ii) Air pressure casting machines
Precautions during pickling:
l In these machines either compressed room air or
l The casting should not be removed using steel twee-
gases like carbon dioxide or nitrogen can be used to
zers; rubber-coated or teflon tweezers are preferred.
force the molten alloy into the mould.
This is because the pickling solution may dissolve
l Here, the alloy is melted in the hollow left by the
the tweezer and plate the component metals onto the
crucible former following which air pressure is ap-
casting.
plied to the molten metal through a suitable valve
l Heating the casting and dropping it into the pickling
mechanism.
solution should be avoided as this can damage or
l Air pressure casting machines are only useful for
distort the delicate margins of the casting.
making small castings and are not so popular.
l Use fresh pickling solution each time. If old solu-
Q.3. Porosities in castings. tions are reused, leftover copper from previous cast-
ings can contaminate the new casting.
Ans.
[Ref LE Q.1]
Q.4. Write briefly on casting defects. Q.7. Sprue former.
Ans. Ans.
[Ref LE Q.1] [Same as SE Q.1]
Q.5. Suck back porosity. Q.8. Porosities in dental castings.
Ans. Ans.
a. Localized shrinkage porosity or shrink-spot [Same as SE Q.2]
i. It occurs when the cooling sequence is incorrect and
the sprue freezes before the rest of the casting. The Q.9. Casting defects.
subsequent shrinkage produces voids or pits known Ans.
as shrink-spot porosity.
ii. These are large irregular voids usually found near [Same as SE Q.1]
the sprue-casting junction.
b. Suck back porosity SHORT NOTES:
i. It is a variation of the shrink spot porosity. This is an
external void usually seen in the inside of a crown Q.1. Reservoir.
opposite the sprue. Ans.
ii. A hot spot is created by the hot metal impinging on
the mould wall near the sprue. The hot spot causes l The reservoir is a piece of wax attached to the sprue
this region to freeze last. Since the sprue has already former approximately 1 mm from the pattern.
solidified, no more molten material is available and l A reservoir can be used as an added precaution. The
the resulting shrinkage causes a peculiar type of purpose of the reservoir is to prevent localized shrink-
shrinkage called suck back porosity. It is avoided by age porosity.
reducing the temperature difference between the Q.2. Casting defects.
mould and the molten alloy.
Ans.
Q.6. Pickling.
[Ref LE Q.1]
Ans.
Q.3. Localized shrinkage porosity.
{SN Q.5} Ans.
l This is the process of removing the surface tarnish or i. Localized shrinkage porosity is caused by solidification
oxide layer. It is done by placing the casting in a test shrinkage.
tube or porcelain beaker and pouring a warmed solution ii. Shrink spot or localized shrinkage porosity.
l These are large irregular voids usually found near the
of 50% sulphuric acid or 50% hydrochloric acid over it.
sprue casting junction.
It occurs when the cooling sequence is incorrect and

l Sprue former
the sprue freezes before the rest of the casting. Dur- l A sprue former is made of wax, plastic or metal. Thick-
ing a correct cooling sequence, the sprue should ness is in proportion to the wax pattern. A reservoir is
freeze last. attached to the sprue or the attachment of the sprue to
the wax pattern is flared.
Q.4. Back pressure porosity.
Functions of sprue former
Ans. i. To form a mount for the wax pattern.
ii. To create a channel for an elimination of wax during
Back pressure porosity is caused by:
burnout.
i. Inadequate venting or air escape of the mould.
iii. Forms a channel for entry of molten alloy during
ii. When the molten metal enters the mould, the air inside
casting.
is pushed out through the porous investment at the bot-
iv. Provides a reservoir of molten metal which compen-
tom. If the bulk of the investment is too great, the es-
sates for alloy shrinkage during solidification.
cape of air becomes difficult causing increased pressure
in the mould. The gold will then solidify before the Q.7. Pinhole porosity.
mould is completely filled resulting in a porous casting
Ans.
with rounded short margins.
iii. Back pressure porosity can be avoided by: Many metals dissolve gases when molten. Upon solidi-
l Using adequate casting force. fication the dissolved gases are expelled causing tiny voids,
l Use investment of adequate porosity. e.g. platinum and palladium absorb hydrogen. Copper and
l Place pattern not more than 6–8 mm away from the silver dissolve oxygen.
end of the ring. Q.8. Significance of reservoir.
l Providing vents in large castings.
Ans.
Q.5. Pickling.
[Same as SN Q.1]
Ans.
Q.9. Enumerate casting defect.
[Ref SE Q.6]
Ans.
Q.6. Sprue and sprue former.
[Same as SN Q.2]
Ans.
Q.10. Back pressure porosity in gold.
Sprue
Ans.
l The mould channel through which molten metal or ce-
ramic flows in to the mould cavity is known as sprue. [Same as SN Q.4]
Topic 14
Direct Filling Gold Restorations
LONG ESSAYS:
1. What are the types of direct filling gold? Describe compaction technique and its uses in dentistry. How is a gold
foil restoration finished?
2. Indications for direct filling gold. [Same as LE Q.1]
SHORT ESSAYS:
1 . Annealing and compaction procedures in direct gold.
2. Direct filling gold. [Ref LE Q.1]
3. Thermoplasticized.
4. Compaction and condensation of direct filling gold. [Same as SE Q.1]
5. Indications for direct filling gold. [Same as SE Q.2]
6. Types of direct filling gold. [Same as SE Q.2]
SHORT NOTES:
1 . Direct filling gold. [Ref LE Q.1]
2. Composition and properties of Type III Gold.
3. Annealing and compaction procedures in direct gold. [Ref SE Q.1]
4. Powdered gold. [Same as SN Q.2]
5. Mat gold.
6. Gold foil.
7. Electralloy.
SOLVED ANSWERS
LONG ESSAYS:
Q.1. What are the types of direct filling gold? Describe l Compaction of direct gold can be achieved by malleting
compaction technique and its uses in dentistry. How is a using either a hand mallet or an electro mallet.
gold foil restoration finished? l With either of these mallets, condensers are used to de-
liver the forces of compaction to the direct gold.

Ans. l Hand condensers used with hand mallet have long
(SE Q.2 and SN Q.1) shanks and a blunt-ended handle that receives light
blows from the hand mallet.
l On the other hand, condensers used with electro mallet
{(Types of direct filling gold
There are several forms of direct gold available for re- have a short shank that fits into the malleting handpiece.
storative purposes. All of these are cohesive and are 99.9% Condenser nibs are of different shapes and sizes:
pure. Direct filling gold may be categorized as follows: (i) Round: This is used to start the direct gold restoration
I. Gold foil and form ‘ties’.
l Sheets (ii) Parallelogram: This is used to build the bulk of the
l Pellets (hand-rolled and preformed) restoration.
l Cylinders (iii) Rectangular: This is used for condensation at the cavo-
l Corrugated foil surface and surface hardening of the restoration.
l Platinized foil l All condenser nibs have pyramidal serrations on the
l Laminated foil nib face to prevent slipping on the gold.
II. Electrolytic precipitated gold
l Mat gold
Certain principles have to be strictly followed for compac-
l Mat foil
tion of direct gold as follows:
l The forces of condensation should be at 45° to the cav-
l Gold calcium alloy
III. Powdered gold ity walls and floors. This produces maximum adaptation
l Goldent)}
of the gold into all details of the cavity preparation.
l The forces of condensation must be at 90° to previously
Principles of compaction of direct gold restorations condensed gold to prevent displacement of the already
l During insertion direct gold must be compacted into the condensed pieces of gold.
prepared cavity. This adapts the gold into the details of the l Whenever condensing a piece of direct gold, always
preparation such as the line angles, point angles and walls. start at a point on one side and proceed in a straight line
l It also removes the voids between the pieces of direct to another point on the opposite side, then back to the
gold and makes them attach to one another by cohesion. original side on a different straight line.
l During these movements, the condenser should overlap

{SN Q.3}
at least half of the previously condensed area. This pro-
cess is called ‘stepping’. This ensures maximum adapta- l ‘Degassing’ is the process of heating direct gold ma-
tion of the gold to the cavity walls and also cold welds terials to remove the surface contaminants. It is also
each increment of gold, thus reducing the voids. referred to as ‘annealing’.
l Minimally sized increments of gold should be used. Degassing may be achieved by:
l Powdered gold is generally compacted using hand con- (i) Heating the gold foil over pure ethanol flame.
densers with heavy hand pressure. (ii) Heating in a mica tray mounted over an alcohol
l Gold foil requires hand condensers with the hand mallet lamp.
delivering light blows. (iii) Heating in an electric annealer.
l Direct gold restorations require very little finishing if the
previous steps are properly done. Finishing can be done us-

ing tin oxide powder on soft bristle brushes or rubber cups. (i) Heating over an open alcohol flame: In this method
l Final burnishing is done after polishing to make the each piece of direct gold is held in the middle zone
surface of the restoration smooth and free from voids. (high energy reducing zone) of an alcohol flame for
3–5 s before inserting into the cavity preparation.
[SE Q.2] (ii) Heating in a mica tray over the alcohol flame: This
{Uses of direct filling gold is a bulk method where several gold pellets are de-
i. Class I cavity: Direct gold is indicated for small carious gassed in mica trays held over the alcohol flame.
lesions in pits and fissures of posterior teeth and lingual However, it is necessary to prevent the gold pieces
surfaces of anterior teeth. from sticking together.
ii. Class II cavity: Direct gold is indicated for minimal (iii) Heating in an electric annealer: This is the most con-
proximal caries in posterior teeth especially premolars trolled and standardized method of decontaminating
when marginal ridges are not subjected to heavy oc- direct gold materials. The desired amount of gold is
clusal stresses. placed in the compartments of the annealer and the lid
iii. Class III cavity: Direct gold can be used for small cari- is closed. The gold is heated to 850ºF for 10 min and
ous defects in anterior teeth when the defect is only on then allowed to cool before it is placed in the cavity.
the proximal surface and aesthetics will not be affected. Hazards during degassing
iv. Class V cavity: For minimal caries in the cervical one- i. Overheating
third of teeth, direct gold can be used. It is also indi- Recrystallization and grain growth, decreased plasticity
cated for small abrasion, erosion or abfraction defects of the material and improper compaction of the gold can
on the facial surfaces of teeth. occur if the gold is heated for prolonged periods of time
v. Class VI cavity: For restorations involving incisal edges or to too high temperatures due to excessive sintering
or cusp tips, direct gold may be used, provided there is and contamination from the tray, instruments or flame.
no heavy occlusal stress. ii. Underheating
vi. Defective crown margins: Defective crown margins of If the gold is not heated adequately it results in incom-
cast gold crowns may be repaired with direct gold. plete removal of surface impurities leading to poor co-
Whenever access openings are done through existing hesion between the gold pieces on condensation causing
cast gold crowns, they may be sealed with direct gold pitting and porosity in the final restoration.
after the endodontic therapy.}
Compaction
Q.2. Indications for direct filling gold. l During insertion direct gold must be compacted into the
Ans. prepared cavity. This adapts the gold into the details of
the preparation such as the line angles, point angles and
[Same as LE Q.1] walls.
l It also removes the voids between the pieces of direct
SHORT ESSAYS: gold and makes them attach to one another by cohesion.
l Compaction of direct gold can be achieved by malleting
Q.1. Annealing and compaction procedures in direct by using either a hand mallet or an electro-mallet.
gold. l With either of these mallets, condensers are used to de-
Ans. liver the forces of compaction to the direct gold.

l The forces of condensation should be at 45° to the cav-
l The gold should be made cohesive, for successful weld- ity walls and floors. This produces maximum adaptation
ing of gold to occur during restoration. of the gold into all details of the cavity preparation.
l The forces of condensation must be at 90° to previously Q.2. Composition and properties of Type III Gold.
condensed gold to prevent displacement of the already
Ans.
condensed pieces of gold.
l Whenever condensing a piece of direct gold, always l Powdered gold is made by a combination of chemical
start at a point on one side and proceed in a straight line precipitation and atomization with an average particle
to another point on the opposite side, then back to the size of 15 micron.
original side on a different straight line. l Since powders are difficult to manipulate the particles
l During these movements, the condenser should overlap are mixed together in wax, cut into pieces and wrapped
at least half of the previously condensed area. This pro- in gold foil as pellets.
cess is called ‘stepping’. This ensures maximum adapta- l Commercially this is available as Goldent or Williams
tion of the gold to the cavity walls and also cold welds E-Z gold.
each increment of gold, thus reducing the voids.
l Minimally sized increments of gold should be used. Q.3. Annealing and compaction procedures in direct
gold.
Q.2. Direct filling gold.
Ans.
Ans.
[Ref SE Q.1]
[Ref LE Q.1]
Q.4. Powdered gold.
Q.3. Thermoplasticized.
Ans.
Ans.
[Same as SN Q.2]
l Pure gold is soft, malleable and ductile and does not
oxidize under normal atmospheric conditions. Q.5. Mat gold.
l Gold fuses at 1063°C and boils at 2200°C. Ans.
l The Brinnell hardness number for gold is 25. This
makes it very soft. However during compaction the l This is a crystalline electrolytically precipitated gold
hardness increases to 58–82 making it a strong material. that is formed into strips.
l The dentist can cut the strips into desired sizes.
l The coefficient of thermal expansion of gold is 14.4 3
l This form is easy to use for building the internal bulk of
10.6/QC which is close to that of tooth structure.
l Gold exhibits high thermal conductivity. the restoration because of ease of compaction.
l But mat gold is loosely packed so it shows numerous
l The most important property of gold which has enabled
its use as a direct filling material is its ability to be ‘cold voids between the particles.
l Hence, it is not recommended for the external surface of
welded’ at room temperature.
l When two clean pieces of gold are pressed firmly to- the restoration as it can become pitted.
gether under sufficient force at mouth temperature they Q.6. Gold foil.
get welded together.
Ans.
Q.4. Compaction and condensation of direct filling gold.
l This is called fibrous gold. It is available as sheets, pel-
Ans. lets, cylinders, ropes and precondensed laminates of
[Same as SE Q.1] varying thickness.
l Gold foil sheets – they are manufactured by beating or
Q.5. Indications for direct filling gold.
rolling pure gold ingots into thin sheets.
Ans. l Gold foil pellets – these can be hand-rolled or commer-
[Same as SE Q.2] cially produced from a no. 4 gold foil sheet.

l Gold foil cylinders – large sheets are cut and rolled into
Q.6. Types of direct filling gold.
cylinders.
Ans. l Corrugated gold foil – thin sheets of paper are placed in
[Same as SE Q.2] between the gold foil sheets and ignited. Corrugated
gold is obtained when the paper gets charred.
SHORT NOTES: l Platinized gold foil – this is a sandwich of gold and
platinum.
Q.1. Direct filling gold.
Q.7. Electralloy.
Ans.
[Ref LE Q.1] Ans.
l Gold calcium alloy is another form of electrolytically l The addition of calcium produces a stronger restoration
precipitated gold which is alloyed with 0.1% calcium. by dispersion strengthening.
l It is commercially available as Electralloy RV. l This is sintered so as to make the gold into strip form.
Topic 15
Lasers in Operative Dentistry
SHORT ESSAYS:
1 . Laser.
2. Lasers in dentistry. [Same as SE Q.1]
SOLVED ANSWERS
SHORT ESSAYS:
Q.1. Laser. l Cavity preparation is based on the photothermal and
photoablation effects.
Ans.
l The laser light vaporizes the water present in the
Lasers are used in dentistry in a number of ways. These enamel and dentine and causes microexplosion of
are discussed as follows: the hydroxyapatite. This creates microcraters on the
i. Caries detection tooth surface.
l This can be done using laser-induced fluorescence.
l Adverse effects on the pulp due to the heat generated
l The light from this lamp is filtered by a blue-trans-
are minimized by the water spray that accompanies
mitting filter. the laser light.
l A light guide transports this blue light of wavelength
iv. Disinfection of prepared cavities
405 nm to the teeth. l Lasers can be used for photoactivated disinfection of
l Natural teeth show green fluorescence whereas cari-
prepared cavities to destroy any residual microorgan-
ous lesions demonstrate red fluorescence and thus isms using solution of tolonium chloride along with
enable detection. a visible red laser light at 63 nm.
l For more accurate caries detection, a handheld de-
l The combination releases nascent oxygen that can
vice Diagnodent is used which uses a diode laser at destroy bacterial cell walls.
a wavelength of 655 nm. l It effectively disinfects prepared cavities prior to
ii. Caries prevention placement of restorations.
l Argon laser and Nd:YAG laser shows alteration of
v. Laser etching of enamel and dentine
the characteristics of enamel. l Using Er:YAG and Er,Cr:YSGG produces chalky
l It makes enamel more resistant to caries without en-
white surfaces.
dangering the pulp. l Laser irradiation of dentine results in a surface that is
l It makes enamel more acid resistant and increases its
free of smear layer.
fluoride uptake when topical fluorides are applied. l But still additional acid-etch techniques are recom-
iii. Cavity preparation mended before composite resin placement.
l For cavity preparation, hard tissue lasers in the infra-
vi. Laser curing of composite resins
red area of the electromagnetic spectrum are used. l Argon lasers emit a blue light at a wavelength of
l The two lasers used for these are the Er,Cr:YSGG
457–502 nm which is suitable for curing composite
(2780 nm) and the Er:YAG (2940 nm). resins.
Advantages: l Nd:YAG and CO2 laser irradiation of dentine results

l It increases degree of polymerization of com- in recrystallization of dentine which induces occlu-
posite resins. sion or narrowing of dentinal tubules and thus con-
l Greater depth of cure of composite resins. trolling hypersensitivity.
l Polymerization is uniform even if the light guide viii. Gingival tissue management
is at a distance from the composite material. l CO2 lasers, Nd:YAG, argon and diode lasers are used
Disadvantages: for soft tissue surgery.

l Adjacent restorations may be affected by lasers. l Diode lasers are used for gingival tissue retraction
l Rise in temperature due to the laser may dam- during restorative procedures or for recontouring the
age the pulp. gingiva during smile design procedures.
l Rapid polymerization can increase polymer-
Q.2. Lasers in dentistry.
ization shrinkage stresses.
l High cost. Ans.
l Need for safety equipment.
[Same as SE Q.1]
vii. Desensitization of dentine
l Studies show that He:Ne and diode lasers prevent the
transmission of pain by blocking the depolarization

of A8 and C-fibres.
Topic 16
Miscellaneous
SHORT ESSAYS:
. Dentifrice.
1
2. Desensitizing agents.
3. Tissue conditioner.
SHORT NOTES:
. Phosphoric acid.
1
2. Slice preparation.
SOLVED ANSWERS
SHORT ESSAYS:
ii. They polish teeth to provide increased light reflectance
Q.1. Dentifrice.
and superior aesthetic appearance.
Ans. iii. Act as vehicles for delivery of therapeutic agents with
known benefits, e.g. fluorides, tartar control agents and
Dentifrices are available as toothpastes, gels and powders,
desensitizing agents.
which provide three important functions.
i. Their abrasive and detergent actions provide more effi- Compositions
cient removal of debris, plaque and stained pellicle ● Abrasives
compared with the use of a toothbrush alone. ● Detergents
● Colourants ● Liquid: Aromatic ester in ethanol or an alcohol of high

● Flavouring agents molecular weight.
● Water
Manipulations
● Humectant
● The denture is relieved on the tissue surface.
● Binder
● Powder and liquid are mixed together to form a gel and
● Fluoride
it is inserted on the tissue surface of the denture and the
● Tartar control agents
denture is placed in the mouth.
● Desensitizing agents
● The gel flows readily to fill the space between the den-
Q.2. Desensitizing agents. ture base and the oral tissues.

Ans. Properties that make tissue conditioners effective
● Viscous properties, which allow excellent adaption to
Various desensitizing agents are as follows:
irritated denture-bearing mucosa over a period of sev-
A. Desensitization by occluding dentinal tubules
eral days.
● Formation of a smear layer over exposed dentine.
● Elastic behaviour which cushions the cyclic forces of
i. Use of topical agents to occlude the exposed
mastication and bruxism.
tubules:
● Calcium hydroxide paste
● Calcium phosphate paste SHORT NOTES:

● Silver nitrate
Q.1. Phosphoric acid.
● Fluorides
● Strontium chloride Ans.

● Fluoride iontophoresis
● Phosphoric acid is used as an etchant.
● Potassium oxalate
● Presently 37% of phosphoric acid is used to etch enamel
● Varnishes
to achieve good retention.
● Dentine adhesives
● It creates microtags in the enamel and helps to get good
ii. Placement of restorations
retention by increasing surface area.
iii. Use of lasers
● Phosphoric acid is also used as one of the liquid compo-
● CO2 laser
nent in zinc phosphate cements.
● Nd:YAG, Er:YAG laser
● He:Ne laser Q.2. Slice preparation.

B. Desensitization by blocking pulpal sensory nerves
Ans.
● Potassium nitrate toothpastes.
● Slice preparation is a type of cavity preparation for class

Q.3. Tissue conditioner.
II cast restorations.
Ans. ● The proximal portion is formed by removing a sufficient
slice of the proximal convexity of the tooth to achieve

● Tissue conditioners or temporary soft liners are materi-
cleansable margins and a line of draw; a tapered keyway
als whose usefulness is very short, generally for a few
or two keyed grooves or channels in the proximal sur-
days.
face provide retention form.
Composition
● Powder: Polyacrylic (methacrylate) or one of its
copolymers.
Section I

of Previous Years
PART II ENDODONTICS
Topic 1 Clinical Diagnostic Aids in Endodontics 143
Topic 2 Endodontic Emergencies 150
Topic 3 Dental Pulp and Periradicular Tissues:
Embryology and Anatomy 153
Topic 4 Diseases of Dental Pulp and Periradicular Tissues 154
Topic 5 Principles and Rationale of Endodontic Treatment 161
Topic 6 Endodontic Instruments and Sterilization 162
Topic 7 Endodontic Microbiology 171
Topic 8 Tooth Morphology and Access Cavities 174
Topic 9 Endodontic and Biomechanical Preparation
and Working Length Determination 179
Topic 10 Materials in Endodontics 187
Topic 11 Obturation of Root Canal 199
Topic 12 Postendodontic Restorations 205
Topic 13 Mishaps and Failures of Endodontic Treatments 209
Topic 14 Treatments of Traumatized Teeth 215
Topic 15 Endodontic Surgery and Replantation and Transplantation 221
Topic 16 Endodontic Periodontal Inter-relationships 230
Topic 17 Lasers and Endodontic Implants 233
Topic 18 Single-Visit Endodontics 237
Topic 19 Bleaching of Discoloured Tooth 237
Section I

of Previous Years
Part II
Endodontics
Topic 1
Clinical Diagnostic Aids in Endodontics
LONG ESSAYS:
1 . Describe the various diagnostic aids employed in endodontic practice.
2. Discuss various diagnostic aids in endodontics. Add a note on limitation of the endodontic radiographs.
3. List out the various tests for determining the vitality of the teeth. Discuss in detail about thermal tests in their
efficiency. [Same as LE Q.1]
4. Mention the various clinical diagnostic aids used in endodontics and write in detail the vitality tests.
[Same as LE Q.1]
5. Write briefly on diagnosis and treatment planning in endodontics and add a note on pulp testers. [Same as LE Q.1]
6. Enumerate the different diagnostic aids in endodontics. Write in detail the procedure of electrical pulp testing.
Add a note on false responses. [Same as LE Q.1]
7. Enumerate various diagnostic aids in endodontics. Discuss in detail the importance of radiographic examination
and give its limitations. [Same as LE Q.2]
8. Enumerate the various diagnostic aids used in the field of operative dentistry and endodontics. Discuss in detail
the importance of radiographic examination and its limitation. [Same as LE Q.2]
SHORT ESSAYS:
1 . Thermal tooth vitality test. [Ref LE Q.1]
2. Percussion test.
3. Radiography in endodontic. Limitations of radiographs. [Ref LE Q.2]
143
4. Radiovisiography.
5. Endometer.
6. Transillumination in endodontics.
7. Describe diagnostic aids used in endodontia and electric pulp test. Electric pulp testing-false-positive and false-
negative reading. [Ref LE Q.1]
8. Heat test. [Ref LE Q.1]
9. Thermal vitality test. [Ref LE Q.1]
10. Pulp vitality test. [Ref LE Q.1]
SHORT NOTES:
1. Endodontic triad.
2. Glass bead sterilizer.
3. Diagnostic aids used in endodontics. [Ref LE Q.1]
4. Thermal test. [Ref LE Q.1]
5. Cold test. [Ref LE Q.1]
6. Heat test for tooth vitality. [Ref LE Q.1]
7. Test cavity.
8. Limitations of radiographs. [Ref LE Q.2]
9. RVG. [Ref SE Q.4]
10. Percussion test. [Ref SE Q.2]
11. Laser Doppler flowmetry. [Ref LE Q.1]
12. Cold testing for tooth vitality. [Ref LE Q.1]
13. Thermal diagnostic test and heat testing in endodontics. [Ref LE Q.1]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Describe the various diagnostic aids employed in ii. Heat testing
endodontic practice. I II. Laser Doppler flowmetry (LDF)
IV. Pulse oximetry
Ans.
V. Liquid crystal testing
VI. Hughes Probeye camera
{SN Q.3} I. EPT

l EPT relies on electric impulses directly stimulating
The following are the various diagnostic aids employed the nerves especially a-delta sensory nerves of the
in endodontic practice to arrive at a correct diagnosis: pulp.
i. Visual and tactile inspection l EPT like Digitest, Gentle pulse, Neotest, Dentometer
ii. Palpation and percussion checks the status of the pulp.
iii. Mobility test l EPT shows only the responsive or nonresponsive
iv. Radiographic examination status of the pulp; it does not give any idea about
v. Electric pulp vitality test vascular supply or histological status of the pulp.
vi. Thermal test l EPT is technique sensitive and has drawbacks like
vii. Test cavity preparation adequate stimulus, proper application method and
viii. Anaesthetic test careful interpretation of the results.
Factors that affect the level of response in EPT are
l Thickness of enamel
Various methods employed to check vitality of the teeth l Probe placement on the tooth
are described below: l The cross-sectional area of the probe tip
I. Electric pulp test (EPT) l Amount of calcification in dentine
II. Thermal test l Recently traumatized teeth
i. Cold testing l Interfering restorative materials

l The level of anxiety in patient

{SN Q.4}
l Use of any sedative medications
Procedure These tests rely on fluid flow in dentinal tubules.
l Explain the procedure to the patient to reduce Cold test can be done with:
anxiety then isolate and dry the teeth with cotton l Ice sticks
rolls. l Ethyl chloride
l Tooth paste or a similar electrical conductor is l Endo ice
applied to the tip of the electrode. l Frozen CO2
l To complete the circuit, patient should be asked to Heat test can be done with:
place a finger on the handle of the device or use a l Hot water
lip clip. l Hot burnisher
l Multirooted teeth may need to be tested by plac- l Hot green stick compound
ing the electrode on more than one location on the l Heated gutta-percha [GP]
crown.
l The electrode should be applied to the dried
enamel at middle third of the facial surface of the {SN Q.5}

crown (5–20 mA strength currents are used).
A. Cold testing
l The current flow should be slowly increased till
l It is one of the most reliable tests.
the tingling sensation becomes painful.
l It is used in differentiating reversible from irre-
l An average result is recorded after applying the
versible pulpitis and also necrotic pulp.
electrode for two to three times.
Cold testing can be performed with:
Precautions
i. Air blast.
l Patients with cardiac pacemaker.
ii. Cold drink/water/ice sticks.
l Against devices such as desensitizers and electro-
iii. Ethyl chloride spray causes enamel craze
surgical units that could produce unknown current
lines.
leaks.
iv. Skin refrigerant spray: It is also known as
EPT false readings
endo ice, i.e. tetrafluoroethane with a tem-
A false-positive response means that pulp is necrotic,
perature of –26.2°C. It is used on a cotton
but patient feels sensation in tooth. It could be due to:
pellet and applied on the mid-facial surface
l Moist gangrenous pulp is present in root canal.
of mature tooth.
l Multirooted teeth with partially necrotic pulp.
v. Frozen CO2:
l Improper isolation.
l It is known as dry ice or CO2 snow with a
l Patient anxiety.
temperature of –56 to –98°C containing
l Proximal metallic restoration.
dichlorodifluoromethane.
A false-negative response means that pulp is vital, but
l It is delivered in small plastic syringe. It
patient does not complain of sensitivity. It could be
is protected from soft tissues to prevent
due to:
soft tissue burns.
l Calcified pulp chambers.
l No irreversible changes in pulp or enamel
l Teeth with extensive restoration and protective
crazing occur.
bases.
Procedure
l Recently traumatized tooth.
l Both endo ice and frozen CO2 can be effec-
l Recently erupted teeth with incomplete root for-
tively used on tooth with full coverage crowns.
mation (has more unmyelinated axons than the
However, frozen CO2 may cause pitting of the
mature teeth).
porcelain surface.
l Patient on sedatives/alcohol.
l The teeth are isolated, and immediately the ice
l Patients with unusually high-pain threshold.
stick should be applied to the middle third of
l Low battery.
the facial surface of the tooth or on any exposed
l Inadequate conductor media.
metal surface of crowns, kept for 5 s in contact
l Patients with psychotic disorder.
with the tooth or until the patient begins to feel
l Cervical full pulpotomy.
pain.
[SE Q.1] l For any of the cold tests, it should always be
started with the most posterior tooth and ad-

{II. Thermal tests vance towards the anterior teeth.
l During testing, if the pain lingers, it is diag- of the light to be back-scattered out of the tooth.
nosed as irreversible pulpitis; if pain subsides The reflected light is detected by a photocell
immediately after the removal of stimulus, it which is present on the tooth surface, the output
is diagnosed as hypersensitivity or reversible of which is proportional to the number and veloc-
pulpitis. ity of the blood cells. However, the frequency will
not change as it passes through a static tissue (ne-
crotic pulp).
{SN Q.6}
B. Heat testing Disadvantages:
It can be done with: l Altered results are expected in smokers and
l Heated GP stick patients on antihypertensive medications such as

l Hot water nicotine which may affect the blood flow of the
l Hot instrument like heated burnisher pulp.
l Equipment is too expensive.
l Hot green stick compound}
IV. Pulse oximetry
l This technique is widely used and its main purpose
[SE Q.1] is for recording oxygen saturation levels of blood
{Procedure: during the intravenous administration of anaesthesia.
l The teeth are protected with a thin coating of petro- l Increased acidity and metabolic rate produced by
leum jelly to prevent the warm temporary stopping inflammation causes deoxygenation of haemoglobin
from sticking to them. and changes the oxygen saturation level of the blood.
l The stopping should be warmed until it begins to l It uses a probe containing a diode that emits light in
glisten, applied on the middle third of the facial sur- two wavelengths:
face of the crown which leads to a response in less a. Red light of approximately 660 nm.
than 2 s. b. Infrared light of approximately 850 nm.
l If hot water is used, then the tooth should be isolated l The light is received by a photo detector diode con-
under a rubber dam. The tooth is then immersed in nected to a microprocessor.

hot coffee/water delivered from a syringe, and the l The device compares the ratio of the amplitude of
patient’s reaction (5 s) is noted.} the transmitted infrared with red light.

l Pulse oximetry can detect inflammation of the pulp
(SE Q.1 and SN Q.6) or partial necrosis in vital teeth by monitoring
{(Response to thermal tests changes in oxygen saturation.
l Expensive instrument.
There are four possible responses to thermal stimulation.
i. Nonvital pulp: No response. V. Liquid crystal testing
l Cholesteric liquid crystal has been used to show the
ii. Normal pulp: Mild-to-moderate pain that subsides
within 1–2 s after removal of the stimulus. difference in tooth temperature between teeth with
iii. Reversible pulpitis: Strong, momentary pain that vital (hotter) pulps and necrotic (cooler) pulps.
subsides within 1–2 s after removal of the stimulus. VI. Hughes Probeye camera
l This is capable of detecting temperature changes as
iv. Irreversible pulpitis: Moderate-to-strong pain that
lingers for several seconds or longer after the stimu- small as 0.1°; it has also been used to measure pulp
lus has been removed.)} vitality experimentally.
False-positive results
l False-positive results mean positive response of a
{SN Q.11} non vital tooth to pulp testing.

l In anxious or young patients who expect to feel an
III. LDF
unpleasant sensation, a premature response may
l This method is used to determine the blood flow
occur.
in microvasculature system.
l In one part of the root canal system, breakdown
l It uses a laser beam of known wavelength which
products can conduct the electric current from an
is directed through the crown of the tooth to the
electric pulp tester which results in a false-positive
blood vessels within the pulp.
result.
l The moving red blood cells cause the frequency
l Presence of vital tissue in partially necrotic root
of the laser beam to be Doppler shifted and some
canal system: Conduction of the current to the
periodontium may occur, if there is contact with Confirm the position and adaptation of the master
l
metal restorations which gives a false-vital re- cone and evaluation of the final root canal filling.
sponse; the same may occur with inadequately l Examination of fractured tooth fragments and other
dried teeth prior to testing. foreign bodies following traumatic injury.

False-negative results l Evaluate the outcome of endodontic treatment.}
l False-negative results means vital teeth showing Radiographic interpretation

negative response to testing. l A single root canal should appear tapering from
l Teeth with incomplete root development have a crown to apex; however, a sudden change in appear-
higher threshold to testing in these conditions ance of canal from dark to light indicates that the
cold testing is more reliable than electric pulp canal is bifurcated or trifurcated.
testing. l When the X-ray beam is directed from the mesial
l Traumatized teeth may not give initial response to aspect of a particular tooth, the canals or roots that
thermal or electric pulp testing due to nerve rup- are placed in the buccal and lingual aspects are
ture but the pulps of the teeth may still be vital as separated. The lingual root always appears to the
their blood vessels may remain intact or have mesial on the film which is called SLOB rule
revascularized. (Same Lingual Opposite Buccal), Clark’s rule,
l It has been shown that orthodontic movement can when a mesial horizontal angulation is given, lin-
produce changes in tissue respiration, and there is gual canal appears more towards the mesial (than
reduction in blood flow. buccal canal)-buccal object rule, cone/tube shift
l Patients with psychotic disorders may not show technique.
any response to pulp testing. l Radiographic appearance of periapical pathosis de-
l People who are under the influence of sedative pends on the relationship of periapex with cortical-
drugs/alcohol may either not respond or respond cancellous bone junction.
to stronger stimulation due to their increased l Radiographic differentiation of internal and external
threshold to nerve excitation. resorption.

a. Internal resorption – have sharp smooth margins
Q.2. Discuss various diagnostic aids in endodontics.
and the pulp ‘disappears’ into the lesion.
Add a note on limitation of the endodontic radio-
b. External resorption – margins are not smooth and
graphs.
pulp appears to pass through the lesion unaltered.
Ans. Radiographic misinterpretation
l Presence of periapical radiolucency on a tooth does
[SE Q.3]
not indicate a diseased tooth. In many instances, an
{Radiographs are one of the most important clinical area of rarefaction or normal anatomy on the root
tools in making a diagnosis: apex may be the superimposition of an image on the
Application of radiography in endodontics apex, e.g. maxillary sinus, incisive and mental fora-
l To determine the loss of hard tissue in the coronal tooth men, medullary space, traumatic bone cysts.
structure and its proximity to pulp horn/chamber. l Apical scar – This scar is seen after apical surgery
l To diagnose hard tissue alterations of teeth and peri- where a connective tissue healing takes place without
radicular structures. bony healing. A number of pathological changes in
l To diagnose the tooth anomalies like dens invagina- and near the alveolar process may be mistaken for
tus, dens evaginatus, taurodontism and others. true periapical lesions.
l Locating a pulp that is markedly calcified or receded. l Nonodontogenic cysts – Lamina dura is intact in all
l To examine the status of lamina dura periapically. nonodontoblastic cysts.

l Detection of any fractures.
l Evaluate the formation of dentine bridges after pulp-

(SE Q.3 and SN Q.8)
capping procedures. {(Limitations of radiographs
l GP tracing of sinus tract with radiograph to differen- l The dimensions are easily distorted through im-
tiate endodontic lesion from periodontal lesion. proper technique, anatomic limitations or processing
l The number, location, shape, size and direction of since there are two-dimensional images shown on
roots and root canals should be determined. the film. The buccal-to-lingual dimension is absent
l Before instrumentation, the length of root canals on the film.
should be measured and confirmed. l Various states of pulpal pathosis are undifferentiable
l To detect perforations or any other mishaps, resorp- (sterile or infected states of hard or soft tissue is not
tion of root and adjacent bone. detectable other than by inference).
l Periradicular soft tissue lesions cannot be accurately

{SN Q.10}
diagnosed by radiographs; they require histological
verification. l Percussion test is a type of test which is used to de-
l Lesions of the medullary bone are likely to go unde- termine the status of the periodontium surrounding a
tected until the resorption has expanded and eroded a tooth.
portion of the cortical plate.)} l The handle of the instruments like mouth mirror and
probe is used and the tooth is struck a quick, moder-

Q.3. List out the various tests for determining the vital-
ate blow initially with low intensity to determine
ity of the teeth. Discuss in detail about thermal tests in
whether the tooth is tender.
their efficiency.
l Periodontitis is indicated when a sensitive response
Ans. differing from that of the adjacent teeth is felt.

l To eliminate bias on the part of the patient one must
[Ref LE Q.1]
change the sequence of the teeth percussed on suc-
Q.4. Mention the various clinical diagnostic aids used in cessive tests, the percussion test alone cannot help
endodontics and write in detail the vitality tests. diagnose a condition.
l One should change the direction of the blow from the
Ans.
vertical occlusal to the buccal or lingual surface of
[Ref LE Q.1] the crown and strike separate cusps in a differing
order.
Q.5. Write briefly on diagnosis and treatment planning
l One must not percuss a sensitive tooth beyond the
in endodontics and add a note on pulp testers.
patient tolerance.
Ans. l According to percussive sounds, a dull note signifies
abscess formation, a sharp note denotes inflammation.

[Ref LE Q.1]
Q.6. Enumerate the different diagnostic aids in end-
odontics. Write in detail the procedure of electrical pulp Q.3. Radiography in endodontic. Limitations of radio-
testing. Add a note on false responses. graphs.
Ans. Ans.
Q.7. Enumerate various diagnostic aids in endodontics. Q.4. Radiovisiography.
Discuss in detail the importance of radiographic exami-
nation and give its limitations. Ans.
Ans.
[Ref LE Q.2] {SN Q.9}
Q.8. Enumerate the various diagnostic aids used in the l Radiovisiography (RVG) technique has the ability
field of operative dentistry and endodontics. Discuss in to capture, view, enhance and store radiographic
detail the importance of radiographic examination and images.
its limitation. l It has an intraoral sensor that captures the image by
Ans. radiation source. Sensor is a fluoroscopic sensor, a

set of optic fibres and a miniature charged coupling
[Ref LE Q.2] device that translates the image and an electronic
signal is produced, which is displayed.
SHORT ESSAYS: l The sensor is attached to the computer, which inter-
Q.1. Thermal tooth vitality test. prets the signal and transforms it into digital image.
l This image is instantly displayed and visualized in a
Ans. computer/video monitor.
l This image can be stored and recalled whenever
[Ref LE Q.1]
required.
Q.2. Percussion test. l A graphic component that has a high-resolution
printer helps in obtaining a printout of the image.

Ans.
l A specialized fibreoptic wand, otoscope with fibreoptic

Advantages:
attachment, a bore light or fibreoptic handpiece is used
l X-ray film is not used.
for transillumination.
l Exposure time (1/100 of a second) is significantly
decreased. Q.7. Describe diagnostic aids used in endodontia and

l Instantaneous image display. electric pulp test. Electric pulp testing-false-positive and
l Increased edge enhancement, different areas of the false-negative reading.
image can be zoomed.
Ans.
l No distortion; magnifies the image up to four times.
l Images can be coloured. [Ref LE Q.1]

l Useful for patient education.
Q.8. Heat test.
Disadvantage:
Ans.
l Expensive.
[Ref LE Q.1]
Q.9. Thermal vitality test.
Q.5. Endometer. Ans.
Ans. [Ref LE Q.1]
l Endometer is an electronic device which is used to deter- Q.10. Pulp vitality test.
mine the root canal length, based on measuring the elec-
trical impedance between the oral mucous membrane and Ans.
apical foramen. [Ref LE Q.1]
l It is based on recent research and constructed by apply-
ing modern structural solutions that provide a high level

of accuracy of measurement in a dry or wet root canal. SHORT NOTES:
l The position of the needle in the root canal can be easily Q.1. Endodontic triad.
seen on the analogical screen instrument.
l If needle penetrates beyond the apical foramen, an
Ans.
additional sound of an adequate tone and intensity level l Endodontic triad includes biomechanical preparation, mi-
is announced. crobial control and complete obturation of the canal space.
l This is the base of endodontic therapy.
Advantages:
l The ultimate goal of the treatment is to create an envi-
l It is beneficial in cases where radiographs are difficult
to read accurately. ronment in which the body will heal itself.
l Penetration of the needle beyond the apical foramen can Q.2. Glass bead sterilizer.
be prevented.
l It helps the patient and practitioner to avoid unnecessary
Ans.
exposure to radiation and accelerates the endodontic l Glass beads are effectively substituted for the hot salt
therapy. sterilizer provided glass beads less than 1 mm diameter.
l There is no effect of conditions like temperature, humid- l Larger beads are not effective in transferring the heat to
ity, worn-out batteries on the accuracy of measurement. the endodontic treatment.
l Temperature: 425–475°F (218–246°C). Time: 5 s.
Q.6. Transillumination in endodontics.
Ans. Disadvantage:
l Only small instruments can be sterilized.
l Use of fibreoptic transillumination device reveals a
vertical fracture line, vital and necrotic pulp in young Q.3. Diagnostic aids used in endodontics.
patients. Ans.
l In the presence of fracture line, the light will illuminate
the side of crown that it contacts. [Ref LE Q.1]

l The portion of the crown on the opposite side of the Q.4. Thermal test.
fracture will remain dark.
l Necrosed tooth appear opaque and dark because of
Ans.
breakdown by blood in the pulp chamber. [Ref LE Q.1]
Q.5. Cold test. Q.9. RVG.

Ans. Ans.
Q.6. Heat test for tooth vitality. Q.10. Percussion test.
Ans. Ans.
Q.7. Test cavity. Q.11. LDF.
Ans. Ans.
l Test cavity is a last resort for the detection of vitality of [Ref LE Q.1]
the tooth.
Q.12. Cold testing for tooth vitality.
l Technique: a small Class I cavity is prepared with high
speed No. 1 or 2 round but with proper air and water Ans.
coolant till it reaches the Dentino Enamel Junction
[Ref LE Q.1]
(DEJ) in an unanaesthetized tooth.
l Pulp is vital when the patient experiences sensitivity or Q.13. Thermal diagnostic test and heat testing in
pain. endodontics.
l No endodontic treatment is indicated, a sedative cement
Ans.
is then placed in the cavity.
l If no pain is felt, pulp is necrotic and endodontic treat- [Ref LE Q.1]
ment is indicated.
Q.8. Limitations of radiographs.
Ans.
[Ref LE Q.2]
Topic 2
Endodontic Emergencies
LONG ESSAYS:
1 . Classify endodontic emergencies. Write clinical features of phoenix abscess and management.
2. Enumerate the endodontic emergencies. Discuss any one in detail and its management.
3. Classify endodontic emergencies and give in detail diagnosis, management and treatment of acute periapical
abscess. [Ref LE Q.1]
4. Classify the endodontic emergencies and write effective methods of treatment of any one of them. [Ref LE Q.2]
SHORT ESSAYS:
1 . Discuss phoenix abscess. [Ref LE Q.1]
2. Classify emergencies in endodontics. [Ref LE Q.2]
3. Write clinical features of phoenix abscess and management. [Ref LE Q.1]
SHORT NOTES:
1 . Hyperaemia of pulp.
2. Define phoenix abscess.
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Classify endodontic emergencies. Write clinical Patient may have soft diffuse swelling in the
l
features of phoenix abscess and management. oral mucosa of responsible teeth, causing
asymmetry of the face.
Ans.
l Mucosa over the radicular area appears red and
Classification of endodontic emergencies swollen.
I. Before treatment l Tissue at the surface appears taut and inflamed,
i. Acute pulpitis pus starts from beneath it.
l Acute reversible pulpitis l Patient may have fever, malaise, nausea, dizzi-
l Acute irreversible pulpitis ness and lymphadenopathy.
ii. Acute abscess Diagnosis
l Alveolar abscess l Radiographs reveal well-defined periradicular
l Periodontal abscess radiolucency indicating a lesion.
iii. Acute pulpitis with apical periodontitis l Tooth does not respond to electric or thermal
iv. Traumatic injury tests.}
II. During treatment Histopathology
i. Hot tooth l Areas of liquefaction necrosis with disintegrat-
ii. Interappointment flare-ups ing (Polymorphonuclear leukocytes) PMNLs
III. After treatment and cellular debris (pus) which is surrounded
i. Postendodontic pain by lymphocytes and plasma cells.
ii. Vertical root fracture
[SE Q.1]
[SE Q.1]
{Treatment
{Phoenix abscess l Biphasic treatment, pulp debridement and inci-
l ‘Phoenix abscess’ (or recrudescent abscess) is an sion of drainage.
acute exacerbation of a chronic lesion. l Calcium hydroxide is the intracanal medica-
l It is an acute inflammatory reaction superimposed ment of choice.
on an existing chronic lesion like cyst or granu- l Local anaesthesia is contraindicated.
loma. l Antibiotics should be given in case of systemic
l It is a condition characterized by the formation symptoms.
and retention of pus in the alveolar bone around l For controlling of pain postoperatively, NSAIDs
the root apex of a tooth with a non vital pulp (nonsteroidal antiinflammatory drugs) should
along with the extension of the infection be given.}
through the apical foramen into the periapical l RCT (root canal treatment).
tissues.
Aetiology Q.2. Enumerate the endodontic emergencies. Discuss
l When there is periradicular tissue reaction to
anyone in detail and its management.
noxious stimuli from the diseased pulp which Ans.
is in a state of equilibrium, a granuloma or a
cyst is formed. [SE Q.2]
l Sometimes an influx of necrotic products or {Classification of endodontic emergencies
bacteria from a diseased pulp may trigger an I. Before treatment
acute inflammatory response. i. Acute pulpitis
Symptoms l Acute reversible pulpitis
l The affected tooth will be very sensitive to l Acute irreversible pulpitis
touch. ii. Acute abscess
l First symptom is tenderness on percussion. l Alveolar abscess
l As inflammation progresses tooth may be ele- l Periodontal abscess
vated in its socket and mayor may not become iii. Acute pulpitis with apical periodontitis
mobile. iv. Traumatic injury
II. During treatment ii. Diagnosis

i. Hot tooth l In severe cases, fracture of the root may be seen
ii. Interappointment flare-ups radiographically.

III. After treatment l The characteristic radiographic appearance is
i. Postendodontic pain the presence of a lateral diffuse widening of the

ii. Vertical root fracture} periodontal ligament.
Acute irreversible pulpitis l An isolated, narrow pocket adjacent to the frac-
l The characteristic features are spontaneous pain and ture site may be found by periodontal probing.
exaggerated response to hot or cold that lasts even l Reflection of full-thickness mucoperiosteal flap
after the stimulus is removed. is necessary. To corroborate the diagnosis, the

l Extensive caries or restoration may be seen in the root should then be stained and viewed under
involved tooth. magnification.
l The pain increases on lying down and interfere with iii. Management
sleep. l The prognosis is poor for vertical root fracture
l On extraoral examination, the site may be tender and extending apically from the alveolar crest.
the local lymph nodes may be enlarged and tender on l Tooth extraction is often indicated.
palpation, if lesion is from long time. Following are the recommended standard regi-
l On radiographic examination, the widening of the men of antibiotics:
periodontal ligament may be seen. i. Penicillin V, 2.0 g orally 1 h before the pro-
l Initially, pain disappears by simple analgesics, but as cedure, then 1.0 g, 6 h later.
inflammation increases the drugs become less effective. ii. If the patient is allergic to penicillin, erythro-
l The treatment to be done is pulpotomy or pulpec- mycin 1.0 g. orally 1 h before, then 500 mg
tomy with a small course of medication with anti- 6 h later should be given.
biotics, if required, and analgesics, as and when l Tetracycline is a broad-spectrum antibiotic,
required. which is effective against Gram-positive and

Technique for pulpectomy Gram-negative organisms. It can inhibit bacterial
l Administer local anaesthesia in the affected tooth protein synthesis and is bacteriostatic in nature.
and the rubber dam is applied. Q.3. Classify endodontic emergencies and give in detail
l Prepare the access cavity, remove the pulp from the
diagnosis, management and treatment of acute periapi-
chamber, debride and irrigate the pulp chamber. cal abscess.
l Locate the root canal orifices and explore the root
canals. Ans.
l Determination of working length.
[Ref LE Q.1]
l Total extirpation of the pulp followed by cleaning
and shaping of the root canal. Q.4. Classify the endodontic emergencies and write
l Thorough irrigation of the root canal system and dry- effective methods of treatment of any one of them.
ing the canal with the help of sterile adsorbent points. Ans.
l Seal the access cavity and relieve the occlusion.
[Ref LE Q.2]
l Appropriate analgesic therapy and antibiotics are
used, if needed.
l Complete the obturation and provide postendodontic SHORT ESSAYS:
restoration. Q.1. Discuss phoenix abscess.
Vertical root fracture
l It comes under post treatment endodontic emergencies. Ans.
i. Aetiology [Ref LE Q.1]
l During obturation, the wedging effect of a
spreader or plugger can cause fracture. Q.2. Classify emergencies in endodontics.

l Root canal treated teeth which have structurally Ans.
weakened root that has been restored with a short,
wide, tapered post. [Ref LE Q.2]
l There is a great chance for fracture if the coronal Q.3. Write clinical features of phoenix abscess and
restoration fails to provide a ferrule effect on the management.
remaining root structure.
l The most common symptom is pain during
Ans.
mastication. [Ref LE Q.1]
SHORT NOTES: 2. Treatment

l Application of resin adhesive, varnish and place-
Q.1. Hyperaemia of pulp. ment of an insulating base under metallic restora-
Ans. tion will reduce hyperaemia.
l Hyperaemia is a condition caused by increased blood Q.2. Define phoenix abscess.
flow in the pulp. Ans.
1. Clinical feature
l Tooth becomes sensitive to thermal changes, es- l Phoenix abscess is a condition characterized by the for-
pecially with cold stimulus and disappears after mation and retention of pus in the alveolar bone around
removing the stimulus. root apex of a tooth with a nonvital pulp along with the
l This is because a-delta fibre produces sharp local- extension of infection through the apical foramen into
ized pain. the periapical tissues.
l On the other hand, continued heat application will l Treatment consists of drainage and RCT.
stimulate the slower-conducting C-fibres, which l Good prognosis.
results in dull, long-lasting pain.
Topic 3
Dental Pulp and Periradicular Tissues:
Embryology and Anatomy
SHORT NOTES:
1 . Discuss accessory canals.
2. Nerve fibres of pulp.
SOLVED ANSWERS
SHORT NOTES: l They are usually seen in the apical one-third but may
also occur in the bifurcation or trifurcation of multi-
Q.1. Discuss accessory canals. rooted teeth.
Ans. l Lateral canal is an accessory canal that is located at
approximately right angle to the main root canal.

i. Accessory canal is a canal that branches off from the
main root canal. Q.2. Nerve fibres of pulp.
Mechanism of formation
Ans.
l Unknown.
l They are likely to occur in areas, where there is pre- l The pulp contains both myelinated A-delta nerve fibres
mature loss of root sheath cells because these cells (fast-conducting) and unmyelinated C nerve fibres
induce the formation of the odontoblasts that form (slow-conducting).
the dentine. l Activation of the a-delta fibres will cause a sharp local-
l It can also occur where the developing root encoun- ized response.
ters a blood vessel where the hard substance is not l Whereas activation of C fibres will cause a dull, poorly
deposited. localized response.
Topic 4
Diseases of Dental Pulp and Periradicular Tissues
LONG ESSAYS:
1 . Describe pulpal necrosis and its management.
2. Enumerate the various causes of pulp diseases and describe the clinical features and management of irreversible
pulpitis.
3. Classify the pulp diseases. Give aetiology, signs and symptoms, differential and treatment of acute pulpitis.
4. Classify periradicular lesions/diseases. Write in detail the causes, symptoms, diagnosis, differential diagnosis,
treatment and prognosis of acute alveolar abscess.
SHORT ESSAYS:
1. Pink tooth.
2. In short explain the reaction of dental pulp to bacterial involvement.
3. Reversible pulpitis. [Ref LE Q.3]
4. Acute irreversible pulpitis.
5. Acute alveolar abscess. [Ref LE Q.4]
6. Define cracked tooth syndromes.
7. Define barodontalgia.
8. Internal resorption. [Same as SE Q.1]
9. Acute reversible pulpitis. [Same as SE Q.3]
10. Acute periapical abscess. [Same as SE Q.5]
SHORT NOTES:
1 . Define resorption.
2. Define hyperaemia of pulp. [Ref LE Q.3]
3. Define anachoresis.
4. Define periapical cyst.
5. Define clinical management of apical granuloma.
6. Define acute apical periodontitis.
7. Describe weeping canal.
8. Define barodontalgia. [Same as SN Q.7]
9. Root resorption – classification. [Same as SN Q.7]
SOLVED ANSWERS
LONG ESSAYS: Types
There are two types of pulpal necrosis:
Q.1. Describe pulpal necrosis and its management. A. Coagulation necrosis
Ans. l The tissue is precipitated or converted into
solid mass that contains proteins, fats and

l Pulpal necrosis means death of the pulp, which can be water.
partial or total. B. Liquefaction necrosis
l Necrosis is a sequela to inflammation, in which pulp
l Tissue is converted into softened mass or liquid
tissue is destroyed as a result of an ischaemic infarction by enzyme.
and result in dry gangrenous necrotic pulp.
Aetiology III. Bacterial

● Noxious stimuli injurious to the pulp, e.g. bacteria, A. Direct invasion of pulp from caries or trauma
trauma and chemical irritation. B. Toxins associated with caries
Symptoms C. Anachoresis
● A tooth will be asymptomatic until there is peri D. Fractures
radicular inflammation. According to Ingle
● Discolouration of the tooth is the first indication of I. Bacterial causes
pulpal death. A. Coronal ingress
● Partially necrosed tooth will respond to thermal i. Caries
changes, owing to the presence of vital nerve fibres ii. Nonfracture trauma
passing through the adjacent inflamed tissue. iii. Fracture – complete and incomplete
Diagnosis iv. Anomalous tract – dens invaginatus and
● A large cavity involving the pulp space and thickening dens evaginatus
of the periodontal ligament is seen radiographically. B. Radicular ingress
● Patients give history of severe pain lasting from few i. Caries
minutes to hours, and pain stops after sometime on ii. Haematogenic
its own. iii. Retrogenic infection – periodontal pocket
● Completely necrosed pulp will not respond to elec- and periodontal abscess
tric pulp test or test cavity. II. Traumatic causes
Histopathology A. Acute
● Pulpal cavity shows necrotic pulp tissue, cellular i. Coronal fracture
debris and microorganisms. ii. Radicular fracture
● Apical periodontal ligament may be seen inflamed iii. Vascular stasis
slightly. iv. Luxation
Treatment v. Avulsion
● Root canal treatment (RCT) B. Chronic
Q.2. Enumerate the various causes of pulp diseases i. Adolescent female bruxism
and describe the clinical features and management of ii. Traumatism
irreversible pulpitis. iii. Attrition or abrasion
iv. Erosion
Ans. III. Iatrogenic causes
Various causes of pulp diseases are as follows: A. Cavity preparation: Includes depth of prepara-
According to Grossman tion, heat produced on preparation, dehydra-
I. Physical tion, pulp exposure and pulp haemorrhage
A. Mechanical B. Restoration: Includes force of insertion, ce-
i. Trauma-accidental and iatrogenic dental menting, heat of polishing and either complete
procedures or incomplete fracture of restoration
ii. Pathologic wear C. Intentional extirpation and root canal filling
iii. Crack through the body of tooth D. Intubation for general anaesthesia
iv. Radiation E. Rhinoplasty
v. Restorations F. Electrosurgery
vi. Barodontalgia G. Periodontal and periapical curettage
B. Thermal injuries H. Orthodontic movements
i. Heat produced during cavity preparation IV. Chemical causes
ii. Exothermic heat during setting of cement A. Restorative materials, e.g. plastics, cements,
iii. Frictional heat during the polishing of res- cavity liners and etching agents
torations B. Disinfectant, e.g. phenol, silver nitrate and
iv. Conduction of heat and cold through deep sodium fluoride
restorations without a protective base C. Desiccants: alcohol, ether, etc.
C. Electrical injuries V. Idiopathic causes
l Galvanic shock A. Ageing
II. Chemical B. HIV and AIDS
A. Dental erosion (acids) C. Internal resorption
B. Phosphoric acid, acrylic monomer, etc. D. External resorption
Irreversible pulpitis ii. Acute pulpalgia

l Irreversible pulpitis is defined as a persistent in- l Incipient
flammatory condition of the pulp, which may be l Moderate
symptomatic or asymptomatic caused by a noxious l Advanced
stimuli. iii. Chronic pulpalgia

Aetiology iv. Hyperplastic pulpitis
i. Chemical, thermal or mechanical causes. v. Pulp necrosis
ii. Bacterial invasion through dental caries is most B. Retrogressive changes
common. i. Atrophic pulposis
iii. Reversible pulpitis may deteriorate into irreversible ii. Calcific pulposis
pulpits. II. According to Grossman: based on clinical features
Types A. Pulpitis (inflammation)
A. Acute irreversible pulpitis i. Reversible
B. Chronic irreversible pulpitis l Symptomatic (acute)
Clinical features l Asymptomatic (chronic)
Early stage ii. Irreversible

l Pain is sharp, piercing or shooting and severe, l Acute
intermittent or continuous type. a. Abnormal responsive to cold

l Pain may occur by sudden temperature changes b. Abnormal responsive to heat
particularly to cold, sweet and pressure from the l Chronic
packing food into the cavity. a. Asymptomatic with pulp exposure

l Exacerbation of pain on changing position, lying b. Hyperplastic pulpitis
down or bending over (pain during nights while c. Internal resorption
sleeping is seen). B. Pulp degeneration
l Pain radiates from upper posterior tooth to temple i. Calcific
or sinuses and from lower posterior tooth to ear. ii. Others
Later stage C. Necrosis
l Little exposure of the pulp.
Acute pulpitis
l Patient is often kept awake at night by the pain.
Acute pulpitis can be reversible and irreversible.
l Pain is more severe, boring, gnawing or throbbing.
l Pain is increased by heat and may be relieved by (SE Q.3 and SN Q.2)
cold.
Diagnosis {(I. Acute reversible pulpitis hyperaemia
l Hyperaemia is a condition caused by increased
l On examination, a deep cavity/caries exposing the
pulp. blood flow in the pulp.

l Radiograph reveals exposure of pulp.
Clinical features
l Tooth becomes sensitive to thermal changes,
l Thermal and electrical tests elicit pain that persist
even after the removal of stimulus. especially with cold stimulus and disappears
Treatment after removing the stimulus.
l This is due to a-delta fibres, produces sharp lo-
l Pulpectomy
l Pulpotomy for posterior tooth as an emergency

calized pain.
l On the other hand, continued heat application
procedure
l Extraction of the tooth if it is unrestorable
will stimulate the slower-conducting C-fibres,
which results in dull, long-lasting pain.
Q.3. Classify the pulp diseases. Give aetiology, signs and Treatment
symptoms, differential and treatment of acute pulpitis. l Acute reversible pulpitis can be treated success-
fully by palliative procedures.

Ans. l Recontouring the high spot will relieve the pain
Classification of pulpal diseases and will allow the pulp to recuperate.

I. According to Ingle l Palliative treatment such as the application of a
A. Inflammatory changes (Zinc Oxide Eugenol) ZOE cement as a tempo-

i. Hyper-reactive pulpalgia rary sedative filling.
l Hypersensitivity l If it persists or worsens, the pulp should be
l Hyperaemia extirpated.
l The best treatment is prevention: ii. Radicular cyst

l Application of resin adhesive, varnish and iii. Condensing osteitis
placement of a protective insulating base un- II. Apical abscesses
der metallic restoration will reduce chances i. Acute apical abscess (AAA)
of hyperaemia.)} ii. Chronic apical abscess (CAA)
iii. Phoenix abscess
[SE Q.3]
III. Nonendodontic periradicular lesion
l {Place a pulp protective base under all restorations,
A. Odontogenic cysts
avoid marginal leakage, reduce occlusal trauma if
i. Primordial cyst
present, properly contour all restorations and avoid
ii. Dentigerous cyst
injuring the pulp with excessive heat while prepar-
iii. Lateral periodontal cyst
ing or polishing a metallic restoration.}
iv. Odontogenic keratocyst
II. Acute irreversible pulpitis
v. Residual apical cyst
l This condition is characterized by spontaneous pain
B. Nonodontogenic cyst
and exaggerated response to hot or cold that lingers
i. Nasopalatine duct cyst
after the stimulus is removed.
ii. Traumatic bone cyst
l Extensive caries or restoration may be seen in the
iii. Median palatine cyst
involved tooth.
iv. Globulomaxillary cyst
l The pain increases on lying down and interfere with sleep.
C. Fibroosseous lesions
l On extraoral palpation, the site may be tender and the
i. Periradicular cemental dysplasia
local lymph nodes may be enlarged and tender on
ii. Osteoblastoma and cementoblastoma
palpation, if lesion is from long time.
iii. Cementifying and ossifying fibroma
l On radiographic examination, the widening of the
D. Odontogenic tumours
periodontal ligament may be seen.
l Ameloblastoma
l Initially, pain disappears by simple analgesics, but
E. Nonodontogenic tumours
as inflammation increases the drugs become less
l Central giant cell granuloma
effective.
l Exostosis
l The treatment to be done is pulpotomy or pulpectomy
with a small course of medication with antibiotics, if [SE Q.5]

required, and analgesics, as and when required.
{Acute alveolar abscess
Q.4. Classify periradicular lesions/diseases. Write in Acute alveolar abscess (AAA) can be defined as a
detail the causes, symptoms, diagnosis, differential diag- localized collection of pus in the periradicular tissue fol-
nosis, treatment and prognosis of acute alveolar abscess. lowing death of the pulp due to the extension of infec-
tion through the apical foramen.
Ans.
Aetiology
Classification of periradicular lesions l Bacteria and their by-products
i. Acute periradicular lesions: l Chemical irritation of the periapical tissues
a. Acute apical periodontitis: l Mechanical injury (trauma)
l Vital
Symptoms
l Nonvital
l Tenderness on percussion of tooth is the first symptom
b. Acute alveolar abscess
and tooth may be slightly extruded and mobile.
c. Phoenix abscess
l Swelling, if present is localized.
ii. Chronic periradicular lesions:
l If swelling is left untreated may become diffuse (cel-
a. Chronic alveolar abscess
lulitis) which can lead to asymmetry of the patients’
b. Granuloma
face and in case of upper canines, it may extend to the
c. Cysts
eyelids.
iii. Condensing osteitis
l Fever, malaise and lymphadenopathy are generalized
iv. External root resorption
symptoms.
v. Disease of periradicular tissues of nonodontogenic origin
l Tissue at the surface appears taut and inflamed, pus
Ingle’s classification starts to form beneath it and the proteolytic enzymes

I. Apical periodontitis (trypsin and cathepsin) cause liquefaction necrosis.
A. Acute apical periodontitis (AAP) l A sinus tract which opens on the labial/buccal mucosa.
B. Chronic apical periodontitis (CAP) l This process is the beginning of chronic alveolar ab-
i. Periradicular granuloma scess (CAA).

Bacteriology Aetiology
l If the periodontitis is due to occlusal trauma, chemical l Persistent chronic pulpitis
or mechanical irritation, periapical area will be sterile. l History of trauma
l If bacteria are involved and their by-products are pres- l Idiopathic
ent periapical pathology can be seen.}

Clinical features
Histopathology l More than one tooth may be involved.
l Liquefaction necrosis containing neutrophils and cellu- l Pink hued area on crown of tooth which represents hyper-
lar debris surrounded by macrophages and occasional plastic vascular pulp tissue filling the resorbed area show-
lymphocytes and plasma cells. ing through the remaining overlying tooth substance.
l In the pulp chamber granulomatous tissue replaces the
Pathogenesis
resorbed dentine which is visible through enamel im-
l The blood vessels get dilated and PMNLs are attracted
parting a pink tooth appearance.
to the site as inflammation spreads to periapical area.
They phagocytose the bacteria and dead cells. Radiographic features
l The released lysosomal enzymes digest periradicular l Round/ovoid radiolucent area in central portion of tooth
tissues in the cancellous bone. This forms a semifluid associated with the pulp but not with external surface of
substance called the pus. tooth.
l If the invading bacteria/irritants are destroyed by body’s
Treatment
defence mechanisms, the abscess is absorbed or turns into
l Root canal therapy or extraction of tooth depending on
sterile fluid pack surrounded by a fibrous tissue capsule.
the condition of the tooth.
l If the irritant is profound or bacteria are virulent, then
host tissue loses control and the abscess extends on to Q.2. In short explain the reaction of dental pulp to bac-
the cortical bone and surrounding soft tissues to elicit terial involvement.
acute osteitis, periosteitis or cellulitis.
l Once it perforates cortical bone and a sinus is formed,
Ans.
the pressure is relieved due to drainage and it turns into The reaction of dental pulp to bacterial involvement
a chronic abscess. is as follows:
l The blood vessels get dilated and PMNLs are attracted
[SE Q.5]
to the site as inflammation spreads to periapical area.
{Diagnosis They phagocytose the bacteria and dead cells.
l The affected tooth is tender and slightly mobile on l The released lysosomal enzymes digest periradicular
clinical examination. tissues in the cancellous bone. This forms a semifluid

l Mucosa will be tender around the affected tooth. substance called the pus.
l Vitality tests show signs of necrosis. l If the invading bacteria/irritant are destroyed by body’s
l The radiograph may show a cavity, defective restora- defence mechanisms, the abscess is absorbed or turns
tion, widening of the periodontal ligament or break- into sterile fluid pack surrounded by a fibrous tissue
down of bone in the apical region. capsule.
l If the irritant is profound or bacteria are virulent, then
Treatment
host tissue loses control and the abscess extends on to
l Consists of controlling the symptoms and establishing
the cortical bone and surrounding soft tissues to elicit
drainage.
acute osteitis, periosteitis or cellulitis.
l Tooth is treated endodontically as the symptoms are
l Once it perforates cortical bone and a sinus is formed,
controlled.
the pressure is relieved due to drainage and it turns into
Prognosis a chronic abscess.
l Usually favourable, unless the periodontium is exten-
Q.3. Reversible pulpitis.
sively destroyed.}
Ans.
SHORT ESSAYS: [Ref LE Q.3]
Q.1. Pink tooth. Q.4. Acute irreversible pulpitis.
Ans. Ans.
l It is also known as Pink tooth of mummery. l Acute irreversible pulpitis is a condition characterized
l Resorption begins centrally within the tooth which is by spontaneous pain and exaggerated response to hot or
initiated by peculiar inflammatory hyperplasia of pulp. cold that lingers after the stimulus is removed.
l Extensive caries or restoration may be seen in the in- l In case of irreversible pulpitis: pulp extirpation and
volved tooth. RCT.
l The pain increases on lying down and interfere with
Q.7. Define barodontalgia.
sleep.
l On extraoral palpation, the site may be tender and the Ans.
local lymph nodes may be enlarged and tender on palpa-
tion, if lesion is from long time. {SN Q.8}
l On radiographic examination, the widening of the peri-
odontal ligament may be seen. l Barodontalgia is also known as aerodontalgia.

l Initially, pain disappears by simple analgesics, but as
l It is seen in people flying in high altitudes and also is
inflammation increases the drugs become less effective. seen in deep-sea drivers.
l The treatment to be done is pulpotomy or pulpectomy Classification of aerodontalgia
with a small course of medication with antibiotics, if Class I: In acute pulpitis, sharp momentary pain is seen
required, and analgesics, as and when required. on ascent.
Q.5. Acute alveolar abscess. Class II: In chronic pulpitis, dull throbbing pain is seen
on ascent.
Ans. Class III: In necrotic pulp, dull throbbing pain is seen
[Ref LE Q.4] on descent and a symptomatic on ascent.
Class IV: In case of periradicular abscess or cyst, severe
Q.6. Define cracked tooth syndromes. persistent pain with both ascent and descent.
Ans.
l Incomplete fractures through the body of the tooth may Clinical features
cause pain of apparently idiopathic origin, which is re- l Barodontalgia is generally observed in altitudes over
ferred to as cracked tooth syndrome. 5000 feet but it is more likely to occur at 10,000 feet or
l Mandibular molars are most frequently affected. above like during flight or decompression chamber.
l A patient may complain of poorly localized pain from l Pain is caused by an increase in intrapulpal pressure,
an unidentified posterior tooth on biting or the applica- which is an attempt to compensate for the extraoral de-
tion of cold drinks. compression of ambient pressure (in the plane).
l Clinically and radiographically, there is often no evi-
Treatment
dence of caries, and the offending tooth may not be
l Lining the cavity with a varnish or a base of zinc phos-
heavily restored.
phate cement, with a subbase of ZOE cement in deep
l Affected tooth responds to electrical stimulation.
cavities, helps to prevent barodontalgia.
l Careful examination of the teeth, particularly with an in-
traoral light, may reveal one with vertical hairline cracks. Q.8. Internal resorption.
l The pain may be reproduced if the patient is asked to
close with an object such as a cotton roll placed between Ans.
that and the opposing teeth. [Same as SE Q.1]
l When this fails to produce a response, cold in the form
of ice may be applied on the tooth and a hypersensitive Q.9. Acute reversible pulpitis.
response will indicate the offending tooth.
Ans.
l Mechanism of pain on biting: The crack contains bacte-
ria whose toxins pass down the dentinal tubules to cause [Same as SE Q.3]
pulpal inflammation, as the cusp is wedged by chewing
there is fluid movement in the crack and the communi- Q.10. Acute periapical abscess.
cating tubules will elicit pain in an already sensitive Ans.
tooth.
[Same as SE Q.5]
Treatment
l The treatment depends on whether there have been
symptoms of reversible or irreversible pulpitis.

SHORT NOTES:
l In case of reversible pulpitis, if there is a loose cusp, any Q.1. Define resorption.
restoration should be removed together with the loose
Ans.
cusp and is restored to the shape and size of the cavity.
If there is no loose cusp, tooth may be temporarily l Resorption is defined as a condition associated with ei-
crowned to relieve from pain. ther a physiologic or a pathologic process that result in
loss of substance from a tissue such as dentine, cemen- l Enucleation or marsupialization of large lesion is usu-
tum or alveolar bone is known as root resorption ally done.
(American Association of Endodontics).
Q.5. Define clinical management of apical granuloma.
Classification
Based on the nature Ans.
i. Pathological root resorption
l Granuloma is a growth of inflamed granulation tissue in
ii. Physiological root resorption
the periodontal ligament as a result of pulpal death due
Based on the inflammatory response
to bacteria and their toxin from root canal.
a. Inflammatory resorption
l Asymptomatic.
i. Internal root resorption
l It is diagnosed on routine radiographic examination.
ii. External root resorption
l It does not respond to electric stimuli.
b. Noninflammatory resorption
l The size may vary from a millimetre to a centimetre or
i. Pressure
more.
ii. Transient
iii. Replacement Treatment
l RCT is the choice of treatment.
Q.2. Define hyperaemia of pulp.
l If lesion does not resolve, then surgical approach is
Ans. used.
[Ref LE Q.3] Q.6. Define acute apical periodontitis.
Q.3. Define anachoresis. Ans.
l A painful inflammation of the periodontium as a result
Ans.
of trauma, irritation and infection through the root canal
l Anachoresis is the transportation of microbes through the
regardless of whether the pulp is vital or nonvital is
blood or lymph to an area of inflammation such as a tooth
known as acute apical periodontitis.
with pulpitis, where they may establish an infection.
l The process has been especially associated with bacter- Aetiology
aemia or infective endocarditis. l Vital tooth: Occlusal trauma, blow to the teeth, wedging
l When the pulp undergoes necrosis, it becomes an ideal of a foreign object between teeth and recently inserted
place for bacteria, bacterial by-products and degradation restoration extending beyond the occlusal plane.
products of both microorganisms and pulpal tissues. l Nonvital tooth: Sequelae of the pulpal disease.
Q.4. Define periapical cyst. Clinical features

Pain and tenderness on palpation of tooth; tooth may be
Ans.
slightly extruded and sore.
l Periapical cyst is also known as radicular cyst or dental
root end cyst or apical periodontal cyst. Radiographic features

l Radicular cyst is classified as inflammatory odonto- Thickened periodontal ligament and pulpless teeth may
genic cyst. show periapical rarefaction.
l It is a common squeal in progressive changes associated
Treatment
with bacterial invasion and death of the dental pulp.
l Vital tooth: Determine the cause and relieve the
Clinical findings symptoms.

l Common in maxillary incisor region with male pre- l Nonvital tooth: RCT.
dominance.
Q.7. Describe weeping canal.
l The tooth involved is generally nonvital and is asymp-
tomatic. Ans.
l Large lesions often produce a slow enlarging bony hard l Copious irrigation with sodium hypochlorite is per-
swelling of the jaw with expansion of cortical plates. formed throughout instrumentation to reduce amounts
l If the cyst is secondarily infected, it leads to the forma- of necrotic tissue and bacteria after which canals are
tion of the abscess, which is called ‘cyst abscess’. dried with paper points and filled with calcium hydrox-
l Pus formation in the cyst will lead to sinus and dis- ide paste.
charge of pus. l After placement of a dry cotton pellet, the access is
Treatment sealed temporarily. These teeth should not be left open

l Root canal therapy is the treatment choice. to drain.
l A canal exposed to the oral cavity is a potential source
l If the lesion fails to resolve, extraction of associated
tooth is carried out. for introduced bacteria, food debris and even viruses.
l Occasionally, purulence will continue to fill the canal Q.9. Root resorption – classification.
during the preparation (the so-called weeping canal).
Ans.
Usually, the flow will cease and the access may be closed.
Q.8. Define barodontalgia. [Same as SN Q.1]
Ans.
[Same as SN Q.7]
Topic 5
Principles and Rationale of Endodontic Treatment
COMMONLY ASKED QUESTION
LONG ESSAYS:
1. Describe in detail rationale of endodontic treatment.
SOLVED ANSWER
LONG ESSAYS: He found four well-defined zones of reaction, which are
Q.1. Describe in detail rationale of endodontic treatment. as follows:
i. Zone of infection
Ans. ii. Zone of contamination
l Any injury to pulp due to caries or trauma or chemicals iii. Zone of irritation
can produce many changes. iv. Zone of stimulation
l Microorganisms in the root canal multiply sufficiently I. Zone of infection
to grow out of root canal or the toxins produced by root l It is characterized by PMN leukocytes.
canal flora may diffuse into periradicular area. l Infection is present in the centre of the lesion.
l The host defence decreases as these microorganisms are II. Zone of contamination
virulent and they destroy PMN leukocytes and leads to l It is characterized by round cell infiltration (RCI).
chronic abscess. l Around the central zone, Fish observed cellular
l The proteolytic enzymes released by the dead PMN destruction not only from bacteria themselves but
leukocytes produce pus. also from toxins discharged from the central zone.
l Empty lacunae are appeared as bone cells had died
Following changes occur due to noxious stimuli from
the diseased dental pulp: and had undergone autolysis.
l Lymphocytes were prevalent.
l Periapical infection causing lesion periapical radiolu-
cency at the apex. III. Zone of irritation

l It is characterized by macrophages and osteoclasts.
l Cellular changes like infiltration of lymphocytes, mac-
l Fish found evidence of irritation further from the
rophages, PMN lymphocytes, phagocytes, osteoclasts
and fibroblasts which cause so many changes. central lesion as toxins became more diluted.
l The collagen framework is digested by phagocytic
l These changes in periradicular area due to the diffusion
of toxins from root canal flora are experimentally dem- cells and the macrophages while the osteoclasts
onstrated by FISH. destroy the bone tissue.
l Some amount of repair has seen histopathologically.
l Hence, it is necessary to go for endodontic treatment to
remove the toxins from the root canal. IV. Zone of stimulation
l It is characterized by fibroblasts and osteoblasts.
l This leads to healing, repair and establishment of tooth
l At the periphery, the toxin was mild enough to be a
function and saving the tooth.
stimulant.
Fish zones l In response to this stimulation, collagen fibres were
l Fish established experimental foci of infection in the laid down by the fibroblasts, which acted both as a
jaws of guinea pigs by drilling openings in the bone and wall of defence around the zone of irritation and as
packing in wool fibres saturated with a broth culture of scaffolding on which the osteoblasts built new bone.
microorganisms. l The new bone is built in irregular fashion.
Topic 6
Endodontic Instruments and Sterilization
LONG ESSAYS:
1. Classify endodontic instruments and briefly describe the methods of sterilization of instrument.
2. Classification of endodontic instruments. Describe standardization of endodontic instruments. How the break-
age of instrument inside the root canal is prevented?
3. Classification of endodontic instruments. Describe the hand instruments used for canal preparation.
4. Describe in detail the methods of sterilization. [Same as LE Q.1]
5. Discuss sterilization in endodontics. [Same as LE Q.1]
6. Discuss the various methods of sterilization of root canal instruments. [Same as LE Q.1]
7. Classify endodontic instruments. Describe standardization and sterilizing of these instruments. [Same as LE Q.1]
8. Classify endodontic instrument. How are they standardized? Add a note on standardization of these instru-
ments. [Same as LE Q.2]
9. Classify endodontic instruments. Write about standardization. [Same as LE Q.2]
10. Mention the structure and working of the root canal instruments such as: [Same as LE Q.3]
Barbed Broach
Reamer
K-type File
H-type File
SHORT ESSAYS:
1. Sterilization in endodontics. [Ref LE Q.1]
2. Endosonics.
3. Gates-Glidden drill.
4. Classification of endodontic instruments. [Same as SE Q.1]
5. Advantages and disadvantages of NiTi rotary endodontic instruments.
6. Compare between reamers and files.
7. Sterilization of endodontic instruments. [Same as SE Q.1]
8. Hot salt sterilizer. [Same as SE Q.1]
9. Glass bead sterilizer. [Same as SE Q.1]
10. Classify endodontic instruments. [Same as SE Q.1]
SHORT NOTES:
1. Define disinfection.
2. Chemiclaving.
3. Sterilization of high-speed handpiece.
4. Endosonics. [Ref SE Q.3]
5. Piezo reamer.
6. Barbed broaches. [Ref LE Q.3]
7. Gates-Glidden drills. [Ref SE Q.3]
8. NiTi files. [Ref SE Q.5]
9. Lentulo spiral.
10. Endodontic spreads and pluggers. [Ref LE Q.3]
11. Hot salt sterilizer. [Ref LE Q.1]
12. Glass bead sterilizer. [Ref LE Q.1]
1 3. Apex locators – generations and dentine.

14. Giromatic handpiece.
15. Hedstroem File (H file). [Ref LE Q.3]
16. Sterilization of root canal instruments. [Same as SN Q.3]
17. Flexible files. [Same as SN Q.8]
18. Spiral root fillers. [Same as SN Q.9]
19. Root canal plugger. [Same as SN Q.10]
20. Apex locator. [Same as SN Q.13]
21. Electronic apex locators. [Same as SN Q.13]
22. H-File. [Same as SN Q.15]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Classify endodontic instruments and briefly de- ii. Extirpating/debriding instruments
scribe the methods of sterilization of instrument. l Barbed broaches
iii. Shaping instruments

Ans.
l Reamers
Classification of endodontic instruments l Files
iv. Obturating instruments

[SE Q.4] l Pluggers
{I. ISO and FDA classification of endodontic instruments l Spreaders
l Lentulo spirals}
Classification Types of Instruments Examples III. Other classification of endodontic instruments
Group I Endodontic instruments for Barbed i. Instruments used for initial examination
hand use only; they have a broaches, ii. Instruments used for diagnosis
plastic colour-coded han- K-type and iii. Instruments used for isolation
dle and a metallic operat- H-type files, iv. Instruments used for access cavity preparation
ing cutting head R-type rasps,
spreaders and
v. Instruments used for working length determination
condensers/ vi. Instruments used for canal preparation
pluggers vii. Instruments used for irrigation
Group II Engine-driven instruments; NiTi rotary in- viii. Instruments used for obturation
handle has a plastic latch- struments, e.g. ix. Instruments used for post space preparation
type adaptor for insertion profile, light x. Instruments used for retrieval of broken instrument/
in contra-angle handpiece speed and pro- posts/gutta-percha
a metal cutting head taper
xi. Instruments used for endodontic surgery
Group III Engine-driven latch-type Gates-Glidden
instruments, latch, shaft (GG) and Peeso [SE Q.1]
and operative cutting reamers
head, all composed of a {Sterilization of endodontic instruments
single piece and made l The instrument should first be cleansed of debris us-
from a single metal ing hydrogen peroxide or alcohol, before using any
Group IV Endodontic points Paper points, method of sterilization.
gutta-percha I. Chemical sterilization
points, silver l 2% benzalkonium chloride in 50% isopropyl
points and irri- alcohol.
gation systems
l Swabbing with hydrogen peroxide followed by
tincture of iodine.
II. Grossman’s classification of endodontic instru- l Ethyl alcohol (2 parts) 1 formalin (1 part) may
ments be used to destroy spore formers.

i. Exploring instruments II. Cold sterilization
l Smooth broaches Sterilization by cold chemical solutions like:
l Endodontic explorers a. Quaternary ammonium compounds: Kills
l Pathfinders vegetative organisms.
b. Ethyl alcohol and isopropyl alcohol: Kills l Temperature: 425–475°F (218–246°C).

vegetative bacteria, TB bacilli. l Time: 5 s
c. Alcohol-formalin solution: Kills vegetative l Disadvantage: Only small instruments can be
bacteria, TB bacilli and spores. sterilized.)}

d. Ortho phenyl phenol and benzyl parachloro- VI. Sterilization methods used for some other endodon-
phenol: Kills vegetative bacteria, TB bacilli, tic instruments
certain fungi and viruses but not spores. i. Dappen dish:
III. Autoclaving l Swabbing thoroughly under pressure with tinc-
l Very effective and most common method. ture of thimerosal followed by alcohol, with the
l According to Ingle: Temperature, pressure and intention of physically removing the debris and
time required are: 121°C at 15 psi for 15–40 min. microorganisms.
l The time varies based on the items to be autoclaved, ii. Long handle instruments, tip of cotton pliers,
the size of the load and type of container used. blades of scissors and other instruments:
IV. Chemiclave/chemical vapour sterilization/Harvey l Flaming twice after dipping the working point
chemiclave in alcohol.
l Similar to autoclave. iii. Bulky instruments such as cotton pliers, and ce-
l Solutions used are alcohol, acetone, formalde- ment spatulas:
hyde and water. l Quick sterilization by passing the working
V. Dry-heat sterilization blades through a flame several times.

a. Prolonged dry heat: iv. Mixing slab (glass slab):
l It sterilizes at 160°C for 2 h. l Swabbing the surface with tincture of thimero-
b. Rapid dry-heat sterilization: sal followed by a double swabbing with alcohol.

l Small chamber, high-speed dry-heat sterilizer. v. Gutta-percha cones:
l Operated at 190°C, sterilize unpackaged in- l Screw-capped vials containing alcohol may be
struments in 6 min and packaged instruments used to keep them sterile.

in 12 min. l Sterilized by immersing in 5.2% sodium hypo-
c. Intense dry heat} chlorite for 1 min, then rinse the cone with hy-
drogen peroxide and dry it between two layers
(SE Q.1 and SN Q.11) of sterile gauze.
i. {(Hot salt sterilizer. l Alternative method-immersion in polyvinyl
l Apparatus consists of a metal cup in which pyrrolidone iodine for 6 min.

table salt is kept at a temperature between vi. Silver cones:
425°F–475°F. l Sterilized by immersion in the hot salt sterilizer
l A thermometer is used always to measure the for 5 s or slowly passing them back and forth
temperature. through a Bunsen burner flame for two or four
l Root canal instruments such as broaches, files times.
and reamers are sterilized for 5 s. vii. Burs:
l Absorbent points and cotton pellets for 10 s. l They may be sterilized by dipping in alcohol or
Advantages: using either autoclave or dry-heat sterilization.

l Make use of ordinary salt instead of metal viii. Handpiece sterilization:
or beads. l Handpieces can be sterilized by steam, chemical
l The risk of clogging the root canal is vapour and ethylene oxide gas (ETO).
eliminated.)} Q.2. Classification of endodontic instruments. De-
(SE Q.1 and SN Q.12) scribe standardization of endodontic instruments.
How the breakage of instrument inside the root canal
ii. {(Glass bead sterilizer: is prevented?
l Glass beads are effectively substituted for the
hot salt sterilizer provided glass beads less than Ans.

1 mm diameter. Classification of endodontic instruments
l Larger beads are not effective in transferring I. ISO and FDA classification of endodontic instru-
the heat to the endodontic treatment. ments
Classification Types of Instruments Examples Standardization of instruments:

Group I Endodontic instruments Barbed broaches,
A new line of standardized instruments and filling ma-
for hand use only; they K-type and H- terials was introduced in 1959 is as follows:
have a plastic colour- type files, R-type i. A formula for the diameter and taper in each size of
coded handle and a me- rasps, spreaders instrument and filling material was agreed on.
tallic operating cutting and condensers/ ii. A formula for graduated increment in size from one
head pluggers
instrument to next was developed.
Group II Engine-driven instru- NiTi rotary in- iii. A new instrument numbering system based on instru-
ments; handle has a struments, e.g. ment metric diameter was established.
plastic latch-type adaptor profile, light
for insertion in contra- speed and
Ingle and Levine proposed the standardization of hand
angle handpiece a metal protaper instruments as follows:
cutting head l The instruments are numbered from 10 to 100, the
Group III Engine-driven latch-type Gates-Glidden numbers to advance by five units to size 60, and
instruments, latch, shaft (GG) and Peeso thereby, by 10 units to size 100.
and operative cutting reamers l The instrument number to be representative of the
head, all composed of a diameter of the instrument tip is in hundredth of a
single piece and made
millimetre (1/100), e.g. File No. 20 is 0.20 mm
from a single metal
(20/100) in diameter at the tip.
Group IV Endodontic points Paper points, l The working blades (flutes) should begin at the tip-
gutta-percha
designated site D1 and shall be exactly 16 mm up
points, silver
points and irriga- to shaft terminating at the designated site D2 (D16).
tion systems l The diameter of D2 should be 0.32 mm greater than
that of D1, e.g. File No. 20 shall have a diameter of

0.20 mm at D1 and a diameter of 0.52 (0.20 1 0.32)
II. Grossman’s classification of endodontic instruments mm at D2. This sizing will ensure a constant increase
i. Exploring instruments in taper, that is, for every millimetre increase in
l Smooth broaches
length, the taper (width) will increase by 0.02 mm.
l Endodontic explorers
Modifications from Ingle’s standardization are as follows:
l Pathfinders
l An additional diameter measurement point at D3
ii. Extirpating/debriding instruments is 3 mm from the tip of cutting end of instrument
l Barbed broaches
at D0 (earlier D1).
iii. Shaping instruments l D2 was designated as D16.
l Reamers
l Tip angle of an instrument should be 75 6 15°.
l Files
l Greater taper (0.04, 0.06 and 0.08) are available.
iv. Obturating instruments
l Pluggers
Q.3. Classification of endodontic instruments. Describe
l Spreaders
the hand instruments used for canal preparation.
l Lentulo spirals Ans.
III. Other classification of endodontic instruments Grossman’s classification of endodontic instruments
i. Instruments used for initial examination i. Exploring instruments
ii. Instruments used for diagnosis l Smooth broaches
iii. Instruments used for isolation l Endodontic explorers
iv. Instruments used for access cavity preparation l Pathfinders
v. Instruments used for working length determina- ii. Extirpating/debriding instruments
tion l Barbed broaches
vi. Instruments used for canal preparation iii. Shaping instruments
vii. Instruments used for irrigation l Reamers
viii. Instruments used for obturation l Files
ix. Instruments used for post space preparation iv. Obturating instruments
x. Instruments used for retrieval of broken instrument/ l Pluggers
posts/gutta-percha l Spreaders
xi. Instruments used for endodontic surgery l Lentulo spirals
i. Exploring instruments a. K-file (Kerr manufacturing company)

A. Endodontic explorer l Manufactured from stainless steel square
l A double ended instrument with long tapered blank.

ends at either a right or an obtuse angle, facili- l Does not break easily unless they have an un-
tating the location of canal orifice. detected steel shaft or until the instrument is
l These instruments are very stiff; they should not strained or deformed.
be inserted into canals and should never be heated. l Flutes are tightly twisted.
B. Pathfinder l K-files can be used as ‘Pathfinder’ (to locate
l K-files can be used as ‘Pathfinder’ to locate the the root canal orifices).
root canal orifices. K-flex files
l Manufactured from rhomboidal or diamond-
ii. Extirpating instruments shaped blanks.
l They are designed to have more flexibility and
{SN Q.6} cutting efficiency.
l They have alternating high and low flutes for
A. Barbed broach
l It is manufactured from a tapered, round, soft more efficiency.
iron wire in which angle cuts are made into the
surface to produce barbs.
l Uses: To extirpate the pulp and remove debris {SN Q.15}
and other foreign material from the root canals. i. b. H-type file/Hedstrom files (H-files)
l Available in a variety of sizes from triple extra-
l Manufactured from a round stainless steel
fine to extra coarse. wire machined to produce spiral flutes re-
l Barbs are meant to engage the pulp as the
sembling cones or as screw or Christmas
broach is carefully rotated within the canal. tree appearance.
l They are more aggressive and have higher
cutting efficiency than K-instruments.

l Root canal should be enlarged before insertion of l When placed in contact with the root canal
the broach, as they break easily especially if they wall the cutting edges contact the wall at
bind in the root canal. angles approaching 90° and when the in-
l Sterilization: A barbed broach should be cleaned
strument is withdrawn exert an effective
by scrubbing with a bur brush but when tissue honouring action.
tags or necrotic debris are noticed, place it in a l Cut in one direction only retraction.
5.2% sodium hypochlorite solution for half an l Used in wide opened canals (blunderbuss
hour and then broach is rinsed in running water, canal).
air dried and is sterilized in dry heat. l Used to flare the canal from the apical re-
B. R-type rasps gion to the occlusal or incisal orifice.
l This is similar in design to barbed broach, but
l Used for removing broken instruments,
has shallower and more rounded barbs. gutta-percha and silver points.
l Used to enlarge the root canal but usually pro-
duce rough wall of the root canal. So it is not

preferred often.
iii. Instruments for cleaning and shaping of root canals c. Unifiles (modification of H-file)
l Manufactured from round stainless steel wire
A. Reamers
l Manufactured from stainless steel triangular
by cutting two superficial grooves to produce
blank and has less number of flutes compared flutes in a double helix design.
l Resemble H-file in appearance but less efficient.
with a file. Flutes are loosely twisted.
l Less subject to fracture.
l Do not break easily until the instrument is
strained or deformed. d. S-file (modification of H-file)

l Manufactured from a solid piece of stainless
l Used with a rotating-pushing motion limited to
a quarter to a half turn to engage their blades steel wire that produces a sharp cutting edge.
l Has a double cutting edge and has 90° cutting tip.
into the dentine and withdrawn.
l Similar to unifile except that the angles of the
l Reamers are used by penetration, rotation and
retraction, the cut is made during retraction. flutes remain uniform whereas pitch and
B. Files depth of the flutes increase from the tip to the
l Manufactured from stainless steel square blank.
handle.
l Stiffer than H-files.
l Flutes are tightly twisted.
l Can be used for straight or curved canals.

l Used to condense the filling material laterally
l Used either as a reamer or file.
against the canal walls creating space for inser-
e. C-files
tion of additional auxiliary cones.
l They have small cross-sections and special
l Spreaders should always be fit into the empty
stainless steel blades which are stronger and
canal to ensure that the force is absorbed by the
more flexible to navigate extremely curved
gutta-percha and not the canal walls.
canals without fracturing.
l They are ideal for initial instrumentation and
are available in 21 and 25 mm lengths.

f. NiTi files (nitinol files)
l The name nitinol was derived from the elements
c. Lentulo spirals
l Used for coating sealer on root canal walls in
that make up the alloy, i.e. nickel and titanium
and ‘nol’ for the Naval Ordinance Laboratory clockwise rotary motion.
(who manufactured it for the first time). Prevention of breakage of instrument
l Proper sequential use of instruments without
l Nitinol instruments should be used with a rota-
tional or reaming motion and are effective in excessive pressure especially in curved canals.
l All instrumentation should be done in wet,
the shaping of root canals.
Advantages: lubricated canal.
l Access cavity should be adequately prepared
l Super elasticity, more flexible and better con-
formation to canal curvature. so that the instrument is not strained.

l Instrument should be discarded when they are
l Faster instrumentation and resistance to fracture.
l Enhanced canal negotiation.

strained.
l Less wear. Q.4. Describe in detail the methods of sterilization.
g. Greater toper (GT) hand files
l Designed by Buchanan and are made from
Ans.
NiTi. [Same as LE Q.1]
l The set of four hand files of varying tapers,
0.12–0.16, all have a tip size of ISO 20. Q.5. Discuss sterilization in endodontics.
l They have pear-shaped handles and each file is Ans.
designed for different areas and types of ca-
nals, e.g. 0.12 GT file is suited to canal orifices [Same as LE Q.1]
of relatively straight canals of large apical di- Q.6. Discuss the various methods of sterilization of root
ameter, 0.06 GT file is suited to the apical third canal instruments.
in a thin or curved canal.
l Used in a sequence of counter clockwise and
Ans.
clockwise rotations. [Same as LE Q.1]
l They are intended to allow the creation of a
predetermined funnel-shaped canal with fewer Q.7. Classify endodontic instruments. Describe stan-
instruments than using the ISO series. dardization and sterilizing of these instruments.
iv. Obturating instruments Ans.
[Same as LE Q.1]
{SN Q.10}
Q.8. Classify endodontic instrument. How are they
a. Pluggers (condenser) standardized? Add a note on standardization of these
l They have a smooth and flat apical tip. instruments.
l Used primarily for vertical condensation of
Ans.
gutta-percha during obturation.
l Three or four pluggers to be used in the coro- [Same as LE Q.2]
nal, middle and apical thirds of the canal must
Q.9. Classify endodontic instruments. Write about stan-
be selected to ensure their loose fit.
dardization.
b. Spreaders
l Spreaders are long tapered pointed instruments Ans.
available in wide variety of lengths and taper.
[Same as LE Q.2]
Q.10. Mention the structure and working of the root Q.3. Gates-Glidden drill.
canal instruments such as:
Ans.
Ans.
Gates-Glidden drills/brushes (group III)
[Same as LE Q.3]
{SN Q.7}
SHORT ESSAYS: l Available as a set of six instruments with markings
on the shank which denotes the size of the working
Q.1. Sterilization in endodontics. head.
Ans. l They are made up of stainless steel or NiTi.
l Flame-shaped cutting head with a noncutting safe-

[Ref LE Q.1] end tip to obtain straight-line access up to the point
Q.2. Endosonics. of curvature.
l They are used in brushing strokes at a speed of
Ans. 750–1000 rpm to preenlarge the coronal two-thirds
of the canal.
{SN Q.4}
Advantages:
l Sonics and ultrasonics are energized instruments that l Breakage of the instrument occurs in the shaft near
operate at a speed faster than the sound range. the handpiece.

Sonic Handpiece: Sonic air 1500, Megasonic 1400 and
Modifications of GG:
Endo MM 1500 etc.
l Flexogates is a modified GG with a safe noncutting
l It attaches to regular Airotor airline with pressure:
pilot tip, which is more flexible. It is a hand instru-
0.4 mPa.
l It has an adjustable ring to give an oscillating
ment used for apical preparation.}
range of 1500–3000 cycles/s (2–3 kHz).
l Uses three types of files: Heliosonic (tricut file/
l In modified GG, the safe tip is flattened.
triosonic), Shaper sonic and Rispi sonic.
l All of them have a 1.5–2 mm safe-ended noncut- Q.4. Classification of endodontic instruments.
ting tip.
Ans.
l They oscillate outside the canal which is con-
verted into longitudinal up and down motion [Same as SE Q.1]

when in contact with the walls of the canal.
Q.5. Advantages and disadvantages of NiTi rotary end-
l Irrigants/coolants can be delivered through the
odontic instruments.
handpiece while shaping and cleaning.
l To permit the insertion of a No. 15 sonic file, the Ans.
canal should be initially prepared with the con- NiTi files (nitinol files)
ventional hand files (size 20).
l The sonic file begins its rasping action 1.5–2 mm
from the apical stop, this is known as sonic length. {SN Q.8}
l They are used in a step-down technique.
l NiTi alloy contains 54% nickel, 44% titanium and
Advantages: 2% cobalt.
l Better shaping of the canal.
l They are also known as exotic metals.
l The less amount of debris extrudes beyond apex.
l Nitinol instruments should be used with a rotational
l The canals obtained are cleaner.
or reaming motion.
Disadvantages: l These instruments are effective in the shaping of
l It should be used carefully to prevent transporta-
curved root canals.
tion in small curved canals.
l Compared to conventional files, the prepared Advantages:
canal surfaces are rougher. l Super elasticity and more flexible
Ans.
l Better conformation to canal curvature
l Shape memory l Disinfection is a process that eliminates many or all
l Resistance to fracture pathogenic microorganisms, except bacterial spores, on
l Enhanced canal negotiation inanimate objects.
l Disinfection means the destruction or removal of all
l Faster instrumentation
pathogenic organisms except bacterial spores on inani-
mate objects by chemical disinfectants, e.g. aldehyde,
l Biocompatible and anticorrosive. halogens, alcohols and surfactants. This is the destruction
of most microorganisms, but not all viable organisms,
Disadvantages: particularly highly resistant spores.
l Compared to stainless steel they have poor resistance to
fracture. Q.2. Chemiclaving.
l Cutting efficiency is only 60%.
Ans.
l Exhibits no signs of fatigue before it fractures.
Chemiclave/chemical vapour sterilization/Harvey
Q.6. Compare between reamers and files. chemiclave
Ans. l It is similar to autoclave.
l Solutions used are alcohol, acetone, formaldehyde and

Reamers and files are compared in the table below: water.
l According to Ingle at 132°C at 20 psi for 20 min.
Reamers Files
l According to Grossman, at 135°C at 15 lb for 10–15 min.
i. Made of stainless steel. i. Made of stainless steel.
ii. Manufactured from trian- ii. Manufactured from square Q.3. Sterilization of high-speed handpiece.
gular blanks. blanks.
iii. Used with push motion iii. Used with pull or rasping Ans.
and rotation quarter to motion.
l Handpieces can be sterilized by steam, chemical vapour
half turn. iv. Has more number of
iv. Has less number of flutes. flutes. and ethylene oxide gas (ETO).
v. Flutes are loosely twisted. v. Flutes are tightly twisted. l Autoclaving is very effective and most common method.
vi. Cross-section of reamers vi. Cross-section of K-file is l According to Ingle, temperature, pressure and time
is triangular. square. required are 121°C at 15 psi for 15–40 min.
l The time varies based on the items to be autoclaved, the
Q.7. Sterilization of endodontic instruments. size of the load and type of container used.
Ans. Q.4. Endosonics.

Ans.
[Same as SE Q.1]
[Ref SE Q.3]
Q.8. Hot salt sterilizer.
Q.5. Piezo reamer.
Ans.
Ans.
[Same as SE Q.1]
l Piezo reamer is used for post space preparation in
Q.9. Glass bead sterilizer.
straight canals.
Ans. l As it is not a stiff instrument it follows the slight curve
of the canal.
[Same as SE Q.1]
l It is used in a brushing motion.
l Available in sizes from No. 1–6 with tip diameter rang-

Ans.
ing from 0.7 to 1.7 mm and 28 mm, 32 mm and 38 mm
Q.10. Classify endodontic instruments. lengths.
Ans. It has six series of instruments which are as follows:
l No. 1: 0.70 mm
[Same as SE Q.1]
l No. 2: 0.90 mm
l No. 3: 1.1 mm
l No. 4: 1.3 mm
SHORT NOTES: l No. 5: 1.5 mm
Q.1. Define disinfection. l No. 6: 1.7 mm
Q.6. Barbed broaches. Q.14. Giromatic handpiece.

Ans. Ans.
[Ref LE Q.3] l Giromatic handpiece activates a stainless steel barbed
broach or reamer in the root canal through a 900 reci
Q.7. Gates-Glidden drills.
procating arc at a speed up to 1000 cycles/min.
Ans.
Disadvantages:
[Ref SE Q.3] l It may pack the dentinal shavings in the canal.
l They are less effective and take longer time for root
Q.8. NiTi files.
canal preparation.
Ans. l Have a tendency to create ledges and to produce flaring
at the apex.
[Ref SE Q.5]
Q.15. Hedstroem File (H file).
Q.9. Lentulo spiral.
Ans.
Ans.
[Ref LE Q.3]
l Lentulo spirals have a long spiral working end attached
to a latch type shaft. Q.16. Sterilization of root canal instruments.
l They can be used as hand or rotary instruments.
l Used in clockwise rotary motion.

Ans.
Use [Same as SN Q.3]
l Coating sealer on root canal walls before obturation.
Q.17. Flexible files.

Q.10. Endodontic spreads and pluggers.
Ans.
Ans.
[Same as SN Q.8]
[Ref LE Q.3]
Q.11. Hot salt sterilizer. Q.18. Spiral root fillers.
Ans. Ans.
[Ref LE Q.1] [Same as SN Q.9]
Q.12. Glass bead sterilizer. Q.19. Root canal plugger.

Ans. Ans.
[Ref LE Q.1] [Same as SN Q.10]
Q.13. Apex locators – generations and dentine.
Q.20. Apex locator.
Ans. Ans.
Apex locators are available in various trade names, e.g. [Same as SN Q.13]
Endo meter, Sono explorer and Neosine.
Classification Q.21. Electronic apex locators.
i. First Generation:
l Also known as ‘resistance apex locators’.
Ans.
l Measure opposition to the flow of direct current or [Same as SN Q.13]
resistance.
ii. Second Generation: Q.22. H-File.
l Also known as ‘Impedance Apex Locators’.
Ans.
l Measure opposition to the flow of alternating current
or impedance. [Same as SN Q.15]

Topic 7
Endodontic Microbiology
LONG ESSAYS:
1. Describe in detail the technique of culture examination and its importance in endodontic treatment.
SHORT ESSAYS:
1 . Culture methods in endodontics.
2. Microbiological flora of pulp space.
3. Endodontic microbiology. [Same as SE Q.2]
SHORT NOTES:
1 . Culture media used in endodontics.
2. Culture reversal.
3. False-negative culture.
4. Microbial flora of the pulp space. [Ref SE Q.2]
5. Fish concept.
6. False-positive cultures. [Same as SN Q.3]
7. Root canal flora. [Same as SN Q.4]
SOLVED ANSWERS
LONG ESSAYS: Classification of culture media
Culture media can be classified according to the form or
Q.1. Describe in detail the technique of culture exami- function and use:
nation and its importance in endodontic treatment. I. Classification of culture media according to the form
Ans. i. Liquid media (broth):
● The original medium wine or meat broth
● Culturing is the process of cultivation of bacteria or
other organisms in artificial media or under artificial contains nutrients dissolved in it.
● The bacterial growth is indicated by a
conditions. It is a guide to clinical therapy.
Principles of culturing change in the broth’s appearance from
The two clinical reasons for culturing root canals are as clear to turbid (i.e. cloudy).
● The turbidity increases with bacterial
follows:
● To assess the efficacy of debridement procedure
growth. At least 106 bacteria per millilitre
and determine the bacteriologic status of root canal of broth are needed for turbidity to be de-
system prior to obturation. tected with unaided eye.
● To determine antibiotic sensitivity and to check
ii. Semisolid media (bacteriological medium):
the resistance of microbes in cases of persistent The main constituents are as follows:
● Water
infections.
● Agar: A carbohydrate obtained from weeds
Requirements of culture media
● Growth-enriching constituents: Yeast
The following are major nutritional needs for growth of
all bacteria: extract and meat extract
● Blood: Defibrinated horse or sheep blood
● Source of carbon for making cellular constituents
● Source of nitrogen for preparing proteins

iii. Solid media (agar):
● Robert Koch introduced a solid media for
● Source of energy (ATP)
● Small amounts of salts and trace elements for enzy-

culture using pieces of potato, 2.5–5%
matic activity gelatine and 1% meat extract.
● Gelatine solidified at 24°C and, therefore, ● Methylene blue is generally used as an indicator
was substituted by agar. for the purpose of verifying the anaerobic condi-
● Moller (1966) developed a culture medium tion in the jar.
containing veal heart and peptone products
Q.2. Microbiological flora of pulp space.
in an agar gel.
II. Classification of culture media according to the Ans.
function and use
Culture media are classified as:
1. Basal (simple media), e.g. nutrient agar {SN Q.4}
2. Complex media:
● Microorganisms are major cause of most of the
i. Enrichment media
pulpal and periapical diseases.
ii. Selective media, e.g. MacConkey agar,
● The spread of the disease depends on the type of
Rogosa SL
microorganisms in the necrotic canal.
iii. Differential media, e.g. Thayer-Martin
● Facultative anaerobes dominate the pulpally involved
iv. Transport media, e.g. Stuart’s media
tooth due to caries.
● The microbes seen in the canal are opportunistic or-
SHORT ESSAYS: ganisms, which exist in equilibrium in the oral cavity.
● They are polymicrobial of which species belonging
Q.1. Culture methods in endodontics.
to Porphyromonas, Limnerella, Prevotella, Fusobac-
Ans. terium and Eubacterium are commonly seen.
Various culture methods used in endodontics are as Other microbes found in the canal are as follows:
follows: Root canal species
A. Aerobic culture methods ● Bacillus proteus
The methods of bacterial culture used in laboratory are ● Diphtheroid bacilli
mostly aerobic culture methods. These include: ● Staphylococcus aureus
● Streak culture ● Staphylococcus albus
● Lawn culture ● Streptococcus viridans
● Stroke culture ● Streptococcus haemolyticus
● Stab culture
● Pour-plate culture
● Liquid culture
B. Anaerobic culture methods Gram-positive species

● Yeast
● The simplest method is removal of oxygen from the
● Streptococci
culture medium.
● Staphylococci
● Microorganisms are grown within the culture medium
● Corynebacterium
such as freshly steamed liquid media and deep nutrient
agar with 0.5% glucose with minimum shaking. Gram-negative species
● Neisseria
● It is solidified rapidly by placing the tube in cold water.
● Bacteroides
● Cooked meat broth (CMB, original medium known as
● Spirochaetes
‘Robertson’s bullock-heart medium’) is suitable for
● Pseudomonas
growing anaerobes in air and for the preservation of
● Fusobacterium
stock cultures of aerobic organisms.
● Coliform bacteria
Anaerobic jars
● Anaerobic jars are the method of choice, when an
oxygen-free or anaerobic atmosphere is required Microbes found in root canal in endodontic disease
for obtaining surface growths of anaerobes.
● McIntosh–Filde’s anaerobic jar is the most reli- Facultative
able and widely used anaerobic jar. Obligate anaerobes anaerobes
● The Gas Pak is commercially available as a dis- Gram-positive ● Streptococcus ● Streptococcus
posable envelope containing chemicals which cocci intermedius and ● Peptostreptococ-
generate hydrogen and carbon dioxide on the Streptococcus cus
anginosus
addition of water. Nowadays, it is the method of ● Peptostreptococcus
choice for preparing anaerobic jar.
Facultative ● Trypticase Soy broth with 0.1% agar (TSA).

Obligate anaerobes anaerobes ● TSA 1 0.1% agar facilitates growth of anaerobes.
● TSA 1 5% ascitic fluid or 10% horse serum enables
Gram-positive ● Actinomyces ● Actinomyces
rods ● Lactobacillus ● Lactobacillus
fastidious organisms to grow.
● Propionibacterium Q.2. Culture reversal.
● Eubacterium
Gram-negative ● Veillonella ● Neisseria
Ans.
cocci ● A negative culture that becomes positive culture by the
Gram-negative ● Porphyromonas- ● Capnocytophaga time of obturation is known as culture reversal.
rods endodontalis and ● Eikenella ● The culture reversal may occur due to:
Porphyromonas
i. Improper care in taking the culture
gingivalis
● Tannerella ii. Possible leakage between treatments
forsythensis iii. Capability of the culture medium to sustain growth
● Prevotella nigre- of the microorganisms
cans, intermedia ● It is advisable to allow more than 48 h between taking
tannerae, melanin-
the culture and filling the root canal, preferably 96 h or
ogenica and denti-
cola more and it is recommended that the culture tube be
● Fusobacterium reexamined immediately before obturating a canal to
● Campylobacter make certain that no evidence of growth is present.
Yeasts ● Treponema ● Candida Q.3. False-negative culture.
spirochaetes
Ans.
Management of microbial flora During interpretation of culture, culture tube is held
● Thorough shaping and cleaning of root canals helps to against a white background.
eliminate the bacteria fungi and viruses. ● Turbidity indicates growth of organisms.
● In some cases intracanal medicaments are placed within ● If culture medium remains clear, it indicates sterility.
the pulp chamber and sealed in during the intraappoint- False-positive culture
ment periods. ● May be if there is inadequate sterilization of operat-
● During the obturation phase the sealants used should ing field, leakage from rubber dam, unsterile paper
have antibacterial property which will enable it to seal points, break or loss of previous dressings.
and kill the minute number of microorganisms which False-negative culture
have entered into the dentinal tubules. ● May be seen when there is inadequate absorption of
● During endodontic treatment in special cases with acute exudation by paper point’s presence of antimicrobial
infections, oral antibiotics are administrated. Very rarely agents of root canal and absence of inactivation of cul-
systemic antibiotics are required. ture medium or when there is insufficient incubation.
Q.3. Endodontic microbiology. Q.4. Microbial flora of the pulp space.
Ans.
Ans.
[Ref SE Q.2]
[Same as SE Q.2]
Q.5. Fish concept.
Ans.
SHORT NOTES:
Zones in fish’s concept
Q.1. Culture media used in endodontics. Zone I: Zone of necrosis (zone of infection):
Ans. ● It is a central zone containing pus, PMNLs and
microorganisms.
Several culture media are satisfactory for culturing ma- Zone II: Zone of contamination (exudative inflammatory
terial from root canals they are as follows: zone):
● Thioglycollate broth.
● It is characterized by the presence of PMNLs and
● Glucose as cites broth.
macrophages; it is the central zone. The bacterial
● Stuart’s transporting medium.
toxins are diluted and the inflammatory fluid exhibits
● Moiler’s base culture medium.
antibacterial action. There was an empty lacunae cre-
● Brain heart infusion broth with 0.1% agar.
ated by autolysis of dead bone cells.
Zone III: Zone of irritation (granulomatous zone): ● This is a peripheral zone characterized by fibroblasts
● It contains chronic defence cells (macrophages, lym- and osteoblasts.
phocytes and plasma cells), osteoclasts, mediators of ● The fibroblasts lay down collagen fibres creating a
inflammation and immune system. wall of defence around the zone of irritation on
● The toxins are diluted and this zone is away from the which osteoblasts reside to deposit new bone in an
central zone. irregular fashion.`
● The collagen matrix is degraded by macrophages and
Q.6. False-positive cultures.
the bone is resorbed leaving a small space which is
filled with granulomatous tissue, which prevents the Ans.
spread of necrosis and initiates repair due to presence
[Same as SN Q.3]
of new capillaries and fibroblasts. Occasionally, Rus-
sell bodies, foam cells, cholesterol crystals and epi- Q.7. Root canal flora.
thelial clusters are seen.
Ans.
Zone IV: Zone of stimulation (zone of encapsulation, zone
of productive fibrosis): [Same as SN Q.4]
Topic 8
Tooth Morphology and Access Cavities
LONG ESSAYS:
1. Enlist the rules for access cavity preparation. Write in detail about access cavity preparation for all maxillary
teeth taking into consideration the anatomical variations.
2. Write in detail the importance of tooth morphology in procedures of root canal. [Same as LE Q.1]
SHORT ESSAYS:
1 . Poly antibiotic paste.
2. Apical foramen.
SHORT NOTES:
1. Accessory canals.
2. Anatomy of root canal of maxillary permanent first molar. [Ref LE Q.1]
3. C-shaped canal configuration.
4. Apical foramen. [Ref SE Q.2]
5. Apical constriction.
6. Anatomy of pulp cavity of maxillary first premolar. [Ref LE Q.1]
7. Blunder buss canal and its management.
8. Lamina dura.
9. Access cavity preparation in mandibular molar.
10. Significance of accessory canals. [Same as SN Q.1]
11. What is C-shaped canal configuration? [Same as SN Q.3]
12. Access cavity in mandibular permanent first molar. [Same as SN Q.9]
SOLVED ANSWERS
LONG ESSAYS: Access opening
● It is similar to central and lateral incisors;
Q.1. Enlist the rules for access cavity preparation. Write however, the shape of the access cavity is
in detail about access cavity preparation for all maxil- ovoid as directed by the pulp chamber.
lary teeth taking into consideration the anatomical Mandibular anterior teeth
variations. I. Mandibular central and lateral incisors
Ans. ● Average length of tooth is 20.7 mm.
● One root and one root canal, three pulp horns.

The morphological features and rules to be followed Curvatures
in access cavity preparation for maxillary teeth are as ● Straight in 60%, distal curve in 23% and
follows: labial curve in 13%.
Maxillary anterior teeth ● It is the smallest tooth in the arch with the pulp
I. Maxillary central incisor chamber being wide and ovoid labiolingually.
● The average length of a central incisor is
● In a few cases, an additional canal may be
22.5 mm. present lingually.
● It has one root, one root canal with three pulp
Access opening
horns. ● Similar to maxillary anterior with the varia-
Curvature tion that it is smaller in size and long oval
Usually, it is straight in 75% and curved labially shape.
in 9%, distally in 8%, mesially in 4% and pala- II. Mandibular canine
tally in 4% of population. ● Average length is 25 mm and it has one root and
Access opening one root canal.
● The internal anatomy of the tooth decides the
Curvatures
shape and size of the access cavity. Straight root in 68%, curved distally in 20%,
● The access cavity is triangular in shape with
labially in 7%, mesially in 1% and rarely it is ‘S’
the base towards the incisal edge. or bayonet-shaped.
● When it is funnel-shaped, smooth and con-
Access opening
tinuous with the radicular portion of the pulp ● It is oval or slot-shaped, approaching incisal
cavity providing straight-line access to the edge for straight-line access.
apical third of the root canal, access cavity is
Maxillary premolars
considered to be complete.
II. Maxillary lateral incisor
● Average length of this tooth is 21.8 mm. {SN Q.6}
● It has one root and one root canal with three
pulp horns. I. Maxillary first premolar

● Average length is 20.6 mm.
Curvatures
● It has two roots and two root canals which are
● It usually has a distal curvature in 53%, straight
in 30%, labially curved in 4%, mesially curved narrow mesiodistally, two canal orifices – one
in 3%, ‘S’ or bayonet shaped in 6%. buccal and one palatal.
● Usually the palatal canal is the larger of the two
● A palato gingival groove is seen in most cases
which may result in endo-perio problems. canals. It has two roots that may be fused or
Access opening separated.
● It is similar to central incisor but smaller and
Curvatures
● Buccal root may be straight or palatally curved.
usually more ovoid.
● Palatal root may be straight or buccally curved.
III. Maxillary canines
● Average length of tooth is 26.5 mm.
Access opening
● Ovoid, wide buccolingually, narrow mesiodistally.
● It has one root and one root canal.
● It should not be entered beyond half the lingual
● Root canal is wider buccolingually.
Curvatures incline of the facial cusp and half the facial incline
● It is straight in 39% of cases. It is curved distally
of the palatal cusp.
● When three canals are present the outline be-
in 32%, labially in 13%, palatally in 7% ‘S’
Bayonet shaped in 7% and dilacerations in 2%. comes triangular with base on the buccal aspect.
II. Maxillary second premolar

Curvatures
● The palatal root is buccally curved and the mesial
● It may have one root with one or two root canals
root is distally curved whereas the distal root may
with two pulp horns.
be straight or mesially curved.
Curvatures
● Pulp chamber: It is the largest in the dental arch
Straight in 37.4%, distally curved in 33.9%, buc-
with four pulp horns: mesiobuccal, distobuccal,
cally curved in 15.7% and ‘S’ or bayonet shaped
mesiopalatal and distopalatal.
in 13% of cases.
● The arrangement of the pulp horns gives a rhom-
Access opening
boid shape to the pulp roof in cross section.
● It is same as that for first premolar but it is
● The orifices of the root canals are located in the
slightly smaller buccolingually.
three angles of the floor. They are connected by the
● The orifice is centrally located when there
anatomic dark lines in the floor of the pulp chamber.
is a single canal and when there are two ca-
● Molar triangle is formed when a line is drawn to
nals, the orifices are located buccally and
connect these orifices.
lingually.
● The palatal orifice is the largest among the three and
Mandibular premolars
the mesiobuccal orifice is located under the mesiobuc-
I. Mandibular first premolar
cal cusp. The distobuccal orifice is located 2–3 mm
distal and slightly palatal to the mesiobuccal orifice
● Two pulp horns – buccal and lingual.
and is accessible from the mesial for exploration.
Curvatures
Access opening
Straight in 48%, distally curved in 35%, lin-
● Triangular outline with the base of the triangle
gually in 7%, buccally curved in 2% and ‘S’ or
towards the buccal and the apex is to the palatal.
bayonet shaped in 7% of cases.
Access opening
● It is ovoid with more buccal extension to get Shamrock preparation involves opening on the me-
●
a straight-line access. sial half of the tooth with little involvement of the
● The crown has a 30° lingual tilt that gives the oblique ridge. To permit straight-line access to the
pulp chamber an appearance of mandibular apical region when the mesial root is distally curved,
cuspid. the opening is extended more towards the mesial.
II. Mandibular second premolar II. Maxillary second molar
● Average length is 22.3 mm. ● Average length is 20 mm
● It usually has a single root, but on rare occasions ● Three roots, three root canals, but sometimes
2–3 roots are present, two pulp horns. buccal roots may be fused
Curvatures ● Four pulp horns: Mesiobuccal, mesiopalatal,
● Straight in 39%, distally curved in 40%, buc- distobuccal and distopalatal

cally curved in 10%, lingually curved 3% Curvatures
bayonet curve in 7% and trifurcated root ● Palatal root: Straight or buccally curved.
canals in 1%. ● Mesial root: Distally curved
● The lingual horn is more prominent under a ● Distal root: Straight or mesially curved.
well-developed lingual cusp. ● Teeth with only one canal have also been
Access opening reported.

● Ovoid and similar to the first premolar. It has ● Teeth with two roots and two canals have also
lesser lingual inclination of the crown hence been reported.

it needs less buccal extension. Access opening
Maxillary molars Similar to first molar, but the buccal side of the
triangle is not as wide because the orifices are
close to each other.
{SN Q.2} Mandibular molars
I. Mandibular first molar
I. Maxillary first molar
● Two roots and three root canals.
● Three roots, three or four root canals four pulp
Curvatures
horns, i.e. mesiobuccal, mesiopalatal, distobuccal
● Mesial root is distally curved. Distal root is
and distopalatal.
straight, but sometimes curved distally.
● Roof of pulp chamber is rectangular; three {SN Q.4}

distinct orifices – mesiobuccal, mesiolingual
and distal are seen. ● Apical foramen is also known as major diameter and
● Mandibular molars having additional distolin- is twice as that of the minor diameter or apical con-
gual root are known as radix entomolaris and striction.
those having additional distobuccal root are ● It is the main apical opening on the root through
known as radix paramolaris. which the blood vessels enter the canal.
● Triangular outline form reflects the anatomy of ● This gives it a funnel shape which is described as
the pulp chamber. ‘hyperbolic’ or ‘morning glory’ based on its shape.

● Both mesial and distal walls slope mesially. ● The average distance between the minor and major
● The cavity is primarily within the mesial diameters is 0.5 mm in young patients and 0.75 mm
half of the tooth but is extensive enough to in elderly patients.
allow positioning of instruments and filling ● The actual apical foramen is located away from the
materials. anatomic or radiographic apex.

● Further exploration should determine whether
a fourth canal can be found in the distance, in Clinical significance of the apical third of root
that case, an orifice will be positioned at each ● Most of the curvatures occur in the apical third of the root.
angle of the rhomboid. ● They have to be carefully prepared by balanced-force
Access opening technique or pre-curving the instruments with anticur-
● Trapezoidal with round corners or rectangular vature filing.
if a second distal canal is present. ● The apical third should be prepared adequately to de-
II. Mandibular second molar bride the canal chemically and to hold the irrigants.
Mandibular second molar anatomy and access ● During obturation the filling should end at the apical
opening are similar to mandibular first molar. constriction, to prevent delay of the periapical healing.
● During periapical surgery, apical 3 mm of the root is
Q.2. Write in detail the importance of tooth morphology
in procedures of root canal. resected to avoid lodging of the residual microorgan-
isms and irritants.
Ans.
[Same as LE Q.1] SHORT NOTES:
Q.1. Accessory canals.
SHORT ESSAYS:
Ans.
Q.1. Poly antibiotic paste.
i. Accessory canal is a canal that branches off from the
Ans. main root canal.
● Grossman’s poly antibiotic paste (PBSC/N). Mechanism of formation
● PBSC – penicillin, bacitracin, streptomycin and sodium 1. Unknown.
● They are likely to occur in areas where there is
caprylate.
● Now nystatin is used instead of caprylate.
premature loss of root sheath cells because these
● Sulphonamides.
cells induce the formation of the odontoblasts that
● Penicillin streptomycin caprylate sodium – PSCC
form the dentine.
● It can also occur where the developing root en-
(chloramphenicol).
counters a blood vessel where the hard substance
Advantages: is not deposited.
● It is nontoxic to the apical tissues and does not stain ii. They are usually seen in the apical one-third but may
teeth. also occur in the bifurcation or trifurcation of multi-
● They are active in the presence of organic material. rooted teeth.
Disadvantages: iii. Lateral canal is an accessory canal that is located at ap-
● Sensitization of the patients.
proximately right angle to the main root canal.
● Allergic response. Q.2. Anatomy of root canal of maxillary permanent first
● Development of resistant strains. molar.
Q.2. Apical foramen. Ans.
Ans. [Ref LE Q.1]
Q.3. C-shaped canal configuration. Q.8. Lamina dura.

Ans. Ans.
● C-shaped canals are seen in mandibular second molars ● It is a radiopaque line representing the socket of the
and rarely in mandibular first molar, maxillary first and tooth.
second molars. ● It is seen in sound teeth in continuation with cortical
● It is the cross-sectional morphology of the root and root bone at the alveolar crest.
canal. ● The lamina dura is thicker around teeth that undergo
● The pulp chamber is a single ribbon-shaped orifice with more of occlusal stress.
an arc of 180° (or more), starting at the mesiolingual- ● It is an important diagnostic feature and an intact lamina
line angle and sweeping around the buccolingual to end dura presents healthy pulp.
at the distal aspect of the pulp chamber.
Q.9. Access cavity preparation in mandibular molar.
Types
There are two types: Ans.
● Those with single canal (from orifice to the apex)
Average length: 21.0 mm.
under a C-shaped orifice.
Two roots and three root canals.
● Those with 2–3 distinct canals under a C-shaped
Curvatures
orifice. This is more common and difficult to treat.
● Mesial root is distally curved. Distal root is straight,
Q.4. Apical foramen. but sometimes curved distally.

● Roof of pulp chamber is rectangular; three distinct
Ans.
orifices – mesiobuccal, mesiolingual and distal – are
[Ref SE Q.2] seen.
● Mandibular molars may have an additional distolin-
Q.5. Apical constriction.
gual root or distobuccal root.
Ans. Access opening
● Triangular outline form reflects the anatomy of the
● Apical constriction is also known as minor diameter.
pulp chamber.
● It is the apical portion of the root canal having the nar-
● Trapezoidal with round corners or rectangular if a
rowest diameter (0.5–1.0 mm) short of the apical fora-
second distal canal is present.
men or radiographic apex.
● The access cavity is primarily within the mesial half
● It is close to, but does not necessarily coincide with the
of the tooth but is extensive enough to allow posi-
cementodentinal junction (CDJ).
tioning of instruments and filling materials.
Q.6. Anatomy of pulp cavity of maxillary first premolar.
Q.10. Significance of accessory canals.
Ans.
Ans.
[Ref LE Q.1]
[Same as SN Q.1]
Q.7. Blunder buss canal and its management.
Q.11. What is C-shaped canal configuration?
Ans.
Ans.
● Blunderbuss canal is a gaping canal.
[Same as SN Q.3]
● Apexification is carried out to ensure closure of the canal.
● Special techniques are used to obturate the canal, if Q.12. Access cavity in mandibular permanent first
adequate closure is not achieved. molar.
● Largest gutta-percha point or tailor made gutta-percha is
Ans.
required for the closure of such irregular canals.
● Warm gutta-percha points are preferred for such proce- [Same as SN Q.9]
dures.
Topic 9
Endodontic and Biomechanical Preparation
and Working Length Determination
LONG ESSAYS:
1. What do you understand by cleaning and shaping of root canal? Describe the instruments used for the same.
2. Mention the various instruments used for root canal preparation. Describe in detail the procedure of your
choice to ensure thorough canal preparation.
3. What are the various methods of determining working length in endodontics?
4. Describe in detail cleaning and shaping of root canal. [Same as LE Q.1]
5. Mention the various instruments used for root canal preparation. Describe in detail the procedure of your
choice to ensure the rough canal preparation. [Same as LE Q.1]
6. Mention the different types of root canal preparation and importance. Describe in detail about step-back tech-
niques. [Same as LE Q.1]
7. Classify the techniques for root canal preparation. Discuss crown-down technique. Describe the biomechanical
preparation in endodontics. [Same as LE Q.1]
8. What is biomechanical preparation? Describe various methods of biomechanical preparation and discuss step-
back preparation. [Same as LE Q.1]
9. Describe biomechanical preparation in endodontic practice. [Same as LE Q.1]
10. What do you mean by cleaning and shaping? Describe in detail the step-back preparation in a maxillary right
central incisor. [Same as LE Q.1]
11. Classify endodontic instruments. Discuss cleaning and shaping of the root canal (BMP) by step-back technique.
[Same as LE Q.2]
12. Discuss various methods of working length determination in endodontics. [Same as LE Q.3]
13. What are the various methods of determining working length? Write in detail Ingle’s method of determining
working length. [Same as LE Q.3]
SHORT ESSAYS:
1. Trephination.
2. Access cavity.
3. Access cavities in lower and upper molars.
4. Mechanical instrumentation in endodontic field. [Ref LE Q.2]
5. Crown-down pressure technique. [Ref LE Q.1]
6. Ingle’s method of determining working length. [Ref LE Q.3]
7. Balanced force technique. [Ref LE Q.1]
8. Schilder’s technique.
9. Describe briefly the K-type reamer and K-type file.
10. Step-back preparation. [Same as SE Q.4]
11. Step-back method. [Same as SE Q.4]
SHORT NOTES:
1 . Access opening. [Ref SE Q.2]
2. Recapitulation.
3. Electronic apex locators.
4. Importance of determining the working length of a tooth during root canal treatment.
5. Different methods for root canal length determination. [Ref LE Q.3]
6 . Mention advantages of crown-down technique.

7. Access cavity. [Same as SN Q.1]
8. Working length determination. [Same as SN Q.5]
SOLVED ANSWERS
LONG ESSAYS: ● An apex locator can be used for determination of work-
ing length (WL) and confirmed radiographically.
Q.1. What do you understand by cleaning and shaping ● Initial width of the apical constriction is assessed; the
of root canal? Describe the instruments used for the file which fits snuggly at the apical constriction is called
same. as initial apical file (IAF). This is also called as gauging.
Ans. ● To remove the necrotic debris broach is used passively
up to the coronal/middle third of the canal.

● Cleaning means removal of all contents of the root canal
system like organic substrates, micro flora, bacterial by- Step-back preparation (telescopic preparation or serial
products, food debris, caries, pulp stones, dense collagen, root canal preparation)
previous root canal filling material and dentinal fillings. ● Step-back preparation was proposed by Mullaney,
● Cleaning allows access to files and irrigants during the
Walton, Weine and Martin.
shaping process. ● After proper diagnosis, local anaesthesia is given and
● Shaping is removal of all the content from the root ca-
tooth is isolated by using rubber dam.
nal system, to work deep inside the canal and to create ● After access cavity preparation, canal is shaped from
a smooth, tapered opening to the terminus for three- apex with a fine instrument, working backwards coro-
dimensional obturation. nally progressively with larger instruments.
Procedures involved in root canal treatment Mullaney divided it into two phases
● Diagnosis and treatment plan i. Phase I
● Local anaesthesia ii. Phase II
● Rubber dam application
● Coronal preparation (access preparation) Phase I
● Radicular preparation ● The canal is lubricated and explored using a patency file
(No. 10/15 K-file).

Radicular preparation divided into two main phases ● WL is determined.
Mechanical intraradicular preparation ● The IAF is that instrument which snuggly fits at the
Preparation apical constriction.
● Standardized technique ● The files are used in watch-winding motion till the in-
● Step-back technique strument becomes loose, followed by irrigation.
● Crown-down pressureless technique ● The next size instrument No. 20 is used to same WL,
● Hybrid technique in the same watch winding motion till the instrument
become loose followed by irrigation.
Variations ● File No. 25 is used in the same manner to WL to complete
● Balanced-force technique the apical preparation and the canal is irrigated.
● Reverse balanced-force technique
● Anticurvature filing Phase II-A

● Next size file No. 30 is used 1 mm short, i.e. 19 mm of
Chemical intraradicular preparation the actual WL with watch winding motion till the instru-
● Intra-appointment ment becomes loose and the canal is irrigated.
● Interappointment
● The previous instrument No. 25 is used to the actual WL
20 mm to ensure the patency of the canal followed by

Coronoapical preparation Apicocoronal preparation irrigation. Sequential re-entry and reuse of each previ-
ous instrument is called recapitulation.
● Step down ● Standardized method
● The next instrument No. 35 is used 2 mm short, i.e.
● Crown-down pressureless ● Step back
technique ● Modified step back 18 mm of the WL in a lubricated canal in watch winding
● Double flare technique motion till the instrument becomes loose. The canal is
● Modified double flare irrigated and recapitulated using No. 25.
technique
● Glates-Glidden (GG) drills/orifice opener to remove
● Hybrid/combined
the coronal constriction.
Phase 11-B (refining phase) ● Precurved files remain curved, can be easily inserted
● The last apical instrument No. 25 is used to smoothen and freely pass down the canal.}
all the walls with push–pull strokes followed by copious
irrigation which gives 5% taper to the canal. [SE Q.7]
Serial canal preparation {Balanced force technique

● In serial canal preparation, after the apical stop is en- ● Balanced force technique proposed by Roane and
larged three sizes greater than the IAF, the preparation Sabala.
steps back up the canal by 0.5 mm and one larger instru- ● This is the most efficient way to cut dentine which
ment at a time (unlike 1 mm in the step-back prepara- involves oscillation of the instrument right and left with
tion) which gives taper of 10% to canal. different arch in each direction.
● GG drills are used to do coronal flaring followed by
Modified step-back preparation
irrigation.
● In modified step-back preparation, after the enlargement
● WL is determined.
of the apical stop, the step-back preparation begins
● Balanced force movement of file is followed at the api-
2–3 mm up the canal. This provides a short parallel re-
cal third of the canal. These include three phases.
tention form to the master GP point.
● The entire preparation is completed with step-back
[SE Q.5] technique with copious irrigation.
{Crown-down preparation Three phases

● Proposed by Marshall and Pappin. i. Phase I: File insertion – A straight file is inserted into
● GG drills and larger files are used to do coronal prepara- the root canal until it binds against the wall. The file is
tion and then progressively smaller files are used in an then rotated clockwise through 60–90° so that it binds
apical direction till the desired length is reached. threads within the dentine and advances apically.
ii. Phase II: File cutting – The file is moved anticlockwise
Procedure
through 120–180° with apical pressure, breaking off
● Canal patency is determined using fine file with lubrica-
the dentine threads and enlarging the root canal.
tion, after application of rubber dam.
iii. Phase III: Flute loading – A final clockwise rotation
● Inserting No. 35 file until it binds and measures the
without apical advancement allows flutes to be loaded
length. This is known as radicular access length (RAL).
with debris and removed from the canal.
● Coronal portion is flared using GG to RAL.
● No. 30 file is inserted and rotated clockwise slightly Advantages:

beyond RAL until resistance is felt and the canal is pre- ● It locates the instrument near the canal axis even in se-
pared till the instrument is loose. verely curved canals.
● The next small numbered files are inserted in sequential ● Works effectively without pre-curving.
order to a point 3 mm short of the radiographic apex ● File cutting occurs only at apical extent of the file.
which is known as the provisional WL.
● With the file at the provisional WL a radiograph should Reverse balanced-force preparation
be taken to estimate the true WL. The file that fits ● NiTi Greater taper hand files are the instruments used in
snugly at the true WL is called the IAF. this technique as the flutes of these files are machined in
● The canal walls are finished by circumferential filing by a reverse direction unlike the other files.
continuing stepping down with smaller files to the true WL. ● The handle of these files is increased in size to make the
● Apical stop is enlarged three times the IAF. reverse balanced-force manipulation easier.
Advantages: Technique
● By eliminating the coronal constrictions reduces the ef- ● In reverse balanced force the file is used in 60° anti-
fect of canal curvature and gives better tactile sensation. clockwise movement, followed by 120° clockwise
● It allows effective irrigation and hence the danger of movement with apical pressure using the GT files (larg-
pushing the debris beyond the apex is minimized. est [blue] to smallest [white]) in a crown-down se-
● During apical instrumentation chances of changing WL quence progressively towards the apex.
is less. ● This procedure is repeated till the estimated WL using
● Improves identification of foramen as it accepts larger diagnostic radiograph is reached.

files into the apical one-third which is easier to visualize ● 0.02 Tapered ISO files are used to prepare the apical
on the radiograph. portion (balanced force technique is used).
● The risk of instrument fracture is reduced in crown- ● Radicular preparation is completed using the GT hand
down preparation technique. file of appropriate taper.}

Q.2. Mention the various instruments used for root Phase II-A
canal preparation. Describe in detail the procedure of ● Next size file No. 30 is used 1 mm short, i.e. 19 mm of
your choice to ensure thorough canal preparation. the actual WL with watch winding motion till the instru-
ment becomes loose and the canal is irrigated.
Ans.
● The previous instrument No. 25 is used to actual WL
Instruments used for root canal preparation
20 mm to ensure the patency of the canal followed by
I. Hand instruments
irrigation. Sequential re-entry and reuse of each previ-
1. Broaches
ous instrument is called recapitulation.
i. Smooth
● The next instrument No. 35 is used 2 mm short, i.e. 18 mm
ii. Barbed
of WL in a lubricated canal in watch winding motion till
2. Hand files
the instrument becomes loose. The canal is irrigated and
i. Files
recapitulated using No. 25.
ii. Reamers
● GG drills/orifice opener to remove the coronal constriction.}
iii. Hedstroms
iv. Greater taper (NiTi) hand files Phase II-B (refining phase)
II. Rotary instruments ● The last apical instrument No. 25 is used to smoothen
1. GG drills all the walls with push–pull strokes followed by copious
2. Profile NiTi rotary files irrigation which gives 5% taper to the canal.
3. Greater taper
Serial canal preparation
4. Protaper
● In serial canal preparation, after the apical stop is en-
5. Quantec file series
larged three sizes greater than the IAF, the preparation
6. Hero shapers
steps back up the canal by 0.5 mm and one larger instru-
7. Light speed
ment at a time (unlike 1 mm in the step-back prepara-
8. K3
tion) which gives taper of 10% to canal.
III. Automated (ultrasonic)
IV. Lasers [SE Q.4]
[SE Q.4] {Modified step-back preparation
● In modified step-back preparation, after the enlargement of
{Step-back preparation the apical stop, the step-back preparation begins 2–3 mm
● It is also known as ‘Telescopic Preparation’ or ‘Serial
up the canal. This provides a short parallel retention form
Root Canal Preparation’.
to the master GP point.}
● Step-back preparation was proposed by Mullaney,
Walton, Weine and Martin. Q.3. What are the various methods of determining
● After proper diagnosis, local anaesthesia is given and working length in endodontics?
tooth is isolated using rubber dam.
● After access cavity preparation, canal is shaped from
Ans.
apex with a fine instrument, working backwards coro-
nally progressively with larger instruments. {SN Q.5}
● Mullaney divided it into two phases:
● WL is defined as the length measured from a coronal
A. Phase I
reference point to the point at which canal prepara-
B. Phase II
tion and obturation should terminate.
Phase I Methods of determining the WL
● The canal is lubricated and explored using a patency file
(No. 10/15 K-file). Nonradiographic
● WL is determined, e.g. 20 mm. Radiographic Methods Methods
● The IAF is the instrument which snuggly fits at the api- ● Grossman’s formula ● Digital tactile
cal constriction. ● Ingle’s method sense
● Wiene’s method ● Apical periodon-
● The files are used in watch-winding motion till the in-
● Radiographic grid tal sensitivity
strument becomes loose, followed by irrigation. ● Endometric probe ● Measurement
● The next size instrument No. 20 is used to same WL, in ● Radiographs made with different with paper-
the same watch winding motion till the instrument be- film types or digital films: radio- points
come loose followed by irrigation. visiography (RVG), xeroradiogra- ● Electronic apex
● File No. 25 is used in the same manner to WL to com-
phy, digital subtraction radiogra- locators
phy, radiographic grid and
plete the apical preparation and the canal is irrigated. endometric probe
Radiographic methods to determine the WL IV. WL determination by other radiographic tech-

I. Grossman’s formula to determine the WL niques
Actual length of the tooth 5 radiographic length of ● RVG
the tooth 3 actual length of the instrument radio- ● Xeroradiography
graphic length of the instrument. ● Digital subtraction radiography
II. Ingle’s method ● Radiographic grid
● Endometric probe
[SE Q.6] Radiographic grid
● A simple method in which a millimetre grid is super-
{Materials and conditions required
● Good, undistorted and parallel periapical radio- imposed on the radiograph which overcomes the
graph preoperative radiographs showing the total need for calculation.
● Every 5 mm is darker for easier reading of the radio-
length and all roots of the involved tooth.
● Adequate coronal access to all canals.
graph.
● Endodontic millimetre ruler.
Disadvantages:
● It is inaccurate if radiograph is bent during exposure.
● Knowledge of average length of all of the teeth.
● Grid may not be correctly oriented to the file for
● A reliable and reproducible plane of reference to
an anatomic landmark on the tooth. easy measurement.

● May obscure the tip.
Method
● Measure the length of the tooth on the preopera-
Endometric probe
● They use graduations on diagnostic file that are vis-
tive radiograph and subtract 1 mm for safety al-
lowance for image distortion. ible on radiographic grid.
● Endometric probes are etched at millimetre incre-
● Adjust the stop on instrument at this tentative WL,
keep it in the canal and take a radiograph. ments.

● On the radiograph, the difference between the end of
Disadvantage:
● Smallest file size is number 25.
the instrument and the end of the root is measured
and added to the tentative WL. If the instrument has Nonradiographic methods of WL determination
gone beyond the apex, subtract this difference. i. Digital tactile sense.
● To place it at apical constriction, from this ad-
ii. Apical periodontal sensitivity.
justed length, subtract 1 mm ‘safety factor’. iii. Measurement using paper-point.
● The apical portion of the root canal having the Q.4. Describe in detail cleaning and shaping of root canal.
narrowest diameter is known as apical constric-
Ans.
tion (minor apical diameter) and is 0.5–1.0 mm
short of the centre of the apical foramen or radio- [Same as LE Q.1]
graphic apex.
Q.5. Mention the various instruments used for root
● The new WL is again confirmed with a repeat
canal preparation. Describe in detail the procedure of
radiograph.
your choice to ensure the rough canal preparation.
● Record this final WL. In curved canals, length
should be confirmed after instrumentation is com- Ans.

pleted, as WL may shorten up to 0.5–1 mm as a [Same as LE Q.1]
curved canal is slightly straightened after instru-
mentation.} Q.6. Mention the different types of root canal prepara-
III. Wiene’s recommendations for determining WL tion and importance. Describe in detail about step-back
based on radiographic evidence of root resorp- techniques.
tion/bone resorption Ans.
● If there is no evidence of root or bone resorp-
tion, preparation should terminate 1.0 mm from [Same as LE Q.1]

the apical foramen, i.e. major diameter. Q.7. Classify the techniques for root canal preparation.
● If bone resorption is apparent but there is no Discuss crown-down technique. Describe the biome-
tooth resorption, the length should be shortened chanical preparation in endodontics.
by 1.5 mm.
● If both root and bone resorptions are apparent,
Ans.
the length should be shortened by 2.0 mm. [Same as LE Q.1]
Q.8. What is biomechanical preparation? Describe vari- Prophylactic trephination

ous methods of biomechanical preparation and discuss ● To prevent postoperative pain during single sitting end-
step-back preparation. odontics.
Ans. Indications
● Teeth with large areas of rarefaction.
[Same as LE Q.1]
● When the root canal has been overfilled and pain or
Q.9. Describe biomechanical preparation in endodontic discomfort is present.

practice. ● For postoperative pain following obturation of the canal
by conventional means.
Ans.
● Acute alveolar abscess where drainage through the root
[Same as LE Q.1] canal is inadequate and much pain or swelling is present.

Q.10. What do you mean by cleaning and shaping? De- Procedures
scribe in detail the step-back preparation in a maxillary i. Apical trephination
right central incisor. ● Apical trephination involves the penetration of the
apical foramen through the canal with a small end-

Ans.
odontic file and enlarging the apical opening to a size
[Same as LE Q.1] No. 20 or 25 file to allow drainage from the perira-
dicular lesion into the canal space.
Q.11. Classify endodontic instruments. Discuss cleaning
ii. Cortical trephination:
and shaping of the root canal (BMP) by step-back tech-
● Cortical trephination involves making an incision
nique.
through mucoperiosteal tissue and perforating through
Ans. the cortical plate with a rotary instrument.
● Using either No. 6 or No. 8 round bur in a high-speed
[Same as LE Q.2]
handpiece trephination should be initiated from a
Q.12. Discuss various methods of WL determination in buccal approach to penetrate the cortical plate.
endodontics. ● A reamer or K-file is used to reach the periapical
region through the opening.

Ans.
Q.2. Access cavity.
[Same as LE Q.3]
Q.13. What are the various methods of determining Ans.
WL? Write in detail Ingle’s method of determining WL.
Ans. {SN Q.1}
[Same as LE Q.3] ● Access cavity is a critical step in a series of proce-
dures that potentially leads to three dimensional ob-
turation of the root canal system.
SHORT ESSAYS: ● Access cavities should be prepared in such a way that
the pulpal roof, including all overlying dentine, is

Q.1. Trephination.
removed. The size of the access cavity is dictated by
Ans. the position of the orifice(s).
● The axial walls are extended laterally such that the
● Trephination means surgical technique to alleviate
orifice(s) is just within the outline form the internal
acute pain where an opening is made through the mu-
walls are flared and smoothened to provide straight-
coperiosteum to the alveolar plate of bone over an in-
line access into the orifice and the root canal system.
volved root end, when drainage through the root canal
● Access preparations are well expanded to eliminate
is impossible.
any coronal interference during subsequent instru-
● This can be done by creation of surgical passage in the
mentation.
region of the root apex with bur or special drill.
● The objectives of access preparation are confirmed
● It provides a channel for the escape of blood and pus to
when all the orifices can be visualized without mov-
relative the pressure of accumulated fluid or gas in the
ing the mouth mirror.
jaw bone.
Q.8. Schilder’s technique.

A dramatic improvement in cleaning and shaping
●
potentials is observed when instruments conveniently Ans.

pass through the occlusal opening, effortlessly slide
● The main objective of shaping and cleaning is to remove
down smooth axial walls and are easily placed into
the entire canal contents, disinfect and create a space to
the orifice.
receive an obturating material, all of which favour peri-
apical healing.
Q.3. Access cavities in lower and upper molars. Schilder’s objectives
Ans. i. The canal should be in a continuously tapering funnel
form from the apex to the access cavity.
Access cavity in upper molars ii. As we move down apically, the cross-sectional diameter
Access opening in upper first molar should be narrower at every point.
● Outline is triangular with the base of triangle towards iii. The root canal preparation should flow with the shape of
the buccal and the apex is to the palate. the original canal.
● The opening is on the mesial half of the tooth with little iv. The apical foramen should remain in its original position.
involvement of the oblique ridge. v. The apical opening should be kept as minimal as practical.
● When the mesial root is distally curved, the opening is vi. To leave as much radicular dentine as possible to pre-
extended more towards the mesial to permit straight- vent vertical fracture.
line access to the apical constriction. This is known as
‘Shamrock preparation’. Q.9. Describe briefly the K-type reamer and K-type file.
Access opening in upper second molar Ans.

● Access opening in upper second molar is similar to first K-type instruments
molar except the buccal side of the triangle is not as ● For cutting and machining dentine, K-type file and K-type
wide because the orifice are close to each other. reamers are the useful instruments.
Access cavity in lower molars ● They are made up of stainless steel wire that is ground
Access opening in lower first molar to a tapered square or triangular cross-section and then
● If a second distal canal is present, then it is trapezoidal is twisted to create either a file or reamer.
with round corners or rectangular. ● A file has more flutes per unit length compared to a reamer.
● K-type instruments are used in penetrating and enlarg-

Access opening in lower second molar
● It is same as the mandibular first molar but smaller ing root canals.
● The instrument works by primarily by compression and
opening.
● This is because of the buccoaxial inclination, as some-
release destruction of the dentine surrounding the canal.
● A reaming motion causes less transportation than a fil-
times it is necessary to reduce a large portion of me-
siobuccal cusp too clean and shape the mesiobuccal ing motion.
● A stainless steel K-file can be precurved to a desired
cusp.
form to facilitate insertion and minimize transportation.
Q.4. Mechanical instrumentation in endodontic field. ● Permanent deformation occurs when flutes become
Ans. wound more tightly or are opened widely and when such
deformation occurs, the instrument should not be used.
[Ref LE Q.2] ● Instrument fractures during clockwise motion after
plastic deformation. This occurs when instrument be-

Q.5. Crown-down pressure technique. comes bound while the force of rotation continues.
● Therefore, K-type instruments should be used carefully
Ans.
and when pressure applied should be in a counter clock-
[Ref LE Q.1] wise direction.
Q.6. Ingle’s method of determining working length. Q.10. Step-back preparation.
Ans. Ans.
Q.7. Balanced force technique. Q.11. Step-back method.
Ans. Ans.
SHORT NOTES: ● WL is the distance measured from a coronal reference

point to the point at which canal preparation and obtura-
Q.1. Access opening. tion should terminate.
Ans. Importance of WL determination
[Ref SE Q.2] ● To establish the length at which canal preparation and
obturation has to be done.
Q.2. Recapitulation. ● Optimum length has been established at 1–2 mm short
Ans. of the apex.

● Over-instrumentation causes apical perforation, over-
● Recapitulation means the repeated reintroduction and filling and pain.
reapplication of instruments previously used throughout ● Failure to determine correct WL leads to incomplete
the cleaning and shaping process in order to create well- instrumentation, ledge formation, under-filling with api-
designed unclogged, smooth and evenly tapered step cal percolation and persistent pain and discomfort from
less root canals. retained pulp tissue.
● The entire procedure is called serial reaming and filing
and constant recapitulation. Q.5. Different methods for root canal length determination.
Q.3. Electronic apex locators. Ans.
Ans. [Ref LE Q.3]
● The electronic apex locators are used to determine the Q.6. Mention advantages of crown-down technique.
WL for the canal preparation in conjunction with radio- Ans.
graphs.
● These are devices that use direct or alternating current ● GG drills and larger files are used to do the coronal
to locate the apical constriction. preparation and then progressively smaller files are used
in an apical direction till the desired length is reached.
Parts of an apex locator: lip clip, file clip, electronic
device (usually with a liquid crystal display – LCD) and a Advantages:
cord connecting the three parts. ● By eliminating the coronal constrictions reduces the ef-
fect of canal curvature and gives better tactile sensation.
Indications ● It allows effective irrigation and hence the danger of
● When apical portion is obstructed by impacted teeth, pushing the debris beyond the apex is minimized.
tori, malar process, zygomatic arch, excessive bone ● Chances of changing WL are less likely during apical
density, overlapping roots and shallow palatal cavity instrumentation.
● In pregnant patients
● The risk of instrument fracture is reduced in crown-
● In disabled or heavily sedated patients
down preparation technique.
● Patients with gag reflex
● In children Q.7. Access cavity.

Contraindications Ans.
● Patients with cardiac pacemakers
[Same as SN Q.1]
● In the teeth with open apices
Q.8. WL determination.
Q.4. Importance of determining the working length of a
tooth during root canal treatment. Ans.
Ans. [Same as SN Q.5]
Topic 10
Materials in Endodontics
LONG ESSAYS:
1. What are requirements of ideal root canal filling material? Describe zinc oxide eugenol–containing root canal
sealers.
2. Classify and describe the various intracanal medicaments in root canal treatment.
3. Mention the various irrigants used in endodontics. Describe ideal properties and techniques of irrigation.
4. Classify root canal sealers. Describe zinc oxide eugenol–containing sealers. [Same as LE Q.1]
5. Classify and describe the obturation materials and sealers used in root canal treatment. [Same as LE Q.1]
6. What are requirements of ideal root canal filling material? [Same as LE Q.1]
7. Enumerate various intracanal medicaments and explain in detail mechanism of action of calcium hydroxide in
detail. [Same as LE Q.2]
8. Discuss the use of intracanal medication in affecting sterilization of root canal. [Same as LE Q.2]
9. What are various root canal irrigants? Write in detail requirements and technique of irrigation. [Same as LE Q.3]
10. What is the ideal requirement of irrigants? Describe in detail the various irrigants used during root canal treat-
ment. [Same as LE Q.3]
11. Describe in detail techniques of irrigation. [Same as LE Q.3]
SHORT ESSAY:
1. MTA.
2. CMCP.
3. EDTA.
4. Gutta-percha.
5. Sodium hypochlorite.
6. Medicaments used in endodontics. [Ref LE Q.2]
7. Ideal requirements of root canal sealers.
8. Ideal requirement of irrigants used during root canal treatment. [Ref LE Q.3]
9. Retrograde filling materials.
10. RC prep.
11. Name various chelating agents used in endodontics.
12. Mineral trioxide aggregate. [Same as SE Q.1]
13. Use of sodium hypochlorite in endodontic. [Same as SE Q.5]
14. Calcium hydroxide as intracanal medicament. [Same as SE Q.6]
15. Uses of calcium hydroxide in endodontics. [Same as SE Q.6]
16. Ideal requirements of root canal sealer. Add a note on AH 26. [Same as SE Q.7]
17. Importance of irrigation in endodontics. [Same as SE Q.8]
18. Root-end filling materials. [Same as SE Q.9]
SHORT NOTES:
1 . Pulpotomy medicaments. [Ref LE Q.2]
2. Glutaraldehyde. [Ref LE Q.2]
3. Name various pulp capping agents.
4. Obturating materials for primary teeth.
5. Sodium hypochlorite solution.
6. Composition of EDTA.
7. Calcium hydroxide.
8. Carbamide peroxide.
9. Root canal sealers. [Ref LE Q.1]
10. Grossman’s sealers.
11. Noneugenol sealers.
12. MTA. [Ref SE Q.1]
13. RC prep. [Ref SE Q.10]
14. Hank’s balanced salt solution.
15. Hydrogen peroxide.
16. Gelfoam.
17. Hermetic seal of root canal.
18. Diaket.
19. Tubliseal.
20. Ledermix.
21. Name a few intracanal medicaments. [Same as SN Q.1]
22. Root-end filling materials.
23. Core materials for obturation.
24. EDTA in endodontics. [Same as SN Q.6]
25. Role of Ca(OH)2 in endodontics. [Same as SN Q.7]
26. Ca(OH)2-based root canal sealer. [Same as SN Q.7]
27. Sealers used in endodontics. [Same as SN Q.9]
28. Composition of Grossman’s sealer. [Same as SN Q.10]
29. Mineral trioxide aggregate. [Same as SN Q.12]
30. Uses of MTA in endodontics. [Same as SN Q.12]
SOLVED ANSWERS
LONG ESSAYS: (ii) Based on composition
● Gutta-percha (GP)-based root canal sealers
Q.1. What are requirements of ideal root canal filling ● Zinc oxide eugenol (ZOE)-based root canal sealers
material? Describe zinc oxide eugenol–containing root ● Calcium hydroxide-based root canal sealers
canal sealers. ● Formaldehyde-based root canal sealers
● Glass ionomer-based root canal sealers

Ans.
● Resin-based root canal sealers
● Silicon-based root canal sealers
Requirements of an ideal root canal filling material are as

{SN Q.9} follows:
● It should be easy to introduce into the root canal.
A sealing material used along with a core obturating ● It should be easy and quick to sterilize.
material to obtain an impervious or fluid tight seal fol- ● It should be odourless and tasteless.
lowing canal preparation is known as root canal sealer: ● It should be chemically inert.
Classification ● It should be pliable and mouldable.
(i) Based on absorbability ● It should seal laterally and apically.
A. Absorbable: ● It should not shrink up on setting, i.e. it should be
l Grossman’s sealer dimensionally stable.

l Kerr sealer (Rickert) ● It should be impervious to moisture and make a her-
l Roth root canal cement metic seal.

l Tubliseal, Tubliseal EWT ● It should inhibit bacterial growth.
l Sealapex ● It should be radioopaque.
B. Nonabsorbable: ● It should not stain the tooth.
l Ketac Endo (glass-ionomer-based) ● It should not irritate the periradicular tissues.
l Diaket (polyvinyl resin) ● It should be durable.
● It should be capable of being removed easily from

l AH Plus (epoxy-type resin)
the root canal.
Materials commonly used for obturation ● Available as base and catalyst paste.
● Plastics: GP, Resilon ● Base contains zinc oxide, barium sulphate and
● Solids/metal core: Silver points, stainless steel, gold, vegetable oils while catalyst contains hydroge-
tantalum, titanium and iridium platinum nated rosin, methyl agitate, tannic acid, chloro-
● Cements and pastes: Hydron, calcium oxide, resor- thymol and salicylic acid.
cinol, MTA, calcium phosphate and gutta flow. f. Medicated variants of ZOE cements
ZOE-based root canal sealers ● It includes N2 and endomethasone.
● They were developed as an alternative to GP-based ● Due to their proven toxic and carcinogenic nature
sealers. N2 normal is no longer used.

● They were initially used to fill the entire root canals.
Q.2. Classify and describe the various intracanal medi-
● Various zinc oxide-containing sealers are as follows:
caments in root canal treatment.
a. Kerr root canal sealer
b. Tubliseal Ans.
c. Roth’s sealer
● Intracanal medicaments are defined as antiseptic agents in
d. Wach’s cement
the chemical form applied to the walls of the canal with
e. Nogenol
the objective of eliminating microorganisms present even
f. Medicated variants of ZOE cements
after cleaning and irrigation of the root canal system.
Composition of Kerr root canal sealer
● This is done to disinfect the canal when the canal is not
a. Powder
disinfected enough through only cleaning and shaping.
● Zinc oxide
● Silver Disinfection
● Oleoresins (white resins) ● It is the destruction of pathogenic microorganisms,
● Thymol iodide which presupposes to adequate removal of pulp tissue
Liquid and debris clearing and enlarging of the canal by
● Oil of clove biomechanical means and clearing of its contents by
● Canada balsam irrigation.
Properties ● The four factors either predispose the teeth to infection
● They have germicidal and adhesive properties. or counteract disinfection whether it may be of a wound
● They are radiopaque. or the root canal of a pulpless tooth, i.e. trauma, devital-
● They resorb from periapical tissues over a ized tissue, dead spaces and accumulation of exudate.
period of time. ● Disinfection of root canal is accomplished by intracanal
Disadvantages: medication.
● It stains the tooth. ● Microorganisms present in the canal can invade the
● It sets rapidly in the presence of heat and periapical tissue and may not only give rise to pain but
humidity. also destroy the periodontium including bone.
● There is increased microleakage. ● The intracanal medication reduces or eliminates micro-
● Extruded material periapically causes tissue bial flora present in the root canal.
irritation.
Functions of intracanal medicaments
b. Tubiseal
● Prevents bacterial recolonization of the root canal from
● This preparation is in the form of base and cata-
lateral canals or coronal access
lyst paste.
● Disinfection of root canal
● The mixed paste contains zinc oxide 57.4%, oleo-
● Reduces inflammation by suppression of postoperative
resins 21%–25%, bismuth trioxide and oils 7.5%,
pain
thymol iodide 3.75% and modifier 2.6%.
● Facilitation of periapical healing
● Advantage is the ease of preparation and rapid set
in the presence of moisture is the disadvantage. Requirements of intracanal medicament

c. Roth’s sealer ● It should be an effective germicide and fungicide.
● It is available as Roth’s 801 or u/p root canal ● It should have prolonged antimicrobial effect.
sealer. ● It should be active in presence of residual organic tis-
d. Wach’s cement sues like blood, serum and protein derivatives.

● It is a zinc oxide-based cement. ● It should be able to degrade residual organic and micro-
e. Nogenol bial biofilm.
● It is nonirritating and provides neutral substrate ● It should have low surface tension.
for the adhesion of composite resin. ● It is nonirritating to periapical tissues.

● It should not interfere with periapical healing. ● It has both antiseptic and obtundent properties.
● It should not induce any cell-mediated immune response. ● It is less irritating among other phenolic derivatives.
● It should not diffuse through the temporary seal.
Aldehydes
● It should not affect the physical properties of the tempo-
● Formocresol
rary access cavity restoration.
● Glutaraldehyde
● It should not stain the tooth structure.
● It should be easily placed and removed. These are water-soluble protein denaturing agents and
● It should be stable in solution. considered to be most potent of the disinfectants.
● It should be economical with a long shelf life.
(SE Q.6 and SN Q.21) {SN Q.1}
{(Types of intracanal medicaments Formocresol

l Essential oils ● Buckley, in 1906, mixed 19% formaldehyde with
l Phenolic compounds 35% cresol, dissolved in 46% glycerine and water.
l Aldehydes This is a combination of formalin and cresol in the
l Halogens ratio of 1:2 or 1:1.
● Formocresol is used as a pulpotomy agent. It is a
l Quaternary ammonium compounds
l Heavy metal salts strong disinfectant and can cause necrosis against
l Calcium hydroxide living tissue.
● It is effective in 5–7 days as a bactericidal agent
l Chlorhexidine gluconate (CHX)
l Antibiotics and corticosteroids against aerobic and anaerobic organisms.
● It is placed in the pulp chamber of the tooth with the
l Biocides
l MGP (medicated gutta-percha))} help of a cotton pellet, and the vapours penetrate the
entire root canal including the accessory canals.
Essential oils ● The disadvantage is that it is carcinogenic and muta-
● It is a weak disinfectant, antiseptic and helps relieve genic.
pain, though it is a little irritating to pulp, e.g. eugenol.
Phenolic compounds
● Phenol
{SN Q.2}
● Aqueous parachlorophenol (ACP)
● CMCP Glutaraldehyde
● Thymol ● It is colourless oil that is soluble in water and has an
● Cresol acidic reaction. 2% Glutaraldehyde solution is used
● Beechwood cresol as an intracanal medicament.
● It has a bacteriostatic, disinfectant and fixative effect.
Phenol
● It can cause hypersensitivity.
● It is a white crystalline substance derived from coal tar.
It produces necrosis of soft tissues as it is a protoplasm
poison. Halogens
● It has a pungent odour and foul taste. Sodium hypochlorite (NaOCl)
● The disinfectant action of the halogens is inversely pro-
Parachlorophenol
● Chlorine replaces one of the hydrogen atoms; hence, it portional to their atomic weights. Chlorine, present in
is substitution product of phenols. NaOCl with lowest atomic weight, has the greatest dis-
● One per cent aqueous solution of parachlorophenol has infectant action.
● NaOCl vapours are bactericidal. However, they rapidly
shown to have destructive action on microorganisms.
react with organic matter.
Camphorated parachlorophenol ● It has intense action that is short lived hence frequent
● Consists of two parts of parachlorophenol and three application is required.
parts of gum camphor that acts like a vehicle and a dilu-
ent to suppress the irritating effect of parachlorophenol. Disadvantages:
● It also prolongs the antimicrobial effect. ● Chemical reaction depletes its effect rapidly.
● It is toxic to the periapical tissues.
Cresatin
● It is a clear, stable, oily and low volatility liquid also Quaternary ammonium compounds (quats)
known as metacresylacetate. ● They have low surface tension.
● They are positively charged compounds which attract ● Vapour-forming intracanal medicament should be renewed
negatively charged microorganisms, e.g. aminoacridine once in 3–5 days.
is a mild cationic antiseptic, used more as an irrigant Adverse effects of intracanal medicaments
rather than an intracanal medicament. ● Inflammation
Disadvantages: ● Pain (flare-ups)
● Toxic ● Paraesthesia
● Delayed wound healing ● Cytotoxic effect
● Stains the tooth ● Allergy
[SE Q.6] Q.3. Mention the various irrigants used in endodontics.
Describe ideal properties and techniques of irrigation.
{Calcium hydroxide
● Calcium hydroxide is considered to be superior to Ans.
CMCP and camphorated phenol in antibacterial activity. [SE Q.8]
● Calcium hydroxide is most commonly used as an intra-
canal medicament because of its high alkalinity, tissue {The irrigants are important for removal of debris and
dissolving property, and antimicrobial effects as gram- dentinal chips produced during cleaning and shaping.
positive and gram-negative bacteria commonly found in Requirements of an ideal irrigant
infected root canals. l It should be a good tissue or debris solvent.
● Ca(OH)2 alters some biological properties of bacterial l It should be least toxic and a good lubricant.
Lipo polysaccharide (LPS), to stimulate antibody produc- l It should have antimicrobial properties.
tion by B-lymphocytes. l It should have low surface tension to promote flow
● The antibacterial effect of Ca(OH)2 is attributed chiefly into inaccessible areas.

to its high pH maintained at an extent of 10–12 or 11–13. l It should be biocompatible.
● The vehicle used to mix calcium hydroxide is glycerine- l It should be capable of removing smear layer.
polyethylene glycol, and propylene glycol plays an im- l It should be easily available, user-friendly and eco-
portant role in achieving maximum antibacterial effects nomical.

as an intracanal medicaments. l Adequate shelf life and ease of storage.
● Calcium hydroxide is available as an unstable form as an l It should not be easily neutralized in canal to retain
intercanal medicaments. This can be conveniently used. effectiveness.

Functions of an irrigant
Biological properties of calcium hydroxide l It flushes out the root canal debris.
● It is biocompatible due to low solubility in water and l It has antimicrobial property and thus decreases the
limited diffusion. bacterial count.
● Its ability to encourage mineralization.
l It penetrates the inaccessible areas of the canal-like
● It inhibits root resorption and stimulates periapical
accessory canals/lateral canals.
healing.} l It acts as a lubricant during instrumentation.
Disadvantages: l It removes the intracanal medicament in the subse-
● The difficulties encountered while removing Ca(OH)2 quent visit.

from root canal walls. l It has a bleaching effect.}
● It decreases the setting time of ZOE-based cements. Commonly used root canal irrigants
● Physiologic saline solution
Placement of intracanal medicament
● Proteolytic enzymes
● Nonvapour-forming intracanal medicaments (e.g. calcium
● NaOCl
hydroxide) are placed in the canal using paper points,
● Urea peroxide
spreader, lentulo spirals or injection syringe systems.
● H2O2
● Vapour-releasing intracanal medicament (e.g. formocre-
● CHX
sol) is placed with a cotton pellet from which excess
● Ultrasonic irrigation
medicament has been expressed.
● Ruddle’s solution
Duration of placement of intracanal medicament ● Iodine-based irrigants
● Duration of dressing depends upon the type of intraca- ● MTAD (mixture of tetracycline isomer, acid and
nal medicament used. detergent)
● Calcium hydroxide when used as a routine antibacterial ● Electrochemically activated water.
dressing can be left for a week. In weeping canals it can H2O2
be left for 2 weeks. ● It is always used in conjunction with NaOCl.
It produces nascent oxygen which carries loose de-

● Organic acids
bris to the access opening and kills strict anaerobes. ● Acids were recommended as endodontic irrigants
● H2O2 irrigation should be followed by NaOCl, be- because of their ability to softening dentine and mak-
cause nascent oxygen might cause gaseous pressure ing enlargement of canal system easier.
within the closed cavity, leading to pain, swelling or ● About 20%–30% citric acid was used to remove the
emphysema. smear layer followed by NaOCl irrigation.
● Its antibacterial property is not as good as NaOCl. ● They had toxic effects on periradicular tissues and
CHX hence not used anymore.
● Chlorhexidine is a cationic biguanide in chemical Instruments used for irrigation
form. A. Closed-end needles with a side vent:
● Commercially available oral rinse contains 0.12% ● Prorinse (25 to 28 and 3D-gauge probes)
CHX in base containing water, 11.6% alcohol, glyc- ● Max-I-probe (21-30 guage needles)
erine, flavouring agents and saccharine. B. Open-end needles without a side vent:
Advantages: ● Monoject endodontic needles (23- and 27-gauge
● Has a broad-spectrum antimicrobial action, better needles)
than calcium hydroxide which remains for longer ● Stropko irrigator: The rounded tip prevents the
time. risk of perforating the apex and allows for safe
● The antimicrobial action is best when used along irrigation of the entire length of the root canal. It
with NaOCl. prevents the solution and debris from being ex-
● Can be used in concentrations between 0.2% pressed through the periapical foramen.
and 2%. Method of using irrigants
● It is biocompatible. ● Irrigants are used in a plastic disposable syringe and
Disadvantage: needle.
● It does not dissolve pulp tissue. ● The needle should be of gauge between 21 and 30
NaOCl and should reach 2 mm short of working length/
● It is a clear, straw-coloured reducing agent which apex.
contains about 5% available chlorine. ● It should be bent to an obtuse angle for convenience
● It acts as a lubricant during instrumentation, as well that is, for easy delivery of solution and prevent the
as a solvent of vital and nonvital pulp tissue. solution from extruding beyond apex.
● Removes the smear layer along with chelating agents. ● Special needles with closed tips and lateral openings
● Excellent antimicrobial properties. can be used, e.g. Maxi-probe, Pro rinse probes.
● Destroys bacteria in two phases by penetration into These special needles prevent irrigating solution
the bacterial cell and chemical combination with the from extruding beyond the apex.
protoplasm of bacterial cell that it destroys. ● The syringe is filled by immersing the hub into the
● It is available in different concentrations 0.5% solution placed in a dappen dish and withdrawing
(Dakin’s solution), 1% (Milton’s solution), 2.5%, 3% the plunger. The needle is then attached and placed
and 5.2%. In dentistry, 3% solution is commonly in the canal.
used. ● Needle should not bind into root canal walls and
● As it is a tissue irritant it should be confined to the should be loose enough to permit return flow of the
root canal. solution.
● Bleaches the discoloured tooth to some extent. ● The return of the solution is caught on a gauze
● NaOCl is effective against stubborn microorganisms sponge placed near the access opening.
like Enterococcus faecalis, Actinomyces, Candida ● Irrigation should be done frequently with every
albicans. change of instrument till no debris is seen.
● Inexpensive, has long shelf life. ● The canal is then dried using paper points.
Bis-dequalinium acetate (BDA) ● Once the canal is dry, intracanal medicament is
● It is a disinfectant, chemotherapeutic agent, which placed and access cavity is restored with a temporary
has a low toxicity and a good lubricant. restorative material.
● It has low surface tension, so flows into the accessory
canals easily. Q.4. Classify root canal sealers. Describe zinc oxide
● It has good chelating properties.
eugenol–containing sealers.
● It exhibits low incidence of postoperative pain. Ans.
● An excellent substitute in patients allergic to NaOCl,
e.g. Solvidont. [Same as LE Q.1]

Q.5. Classify and describe the obturation materials and

● When MTA is mixed with water it forms a thick,
sealers used in root canal treatment.
grainy paste.
Ans. ● pH of the material is 10.2–12.5 in 3 h on hydration.
This is very high alkaline pH which determines the

[Same as LE Q.1]
mechanism of action of MTA.
Q.6. What are requirements of ideal root canal filling ● The material sets in presence of moisture slowly
material? within 3–4 h.

Ans.
[Same as LE Q.1] ● MTA has compressive strength of 70 MPA, excellent
sealability and very low solubility which ensures suc-
Q.7. Enumerate various intracanal medicaments and cess in pulpotomy.
explain in detail mechanism of action of calcium hy- ● It is less cytotoxic and nonmutagenic which makes it
droxide in detail. biocompatible material.
● MTA stimulates release of cytokines such as interleu-
Ans.
kin-1a, interleukin-1b and interleukin-6 which helps in
[Same as LE Q.2] bone metabolism.
Q.8. Discuss the use of intracanal medication in affect- ● It also stimulates the propagation of osteoblasts through
ing sterilization of root canal. biologically active substrate for the cells.
Ans. Q.2. CMCP.
Q.9. What are various root canal irrigants? Write in ● CMCP means camphorated para-mono-chlorophenol,
detail requirements and technique of irrigation. which was the most commonly used endodontic medi-
cament earlier.
Ans. ● Composition of CMCP: two parts of parachlorophenol
[Same as LE Q.3] and three parts of gum camphor.

● Camphor acts like a vehicle and a diluent to suppress
Q.10. What is the ideal requirement of irrigants? De- the irritating effect of parachlorophenol and also it pro-
scribe in detail the various irrigants used during root longs the antimicrobial action.
canal treatment. ● The antimicrobial action of CMCP depends on volatil-
Ans. ity of the medicament.

● Compared to other phenolic compounds, CMCP is most
[Same as LE Q.3] toxic and irritating compound followed by cresatin.
Q.11. Describe in detail techniques of irrigation. Q.3. EDTA.
Ans. Ans.
[Same as LE Q.3] ● Nygaard-Ostby suggested the use of EDTA for the first
time.
SHORT ESSAY: ● EDTA is a sodium salt of ethylene diamine tetraacetic acid.
Q.1. MTA. Composition

● It is composed of:
Ans. i. Disodium salt of EDTA
ii. Distilled water
iii. Sodium hydroxide (NaOH)
{SN Q.12}
● It is commercially available as REDTA.
● Mineral trioxide aggregate (MTA) is an alternative to ● EDTA is used in conjunction with NaOCl as a chelating
calcium hydroxide. agent.
● MTA is available in powder form consisting of trical- ● Liquid EDTA removes the smear layer of dentine and
cium silicate, tricalcium aluminate oxide and silicate increases the permeability of the dentinal tubules.
oxide. Bismuth oxide is added to make it radiopaque. ● The optimum working time with EDTA is 15 min.
● Calcium, is 33%, and phosphate, 49%, are the main ● To improve the germicidal effect, Cetavlon is added to
ions. EDTA.
Q.4. Gutta-percha. Mechanism of action:

Ans. ● It has both antimicrobial and tissue solvent properties.
● It destroys the bacteria by two phases by:
● GP is the most commonly used obturating material. i. Penetration into the bacterial cell
● Pure GP exists as alpha and beta forms. ii. Chemical combination with the protoplasm of the
● Recently low viscosity alpha forms of the GP are mar- bacterial cell that destroys it
keted as thermafil, Densfil and Microseal.
Disadvantages:
Composition: ● Unacceptable taste.
● GP: 19%–22% ● It causes irritation to eyes and may cause allergy to
● Zinc oxide: 60%–75% some patient.
● Metal salts: 1%–7% (barium salts) radio pacifiers ● It can cause mechanical breakdown of the ultrasonic
● Wax or resin: 1%–4% plasticizers units because of the corrosive nature of NaOCl.
GP is supplied as: ● It cannot be used in draining canals, as it reacts with the
● Sticks, points or cones exudates to form salts that can results in blockage of the
● Syringe material, e.g. Alpha seal canal.
● Coating on metal or plastic core, e.g. Thermophil
● GP pellets/bars, e.g. Obtura system Q.6. Medicaments used in endodontics.
● GP sealers, e.g. Chloropercha, Eucapercha Ans.
Properties of GP:
[Ref LE Q.2]
● The standardized cones are colour-coded that match the
instrument size. Uses of calcium hydroxide
● They are generally used as master cone. ● Used as direct and indirect pulp capping agent in pulp-
● Nonstandardized cones (conventional points) are more otomy procedures.
tapered and are designated as extra-fine, fine-fine, ● It is used in weeping canals.
medium-fine, fine, fine-medium, medium, large, extra- ● In treatment of phoenix abscess and treatment of
large, etc. They are used as additional or auxiliary cones. resorption.
● GP is disinfected with 2% glutaraldehyde and 2% ● It is used as a sealer for obturation and in apexifica-
chlorhexidine. tion.
● GP has to be stored in cool and dry area. Q.7. Ideal requirements of root canal sealers.
● It should not be expose to light as air and light causes
oxidation of the GP, which makes it brittle. Ans.
Advantages: A sealing material used along with a core obturating
● It is compactable and adapts to irregularities. material to obtain an impervious or fluid tight seal follow-
● It can be softened and made plastic by heat or solvents. ing canal preparation is known as root canal sealer.
● It is inert and dimensionally stable. Requirements of an ideal root canal sealers:
● It should be easy to introduce into the root canal.
● It is tissue tolerant.
● It should be easy and quick to sterilize.
● It does not discolour the tooth structure.
● It should be odourless and tasteless and chemically
● It is radiopaque.
inert.
Disadvantages: ● It should be pliable and mouldable.
● It lacks rigidity and adhesive properties. ● It should seal laterally and apically.
● It is easily displaced by pressure. ● It should not shrink up on setting, i.e. it should be di-
Q.5. Sodium hypochlorite. mensionally stable.

● It should be impervious to moisture and make a her-
Ans. metic seal.
● It should inhibit bacterial growth.
● NaOCl 5.2% is most widely used root canal irrigant. It
● It should be radioopaque and should not stain the tooth.
contains 5% available chlorine.
● It should not irritate the periradicular tissues.
● It is a clear, straw-coloured reducing agent.
● It should be durable.
● It is a solvent of vital and nonvital pulp tissue.
● It should be capable of being removed easily from root
● It removes smear layer along with the chelating agent.
● It has excellent antimicrobial property.
canal.
● It is less effective in narrow root canals than in wide root AH-26:
canals. ● AH-26 is an epoxy-based resin sealer, introduced by
● It is economical and has long shelf life. Schroeder 1957.
● Derives its name from A – Aethoxylinharz (German) for Commonly used root-end filling materials
ethoxyline base; H – hexamethylenetetramine; and 26 – ● ZOE cements (IRM and super EBA)
the test number. ● Glass ionomers
● Was initially used in Europe to completely fill the canal ● Composite resins (retro plast)
but now used extensively as a sealer. ● Resin ionomer hybrids: Composers and Geristore
● MTA
Composition
Powder Less commonly used materials
● Amalgam
l Silver powder 10.0% ● Cavity
l Bismuth oxide (radiopacity) 60.0% ● Gold foil
● Polycarboxylate cements
l Hexamethylenetetramine 25.0%
● Zinc phosphate cements
l Titanium oxide 5.0%
Properties of few commonly used root-end filling mate-
Liquid rials are as follows:
l Bisphenoldiglycidyl ether 100.0%
i. IRM
● IRM releases more eugenol than methoxy benzoic
Properties acid.
● Have good handling characteristics ● More soluble and low compressive strength.
● Can be warmed on a glass slab over an alcohol flame to ii. GIC
decrease viscosity ● It has chemical adhesion to the teeth.
● Seals well and have strong adhesive properties ● It seals better than amalgam.
● Contracts slightly while hardening ● Tissue compatibility comparable to Super EBA and
● Once set, has the lowest toxicities and is well tolerated IRM and better than amalgam.
by periapical tissues ● Disadvantage with this material is moisture contami-
nation increases solubility and reduces bone strength.

AH-plus
iii. MTA
Available as a paste–paste form:
● It is the best root-end filling material.
Composition
● It is available as grey MTA and white MTA.
Epoxide Paste Amine Paste Composition

● It is composed of the following:
i. Diepoxide i. l-Adamantane amine
● CaSiO2 (calcium silicate)
ii. Calcium tungstate ii. N,N’-dibenzyl-5-oxa-
iii. Zirconium oxide nonandiamine-l, 9 ● Bi2O3 (bismuth oxide)
iv. Aerosol iii. TCD-diamine ● CaCO3 (calcium carbonate)

v. Pigment iv. Calcium tungstate ● CaSO4 (calcium sulphate)
v. Zirconium oxide ● CaAl2O2 (calcium aluminate)
vi. Aerosol
● This is mixed with sterile water to form colloi-
vii. Silicon oil
dal gel that solidifies to form hard crystals.
● Calcium oxide in amorphous matrix (calcium,
AH-plus jet root canal sealer: phosphate, carbon, chloride and silica).
● Greater efficiency with no mixing required. ● White MTA lacks tetra calcium alumina ferrite.
● It is available as preloaded, double-barrel syringe, which
Advantages:
provides controlled homogenous mixing of both pastes ● It helps in the regeneration of cementum, help-
directly on the mixing pad or by using its adjustable ing in good apical seal (double seal).
intraoral tip for precision placement. ● It is radiopaque.
● A superior seal is achieved with excellent radiopacity
● pH 9–12.
and low shrinkage. ● The presence of blood/moisture does not alter
Q.8. Ideal requirement of irrigants used during root the property of MTA.
canal treatment. Disadvantages:
● Difficult to place the material though messing
Ans. gun can be used
[Ref LE Q.3] ● Setting time: 2 h 45 min
Q.9. Retrograde filling materials. Q.10. RC prep.
Ans. Ans.
Q.13. Use of sodium hypochlorite in endodontic.

{SN Q.13}
Ans.
● RC prep was developed by Stewart.
● It is the most commonly used chelating agent. [Same as SE Q.5]
● It contains EDTA, urea peroxide in a base of carbo-
wax or propylene glycol which acts as a lubricant. Q.14. Calcium hydroxide as intracanal medicament.
● It is insoluble in water.
Ans.
● It holds the debris in liquid suspension and helps in
floatation of dentinal debris which prevents the [Same as SE Q.6]

blockage of canal.
● The use of RC prep releases nascent oxygen that kills Q.15. Uses of calcium hydroxide in endodontics.
anaerobic bacteria, and it should be neutralized by Ans.
NaOCl and is used for 15 min.
[Same as SE Q.7]
● It removes around 100 mm of dentine from the canal Q.16. Ideal requirements of root canal sealer. Add a note
walls. on AH 26.
● The chamber is filled with the chelating agent and small
K-flex file is used to negotiate the canal. Ans.
Q.11. Name various chelating agents used in endodontics. [Same as SE Q.7]
Ans. Q.17. Importance of irrigation in endodontics.

● Nygaard-Ostby introduced chelating agents. Ans.
● They are mainly used to simplify canal preparation
especially in narrow calcified canals. [Same as SE Q.8]
● They are available in liquid and paste forms.
Q.18. Root-end filling materials.
Mechanism of action:
Ans.
● It forms calcium chelate with the calcium ion of
dentine, making the dentine more friable and easier to [Same as SE Q.9]
instrumentation.
Various chelating agents available:
Liquid chelators
SHORT NOTES:
i. Calcinase
Q.1. Pulpotomy medicaments.
ii. REDTA
iii. EDTAC and DTPAC Ans.
iv. EDTA-T
[Ref LE Q.2]
v. EGTA (ethylene glycol tetraacetic acid)
vi. CDTA (cyclohexane diamine tetraacetic acid) Q.2. Glutaraldehyde.
vii. Salvizol
viii. Decal Ans.
ix. Tubulicid plus [Ref LE Q.2]
x. Hypaque
Q.3. Name various pulp capping agents.
Paste chelators
i. Calcinase slide Ans.
ii. RC prep Various pulp capping agents available are as follows:
iii. Glyde file ● Calcium hydroxide
iv. File care EDTA ● ZOE
v. File-EZE ● Corticosteroids and antibiotics
vi. HEBP (hydroxyethylidene bisphosphonate) ● Tricalcium phosphate cement
Q.12. MTA. ● MTA
Ans. Q.4. Obturating materials for primary teeth.
[Same as SE Q.1] Ans.
Obturating materials commonly used in primary teeth: Q.8. Carbamide peroxide.

● Calcium hydroxide
Ans.
● MTA
● ZOE ● Carbamide peroxide is also known as urea hydrogen

peroxide.
The most commonly used obturating material is cal-
● Available in concentrations of 3%–4.5%, and 10% com-
cium hydroxide.
mercial preparation.
Calcium hydroxide ● A solution of 10% carbamide peroxide breaks down
● It is available as powder or settable and nonsettable into urea, ammonia, carbon dioxide and approximately
pastes. 3.5% H2O2.
● Powder can be mixed with aqueous/nonaqueous vehicles. ● Gel preparation includes glycerine or propylene glycol
● It has alkaline pH of 11. and flavoured argents.

● It is highly soluble, weak material which deteriorates
Q.9. Root canal sealers.
and disintegrates over a period of time.
● It has good antibacterial property, and is not much Ans.
expensive.
[Ref LE Q.1]
Q.5. Sodium hypochlorite solution.
Q.10. Grossman’s sealers.
Ans.
Ans.
● NaOCl solution is a clear, straw-coloured reducing
Commonly used Grossman’s sealer:
agent which contains about 5% available chlorine.
● Contains powder and liquid
● It acts as a lubricant during instrumentation and as well
● Powder contains zinc oxide 42%, staybelite resin 27%,
as a solvent of vital and nonvital pulp tissue.
bismuth subcarbonate 15%, barium sulphate 15% and
● Removes smear layer along with chelating agents.
sodium borate 1%
● Excellent antimicrobial properties.
● Liquid contains eugenol 100%
● It is available in different concentrations 0.5% (Dakin’s
solution), 1% (Milton’s solution), 2.5%, 3% and 5.2%. Q.11. Noneugenol sealers.

In dentistry, 3% solution is commonly used. Ans.
Q.6. Composition of EDTA. ● Noneugenol sealers are developed to overcome the irri-
tating quality of eugenol.

Ans.
● It contains base and accelerator.
● Nygaard-Ostby first suggested the use of EDTA. ● Base contains zinc oxide and barium sulphate; and ac-
● It is a disodium salt of EDTA. 15% EDTA has a pH celerators contain hydrogenated rosin, methyl abietate,
of 7.3. lauric acid chlorothymol and salicylic acid.
● Commercially available as REDTA. ● They are less irritating and improve sealing efficiency
● Liquid form when used along with NaOCl helps in per- with time.
meability of dentinal tubules by removal of smear layer.
Q.12. MTA.
● EDTA removes the calcified/inorganic material, and
NaOCl removes the organic debris. Ans.

● Optimum working time is 15 min.
[Ref SE Q.1]
Composition:
Q.13. RC prep.
● Disodium salt of EDTA
● Distilled water Ans.
● NaOH [Ref SE Q.10]
Q.7. Calcium hydroxide. Q.14. Hank’s balanced salt solution.
Ans. Ans.
● Calcium hydroxide was introduced in 1920. ● It is a storage media for avulsed tooth.
● It is available as powder or settable and nonsettable ● It contains NaCl2, D-glucose, KCl, NaOH, CaCl2, KOH
pastes. and MgCl2.
● It has alkaline pH of 11.
Q.15. Hydrogen peroxide.
● It has good antibacterial property, and is economical.
● It is used as a sealer in root canal in endodontics. Ans.

● H2O2 is always used in conjunction with NaOCl. ● Advantage is the ease of preparation, and rapid set in the
● It produces nascent oxygen which carries loose debris presence of moisture is the disadvantage.
to the access opening and kills strict anaerobes. Q.20. Ledermix.
● H2O2 irrigation should be followed by NaOCl, because
nascent oxygen might cause gaseous pressure within the Ans.

closed cavity, leading to pain, swelling or emphysema. ● Antibiotic and corticosteroids are available commer-
● Its antibacterial property is not as good as NaOCl. cially as Ledermix.
● Ledermix paste is a combination of tetracycline antibi-
Q.16. Gelfoam.
otic, demeclocycline HCl and a corticosteroid, triam-
Ans. cinolone acetonide in a polyethylene glycol base.
● Gelfoam is hard, resorbable, water insoluble gelatin- Q.21. Name a few intracanal medicaments.
based sponge that becomes soft on contact with
blood. Ans.
● Mechanism of action: It stimulates intrinsic clotting [Same as SN Q.1]
pathway that results in platelet disintegration and the
release of thromboplastin, which stimulates the forma- Q.22. Root-end filling materials.
tion of thrombin, thus reducing postsurgical bleeding. Ans.
● Initially it shows greater inflammation, but ultimate
bone healing is good. Materials commonly used for root-end filling are as
follows:
Q.17. Hermetic seal of root canal. ● ZOE cements (IRM and super EBA)
● Glass ionomers
Ans.
● Composite resins (retro plast)
● An airtight seal obtained through proper obturation of ● Resin ionomer hybrids
the root canal is known as hermetic seal of root canal. ● MTA
● It is an earlier concept.
● It prevents seepage of microorganisms in the root canal. Less commonly used materials:
● For a successful root canal treatment a good apical seal ● Amalgam
● Cavity
is necessary.
● GP
● Various root canal sealers are available to obtain her-
● Gold foil
metic seal.
● Polycarboxylate cements
Q.18. Diaket. ● Zinc phosphate cements
Ans. Q.23. Core materials for obturation.
● Diaketparation is in form of powder and liquid. Ans.
● Powder contains zinc oxide and bismuth phosphate.
Core materials used for obturation are as follows:
● Liquid contains, 2,2-dihydroxy-5,5-dichloro diphenyl
● Plastics: GP, Resilon
methane, propionyl acetophenone, triethanolamine, ca-
● Solid/metal core: silver points, stainless steel, gold,
proic acid, copolymers of vinyl acetate, vinyl chloride
tantalum, titanium and irridio-platinum
and vinyl isobutyl ether.
● Cement and pastes: Hydron, calcium oxide, resorcinol,
Properties: good adhesion, low solubility, sets quickly MTA, calcium phosphate and GP.
and superior tensile strength.
Q.24. EDTA in endodontics.
Disadvantages:
● Highly toxic Ans.
● Greater tendency towards fibrous encapsulation if
[Same as SN Q.6]
extruded
Q.25. Role of Ca(OH)2 in endodontics.
Q.19. Tubliseal.
Ans.
Ans.
[Same as SN Q.7]
● Tubliseal preparation is in the form of base and catalyst
pastes. Q.26. Ca(OH)2-based root canal sealer.
● The mixed paste contains zinc oxide 57.4%, oleo resins
Ans.
21%–25%, bismuth trioxide and oils 7.5%, thymol io-
dide 3.75% and modifier 2.6%. [Same as SN Q.7]
Q.27. Sealers used in endodontics. Q.29. MTA.

Ans. Ans.
[Same as SN Q.9] [Same as SN Q.12]
Q.28. Composition of Grossman’s sealer. Q.30. Uses of MTA in endodontics.
Ans. Ans.
Topic 11
Obturation of Root Canal
LONG ESSAYS:
1 . Classify obturating methods. Describe lateral condensation method of obturation of root canal.
2. Describe the indication, contraindication, advantages and disadvantages of gutta-percha points as a root canal
filling material.
3. Define obturation. Describe in detail lateral condensation technique of root canal obturation. [Same as LE Q.1]
4. Give the list of root canal obturating materials and discuss lateral condensation technique.
Enumerate various methods of obturations of root canal system. Describe lateral condensation method. [Same as LE Q.1]
5. Discuss the various methods of root canal obturation. [Same as LE Q.1]
6. Define obturation. Describe in detail the thermoplasticized gutta-percha technique for obturation. [Same as LE Q.2]
SHORT ESSAYS:
1 . Describe in detail any good technique to obtain satisfactory apical seal of root canal.
2. Lateral condensation. [Ref LE Q.1]
3. Classification of root canal obturating materials.
4. McSpadden compaction and obtura III system.
5. Sectional method of obturation.
6. Lateral condensation technique. [Same as SE Q.2]
SHORT NOTES:
1. McSpadden compactor. [Ref SE Q.4]
2. When to obturate the root canal.
3. Composition of gutta-percha cone. [Ref SE Q.3]
4. Later condensation technique. [Ref LE Q.1]
5. Silver points.
6. Section technique of obturation. [Ref SE Q.5]
7. Enumerate various methods of obturations of root canal system. [Ref LE Q.1]
8. Inverted cone method.
9. Gutta-percha. [Same as SN Q.3]
10. Lateral condensation. [Same as SN Q.4]
11. Cold lateral condensation. [Same as SN Q.4]
1 2. Sectional method of obturation. [Same as SN Q.6]

13. Various obturation techniques and their advantages. [Same as SN Q.7]
SOLVED ANSWERS
LONG ESSAYS: ii. System B compaction
Q.1. Classify obturating methods. Describe lateral con- iii. Sectional compaction
densation method of obturation of root canal. iv. Lateral/vertical compaction
a. Endotec II
Ans. v. Thermomechanical compaction
● Obturation is defined as three-dimensional (3D) filling a. Microseal system, Engine-plugger, Maillefer
of an entire root canal system as close to the cemento- condenser
dentinal junction so as obtain an impermeable seal at the b. Hybrid technique
apex. c. JS–Quick-fill
d. Ultrasonic plasticizing
Objectives of obturation D. Thermoplasticized GP
● To eliminate all the leakage from periradicular tissue i. Syringe insertion
into the root canal. a. Obtura
● To create a favourable environment periapically for
b. Inject-R-Fill, backfill
healing tissue. ii. Solid-core carrier insertion
● To seal root canal so that transportation of bacteria can-
a. Thermafil and Densfil
not occur. b. Soft core and 3D GP
Material used for obturating root canal c. Silver points
i. Plastics: Gutta-percha (GP), Resilon. II. Apical third filling
ii. Solids/metal core: Silver points, stainless steel, gold, a. Light-speed SimpliFill
tantalum titanium and iridium platinum. b. Dentine chip
iii. Cements and pastes: Hydron, calcium, resorcinol, Min- c. Calcium hydroxide
eral Trioxide Aggregate (MTA), calcium phosphate and III. Injection or spiral filling
gutta flow. a. Cements
b. Pastes
Classification of various methods of obturating c. Plastics
techniques d. Calcium phosphate
[SE Q.2]
{There are two basic procedures: According to Cohen
. Lateral compaction of cold GP.
A i. The cold compaction of GP.
B. Vertical compaction of warm GP.} ii. The compaction of GP that has been heat softened in
canal and cold compacted.
iii. The compaction of GP that has been thermoplasticized,
injected into canal and cold compacted.
{SN Q.7}
iv. The compaction of GP that has been placed in canal
Ingle’s classification of various obturating tech- and softened through mechanical means.
niques
I. Solid-core GP with sealants [SE Q.2]
A. Cold GP points {Lateral condensation technique for obturating root
i. Lateral compaction canal:
ii. Variations of lateral compaction
B. Chemically plasticized cold GP
{SN Q.4}
Essential oils and solvents
a. Eucalyptol ● Most commonly used obturating technique.
b. Chloroform ● The root canal is coated with sealer, followed by
c. Halothane which placement of a measured point that is laterally
C. Canal warmed GP compacted by spreader with slight vertical pressure
i. Vertical compaction to make room for additional accessory points.
● At canal orifice the mass is severed with a hot instru- clinician to work with ample of working time
ment and vertical compaction is done with a large and minimal dimensional changes.
plugger. ● It should string out at least an inch when the
● The entire procedure is completed in five steps: spatula is lifted from the mix or it should be
i. Primary point size selection held for 10 s on an inverted spatula without
● This step is also known as master-cone selection. dropping off.
● The size usually matches the size of last instru- ● Sealer can be placed in the canal in five different
ment used at the apical constriction (master apical ways:

file) as GP cones comes in standardized sizes and a. Master cone (GP) can be used as a spreader.
colour code.} b. File or reamer used in anticlockwise and
Visual test pumping action.
● The point is measured and marked and the c. Spreader (nickel–titanium or stainless steel)
master cone is tried in the wet canal which of appropriate taper.
should coincide with the reference point in the d. Lentulo spirals.
tooth. e. Ultrasonic file without coolant.
● The next (bigger) size GP should be used if v. Accessory point selection and placement
point goes beyond working length, if that point ● Accessory points are selected that are the same
does not reach the working length and the tip size or smaller in diameter or taper than the
of the previous GP should be cut off with a BP spreader size and are placed in obturating canal
blade or gutta cut and not with a scissor. to obtain a cohesive filling.
Tactile sensation Advantages of lateral compaction
● When the canal is prepared especially with ● Simplest method
certain amount of parallelism at the apical two- ● No need for special instrument
third, then some amount of pulling force is re- ● Provides length control
quired to dislodge it, the resistance to removal Disadvantages of lateral compaction

of the GP is known as TUGBACK. ● Does not fill canal irregularities
● The GP should never be loose. ● Does not produce homogeneous mass}
Patient response Q.2. Describe the indication, contraindication, advan-

● When we cannot be determined with a radio-
tages and disadvantages of gutta-percha points as a root
graph or tactile sensation, this is a good test to canal filling material.
confirm.
● The patient will complain of pain, if anaesthe- Ans.
sia is not given and master cone goes beyond ● Obturation is defined as a 3D filling of an entire root
the apical constriction. canal system as close to the cementodentinal junction so
Radiographic test as obtain an impermeable seal at the apex.
● This is the final test and the GP point should be
0.5–0.75 mm short of radiographic apex. GP
● GP is the most commonly used obturating material.
● It is a hydrocarbon resembling a rubber in origin.
[SE Q.2]
● Pure GP is not used; it exists as alpha and beta forms.
{ii. Selection of spreader size and length ● Alpha form is obtained from the tree and beta form is
● Spreaders are available in different sizes and commonly supplied as the GP points.
tapers. ● Recently low viscosity alpha forms of the GP are mar-
● The spreaders size should be such that, it is loose keted as Thermofil, Densfil, Microseal.
and reaches 1 mm within the working length and
Composition
should not penetrate beyond the apex.
● Zinc oxide 66%
● The force applied by the spreader should be
● GP 20%
against the GP, so that it is absorbed by the GP
● Heavy metal surfaces 11%
and not the wall, as it may fracture the tooth.
● Waxes or resins 3%
iii. Drying the canal
● Canal is dried using paper point and not with air Various forms in which it is available:
syringe. i. GP flow
● Large paper points are followed smaller paper ii. GP points
points until full length is achieved. iii. GP sealers
iv. Mixing and placement of the sealer iv. GP syringes
● The sealer should be mixed in a sterile glass v. GP pellets/bars
slab to a creamy consistency, which allows the vi. Pre-coated core carrier GP
Standardized/core points ● This technique uses controlled temperature

● The standardized sizes coordinate with the ISO sizes of ranging from 160 to 200°, and the size of the
the root canal file. needle was reduced to 20 and 23 gauge.
● Primarily used as the main core material for obturation. ● The canal should be continuously tapering fun-
nel from the apical matrix to canal orifice which

Nonstandardized/auxiliary points
enhances the flow of GP.
● They are more tapered from the tip to top and are used
Method
as secondary and auxiliary cones.
● This system has temperature control panel and a
● These are usually designated as extra-fine, fine-fine,
temperature display.
medium-fine, fine-medium, medium, medium-large,
● It has GP gun into which cannulas containing
large and extra-large.
the GP extrudes through the flexible needle at-
● GP may come in either pellet form or in cannulas for the
tached to the gun.
injectable thermoplastic obturation techniques.
● This needle should be pre-fitted in the canal so
● It is available in heatable syringes for thermomechani-
that it is 3.5–5 mm short of the apex.
cal techniques.
● Small amounts of sealers like AH Plus or Seala-
● GP cones have become available containing an iodo-
pex are used and the canal is slowly filled.
form component called medicated GP, which enhances
● The GP is compacted vertically and after which
the antimicrobial properties.
a radiograph is taken.
Properties Advantages:
● The standardized cones are colour-coded that match the ● It is helpful in filling all accessory canals.
instrument size. ● It is used in obturating C-shaped canals and
● They are generally used as master cone. canals with internal resorption.
● GP is disinfected with 2% glutaraldehyde and 2% Disadvantages:
chlorhexidine. ● The GP may flow beyond the apex.
● GP has to be stored in cool and dry area. ii. Ultrafil 3D

● It should not be exposed to light as air and light oxides ● It is thermoplastic GP injection technique.
the GP, which makes it brittle. ● Temperature used is 70°.
● Types of GP used are

Advantages:
i. Regular set which has low viscosity – sets at
● It is least toxic or inert and radiopaque.
30 min
● It is tissue tolerant or nonallergic.
ii. Firm set which has low viscosity – sets in 4 min
● It does not encourage bacterial growth.
iii. Endo set has higher viscosity – sets in 2 min
● It will not discolour the tooth structure.
● It does not shrink after insertion unless it is plasticized Q.3. Define obturation. Describe in detail lateral con-
by a solvent/heat. densation technique of root canal obturation.
● It can be easily sterilized and easily removed from root
Ans.
canal when necessary.
● As it is plastic, it adapts and seals better with irregulari- [Same as LE Q.1]
ties and contour of canal.
Q.4. Give the list of root canal obturating materials and
Disadvantages: discuss lateral condensation technique.
● It can become brittle with age. Enumerate various methods of obturations of root canal
● It can be easily displaced by pressure. system. Describe lateral condensation method.
● It lacks adhesive quality hence used with a sealer.
● It lacks rigidity so difficult to place in narrow canals and Ans.
canals with extreme curvature. [Same as LE Q.1]
Technique of obturating root canal with GP Q.5. Discuss the various methods of root canal obturation.
i. Thermoplasticized injectable GP obturation
Using beta phase Ans.
● Obtura
[Same as LE Q.1]
● Obtura II
Using alpha phase Q.6. Define obturation. Describe in detail the thermo-
● Ultrafil 3D plasticized GP technique for obturation.
Using obtura II
Ans.
● GP is heated externally and injected or placed in
the canal. [Same as LE Q.2]

SHORT ESSAYS: Q.3. Classification of root canal obturating materials.

Q.1. Describe in detail any good technique to obtain Ans.
satisfactory apical seal of root canal. Materials used for obturation of root canal
Ans. . Plastics: GP, Resilon
A
B. Solids/metal core: Silver points, stainless steel, gold,
● Most of the treatment failures are due to deficiency in tantalum, titanium and iridium platinum
obturation. C. Cements and pastes: Hydron, calcium oxide, resorcinol,
● Bacteria, tissue debris and other irritants are usually not
MTA, calcium phosphate and gutta flow
totally removed during cleaning and shaping of the ca-
nal. These create a potential source of irritation that may GP
lead to failure of root canal. ● It is a trans-isomer of polyisoprene.
● A good apical seal is necessary for a successful root ● Pure GP exists as alpha and beta forms.
canal treatment. ● Alpha form is obtained from the tree, and beta form is
● A root canal sealer is used along with a core obturat- commonly supplied as the GP points.
ing material to obtain an impervious seal (fluid tight ● Recently low-viscosity alpha forms of GP are marketed
seal) following canal preparation. as Thermofil, Densfil, Microseal, etc.

Vertical compaction technique of obturation
Procedure
i. Dry the canal with paper points. {SN Q.3}
● Prefit the three vertical pluggers. Composition
First: Widest plugger – reaching 10 mm depth from ● GP: 19%–22%.
the orifice. ● Zinc oxide: 60%–75%.
Second: Middle plugger – reaching 15 mm depth ● Metal salts: 1%–7% (barium salts) radiopacifiers.
from the orifice. ● Wax or resin: 1%–4% plasticizers.
Third: Apical plugger – 3–4 mm short of apical
terminus.
● A root canal sealer is used along with a core obtu-
● The GP points become brittle as they age due to oxida-
rating material to obtain an impervious seal (fluid
tion, when exposed to artificial light and when ZnO
tight seal) following canal preparation.
level is increased.
● Select the master GP cone that fits 0.5–1.0 mm
short of the working length. Medicated forms of GP

● Coat the canal with sealer and place the GP with ● Iodoform-containing GP: This provides an antibacterial
sealer in the canal. effect against apical and coronal leakage.
● Cut the cone at the incisal reference point. ● Calcium hydroxide-containing GP: A GP with high
ii. Heat transfer instrument – Touch ‘n Heat 5004 is calcium hydroxide content (40%–60%) has been used
heated to cherry red (42–52°C), and placed in coronal as an intracanal medicament and in cases of apexifica-
third of the root canal for 2–3 s and then withdrawn in tion, which becomes ineffective once calcium hydrox-
a slightly circular wiping motion to remove a portion ide has leached out.
of the GP. ● Chlorhexidine diacetate-containing GP: GP matrix em-
iii. To compact the warmed GP, widest plugger should be bedded with 5% chlorhexidine diacetate.
used. ● It is used as an intracanal medicament.
iv. Second, heat wave begins by introducing the heat car- ● Tetracycline-containing GP.
rier back for 2–3 s and 3–4 mm of the GP is removed. ● Electro-conductive GP (used along with apex locators).
v. Mid root lateral canal is obturated using midsized

Resilon
coated plugger with vertical and lateral pressure.
● Resilon is a resin-based obturating system introduced
vi. Third, heat wave is used for 2–3 s and 3–4 mm of the
by Martin Trope, e.g. epiphany and real seal.
GP is removed.
● Resin core material is composed of polyester, dysfunc-
vii. Smallest plugger compact the GP into the apical
tional methacrylate resin, bioactive glass and radi-
preparation. Accessory canal is obturated.
opaque fillers (bismuth oxychloride).
Q.2. Lateral condensation. ● The core material is available as conventional cones,
standardized cones.
Ans.
● They can be placed using lateral compaction technique,
[Ref LE Q.1] vertical compaction technique or thermoplastic technique.

● Resin sealant is mixed to the correct consistency and ● The plastic GP dissolves laterally and apically because
applied to the root canal wall using paper point, Resilon reversed flutes on the compactor blade push the soft-
point or lentulo spiral. ened GP forward and sideways even while withdrawing
● The canal is obturated with Resilon points using lateral the rotation of blade from the canal.
compaction, vertical, thermoplasticized method. ● The most important experience is the feel of the instru-
● Light curing is done from coronal surface which results ment backing out. This indicates the canal is completely
in polymerization of sealer. filled.
● The Resilon core bonds to the resin sealer which micro-
Advantages:
mechanically bonds to the etched walls.
● Time saving, rapid filling of canals and dense 3D obtu-
Metallic filling materials ration is obtained.
● Silver points are the most commonly used solid-core
Disadvantages:
metallic filling material. Other materials used are gold,
● The technique cannot be used in narrow root canals.
iridium platinum and tantalum.
● Frequent breakage of compactor blades.
● Silver points corrode when they come in contact with
● Shrinkage of the GP set filling.
tissue fluids, which then appear black.
● It is available in standard sizes. Q.5. Sectional method of obturation.
● They are indicated in matured teeth with small, calcified
canal, round, straight canal and curved canals. Ans.

● They are contraindicated in open apex and large ovoid
canals. {SN Q.6}

Q.4. McSpadden compaction and obtura III system. ● Sectional obturation is used where the tooth requires
a post and core.
Ans.
● It uses a pre-fit plugger which fits loosely in the canal
and extends within 3 mm of the working length.

{SN Q.1} ● The master cone is fitted to within 1.0 mm of the
working length and is confirmed using a radiograph.

● McSpadden introduced a rotary device known as
● The GP is removed and cut such that only apical 3–4
McSpadden compactor.
mm of the GP is remaining.
● It is a latch type attachment for handpiece. It resem-
● The plugger is warmed on an alcohol flame and the
bles H-file with inverted blades (reverse H-files).
point is luted to the plugger.
● It was used at a speed between 8000 and 20,000 rpm.
● GP is warmed by passing through an alcohol flame
● Variations in McSpadden compactor are Gutta-
and then coated with sealer.
condensor, Engine-plugger, Microseal system, ther-
● The warm GP is then placed and packed into place.
momechanical solid core obturation.
● A radiograph confirms the apical filling.
● McSpadden technique uses a calibrated stainless
● The disadvantage is poor control of the small section
steel McSpadden compactor.
of GP, resulting in an unpredictable outcome.
● Heat is created by rotating a compactor in a slow
speed contra-angled handpiece at 8000–10,000 rpm

along the sides of the GP cone inside the root canal. Q.6 Lateral condensation technique.
● Heat generated by the compactor plasticizes the GP
Ans.
and compacts the root canal.
● Used in straight canals only because the compactor [Same as SE Q.2]
blade breaks if it binds. Method was popular for fill-
ing teeth with resorptive defects.
SHORT NOTES:
Q.1. McSpadden compactor.
McSpadden technique/thermomechanical technique
● Compactor blade is selected according to the width and Ans.
length of the prepared canal.
[Ref SE Q.4]
● Root canal is prepared following step-back method. GP
is inserted into canal short of root apex. Q.2. When to obturate the root canal.
● Compactor blade is inserted between GP and the canal
Ans.
wall and is restricted in the canal within 1.5 mm of the
root apex with the help of rubber stops which prevents A root canal is ready to obdurate when:
forcing of thermoplasticized GP through the root apex. ● The tooth is asymptomatic.
● Canal is dry and no foul odour should be present. Q.8. Inverted cone method.
● Canal is cleaned and shaped to an optimum size.
Ans.
● The canal culture is negative.
● There should be reduction in number of microorganisms. Inverted cone technique
● Temporary restoration with intracanal medicaments Significance:
should be intact. ● It is used when there is wide open apex.
● There should be no active periapical pathology.

Technique:
Q.3. Composition of gutta-percha cone. ● GP cone is selected.
● Butt end of cone is inserted first.
Ans.
● Additional cones are packed around it in the usual
[Ref SE Q.3] manner.
Q.4. Later condensation technique. Q.9. GP.
Ans.
Ans.
[Ref LE Q.1]
[Same as SN Q.3]
Q.5. Silver points.
Q.10. Lateral condensation.
Ans.
Ans.
● Silver points were introduced when 2D sealing of root
canal started. [Same as SN Q.4]
● Silver points are the most commonly used solid-core Q.11. Cold lateral condensation.
metallic filling material.
Ans.
Indications:
● In matured teeth with small, calcified canal
[Same as SN Q.4]
● In round, straight canal and curved canal Q.12. Sectional method of obturation.
Contraindications: Ans.
● Open apex
● Large ovoid canals
[Same as SN Q.6]
Q.6. Section technique of obturation. Q.13. Various obturation techniques and their advan-
tages.
Ans.
[Ref SE Q.5] Ans.
Q.7. Enumerate various methods of obturations of root [Same as SN Q.7]

canal system.
Ans.
[Ref LE Q.1]
Topic 12
Postendodontic Restorations
LONG ESSAYS:
1 . Enumerate indications, contraindications and technique of post and core.
2. What are the principles in covering the restoration from endodontically treated teeth? Describe the restoration
given for endodontically treated tooth.
SHORT ESSAYS:
1 . Tooth preparation for post and core with adequate clinical crown. [Ref LE Q.1]
2. Why are postendodontics restorations necessary?
SHORT NOTES:
1 . Core material.
2. Classification of post.
SOLVED ANSWERS
LONG ESSAYS: Requirements for fabrication of cast post
l Materials used.
Q.1. Enumerate indications, contraindications and tech- l Postspace preparation.
nique of post and core. l Tooth preparation with adequate and inadequate
tooth structure.
Ans. l Fabrication of wax pattern: either direct or indirect.
Dowel or post is a rigid restorative material placed in Materials used for cast post
the root canal of a pulpless tooth or an endodontically l Endopost: Precious metals with high fusing points
treated tooth with reduced coronal tooth structure. available in size 70–140 and may be cast with gold
Core is the supragingival portion of restoration that re- or other precious metals.
places the bulk of lost coronal tooth structure for additional l Endo dowel: These are expensive plastic pins in
retention of crown. standardized sizes 80–140, which burn out of the

Ideal characteristics of the post investment giving rise to one metal casting, it is
l Protection of the root by distributing forces along very expensive.
length of the root l Parapost: They have no taper and are standardized in
l Adequate retention within the root size.

l Should give the core and crown maximum retention The canal is prepared by the following means to
l Should give maximum protection to the crown mar- receive a post:
gin cement seal ● Hot pluggers.
l Pleasing aesthetics in case of anterior teeth ● Rotary drills with noncutting tip (Gates-Glidden/
l Radiopaque Peeso reamers) are used.

l Should be biocompatible ● Touch ‘n Heat 5004.
l Should have optimum resilience, stiffness, flexibility ● H-files.
and strength Preparation of tooth varies based on the amount of

l Should be retrievable clinical crown present
Uses of dowel post
l It retains the restoration when sufficient tooth struc- [SE Q.1]
ture is not present. { a. Tooth preparation with adequate clinical crown
l It protects the remaining tooth structure by directing ● Here the occlusal/incisal height is adequately re-
all the occlusal and lateral forces apically, and it also duced to ensure a core of at least 2–5 mm long is
provides sufficient rigidity under load thus maintain- placed for convenient handling and casting purpose.
ing marginal integrity of the final restoration. ● The tooth surrounding canal should have suffi-
Indication of posts in different situations cient bulk, to ensure a strong working model
l Roots having thin radicular dentine due to extensive and possible fracture of the preparation when
caries, overinstrumentation of walls and internal trying in and cementing.
walls are built up with composite resin and cured with ● The occlusal/incisal edges are given a 45° angle
light transmitting post, to form a postspace for rigid so as to guard the preparation against fracture
metal post. This makes the root stronger by 50%. from the lateral forces of mastication.
l Rigid post should be used in teeth with less than 3–4 ● A fabricated full crown is then placed over the
mm of vertical height or less than 25% of remaining cemented post and core.}
tooth structure. Tooth preparation with an inadequate clinical crown
l In cases with 25%–50% remaining tooth structure, l In these situations, the canal, pulp chamber and extra-
nonrigid post should be used. coronal portion are also to be depended up on for
retention. The unsupported dentine, caries and old Cementation

restoration are removed, with the walls made as paral- l Temporary filling is removed then the preparation is
lel as possible for maximum retention. dried using air/paper points.

l All internal designs should be smooth and rounded l Try in the post/core. It should not be forced.
with sound dentine included within the core. l Check for the clearance of opposing teeth and on the
l Ferrule principle, i.e. reverse bevel should be used in lateral aspects.

the core to decrease the stress. l The cements used are zinc phosphate, zinc polycar-
l Use grooves or key-ways as antirotational devices. boxylate, glass ionomer cement (GIC) and resin
These are called cloverleaf preparation. This pre- cement.
vents twisting of the core. l Mix cement and coat the walls then the post and core
l When aesthetics is considered, the shoulder should is gently placed or seated by hand pressure.
be carried subgingivally; otherwise it can be placed l Grooves may be placed on the core for better reten-
on core during wax up. Adequate opaquer must be tion of the final crown.
used when ceramic crown is to be used. l The crown is then prepared on the core.
Impression for post and core

Q.2. What are the principles in covering the restoration
A. Indirect technique
from endodontically treated teeth? Describe the resto-
● Since the canal-enlarging instrument ends in as a
ration given for endodontically treated tooth.
point, the preparation for post is not flat. So, the
post with a bevel is preferred. The endo dowel has Ans.
a bevel. When other types are used, gentle bevel
Principles involved in selecting the restoration for an
can be placed using Joe Dandy disc/sandpaper.
endodontically treated tooth:
● The selected post should be seated to correct post
i. Post design
length and should resist removal with fingers.
ii. Post length
● The selected post is then bent at the occlusal end
iii. Post diameter
and a lubricant painted on the portion to be within
iv. Number of posts
the canal to facilitate easy removal.
v. Cement used
● Gingival retraction is done.
● Rubber-base impression material is used with a I. Post design

syringe and the material is placed at the orifice a. Custom-made
and around the preparation. Then a regular tray ● These may be fabricated by direct or indirect
material is used to make an impression. The post wax pattern.

should be picked up along with the impression. ● Inlay wax/cold cure is used to produce negative
● Opposite arch impression and bite registration are replica of canal.

taken, if post/core and crown are to be constructed ● Processed in lab using nonprecious casting
from one working model. alloy.

● It is then sent to the lab where working model/cast Advantages:
is prepared for wax pattern. ● It has a better fit and no stress on installation.
B. Direct technique ● It is the first choice in severely flared canals.
● Endopost/endo dowel is used with either inlay ● It is adaptable to large, irregularly shaped canal
wax/dipolymer acrylic resins for core pattern. and orifice.

● The canal wall is lubricated, wax/resin is applied ● It is a single metal for post and core, therefore
on post material and impression of the canal is stronger at interface.

taken. Then core build-up is done. Disadvantages:
● The protruding portion of the post is used as a sprue. ● It acts as a wedge.
● It is then invested and cast using a casting ring. ● They are not as retentive as parallel posts.
After casting, the ring is allowed to cool. The ● Expensive.
casting is separated from the investment. ● Casting failures may occur due to porosity
● The excess post is trimmed and core portion is which results in weak post.
polished. ● It is time-consuming as it involves more number
● The post portion should not be altered except for of sittings.

the removal of the excess material. ● They may require the removal of additional
● Dry cotton is placed in the chamber after taking tooth structure.
the impression and a temporary filling is given. ● Temporization between appointments difficult.
b. Prefabricated posts l Increased post length increases retention irre-

Various types are as follows: spective of the post design, decreases stress and
● Parallel, tapered, parallel with tapered end increases resistance to fracture. So, post length
● Smooth surface, serrated, threaded (threaded is should be increased without changing the apical
also called active posts) seal or risking perforation.
● Hollow, solid, split l It should be half the bone-supported length of the root.
● May or may not have vents l It should lie within the long axis of the tooth.
● Combination of above III. Post diameter

Examples of above combinations are: l The post should be on an average of 1 mm in diameter.
● Kerr Endopost: tapered, smooth l Increased diameter may weaken the tooth, so the
● Whaledent post: parallel, serrated, vented diameter should be less without compromising on
● Dentatus screw: tapered, self-threading post the strength. We should see that root should have
● Radix/Kurer anchor: parallel, threaded more than 1 mm of tooth structure around the post.
● Flexi post: parallel, threaded, split shank IV. Number of posts
Advantages: l More than one post can be placed in teeth with
● It is simple to use, less time-consuming and re- multiple roots.

quires only a single appointment. V. Cement type
● It is easy to temporize and cost-effective. l Usually cements are used to lute a post in place,
● It is remarkably stronger. e.g. zinc phosphate, zinc polycarboxylate, GIC and

Disadvantages: resin cement.
● The root is designed to accept the post but it l Vertical vents in post design decreases hydrostatic
cannot be used when little coronal structure is back pressure that build up during cementation and
present. decreases film thickness.
● Chemical reaction between post and core may l Restoration of endodontically treated teeth is de-
occur. signed to protect the remaining tooth structure from

● Attachments for removable prosthesis cannot be fracture and replace the lost tooth structure.
fabricated. l This restoration includes a dowel, core or coronal
c. Parallel posts restoration.

● Parallel posts are more retentive and resist l Dowel primarily increases retention and protects
torque forces. the tooth by dissipating/distributing forces along

● Greatest stress at apex of the preparation. the length of the root.
● They distribute stress evenly along its length, so
decreases dentine fracture. SHORT ESSAYS:

Disadvantages:
Q.1. Tooth preparation for post and core with adequate
● They cannot be used in tapered roots due to the
clinical crown.
risk of perforation and weakening of dentinal
walls. Ans.
● They are parallel with tapered ends resulting in
[Ref LE Q.1]
wedging effect.
● The tapered posts have decreased retention, and Q.2. Why are postendodontics restorations necessary?
the stress concentration is on coronal shoulder.
Ans.
Effect of surface texture:
● The retention decreases in the following order Postendodontic restorations are necessary for the
of post design: threaded, serrated and smooth. following reasons:
● The stress increases in following order of post i. Functional requirement
design: threaded, serrated and smooth. l Endodontically treated tooth is considered weak
● To decrease stress in threaded post, half counter because there is loss of the tooth structure due to
rotation is done. Parallel sided-serrated, vented caries, restoration, fracture, loss of roof of the pulp
post is preferred, though parallel threaded posts chamber and root canal shaping procedures.
offer best retention. l Changes in physical characters of dentine, e.g. use
II. Post length of high concentration of NaOCl reduces the dentine
l Should be two-thirds the working length (2:1) or at strength.
least the crown length (1:1). ii. Aesthetic requirement
l A minimum of 4 mm of apical filling should be l Darkening of tooth structure due to the presence
present. of degradable vital tissue, placement of certain
intracanal medicament in the pulp chamber, gutta- 3 . Glass ionomer resin

percha and sealers left behind in the pulp chamber. 4. Cast metal or ceramic
Q.2. Classification of post.
SHORT NOTES: Ans.
Q.1. Core material.
Posts can be classified as follows:
Ans. i. Prefabricated and cast post
ii. Metallic and nonmetallic post
● The core is a restorative material placed in the coronal
iii. Rigid and nonrigid post
area of a tooth which replaces carious, fractured or
iv. Aesthetic and nonaesthetic post
missing coronal structure and retains the final crown.
Core materials are:
1. Amalgam
2. Composite resin
Topic 13
Mishaps and Failures of Endodontic Treatments
LONG ESSAYS:
1 . Write various endodontic failures. How will you overcome them?
2. What are the causes of endodontic failures? Explain each cause? [Same as LE Q.1]
3. What are the procedural problems during endodontic therapy? Discuss their management. [Same as LE Q.1]
4. What are the complications encountered during routine endodontic treatment? Give aetiology and management
of broken instrument in root canal. [Same as LE Q.1]
SHORT NOTES:
1 . Ledge formation.
2. Management of separated instruments within the root canal.
SOLVED ANSWERS
LONG ESSAYS: ● It is seen in the following:
l Abscessed periapical periodontitis
Q.1. Write various endodontic failures. How will you l Periapical actinomycosis
overcome them? l Overinstrumentation
Ans. l Infected periapical pocket cyst
Treatment: Surgical treatment (apicoectomy)

● Failure in an endodontically treated tooth is considered
2. Nonmicrobial causes
when the hard tissue healing is incomplete with non
● Foreign bodies
resolving posttreatment periapical radiolucency. This
● Cholesterol crystals
lesion may be symptomatic or asymptomatic.
● True cyst
● Persistent radiolucency can be seen due to:
● Scar tissue healing
l Extraradicular factors
(a) Foreign bodies
l Interradicular factors
● Gutta-percha (GP), fragments of temporary
I. Extraradicular factors
filling material, broken instruments, sealers,
1. Microbial causes
cotton fibrils (cellulose granuloma), amal-
● Most common bacteria found are Actinomyces
gam, pulses (pulse granuloma), which reach
israelii and P. propionicum.
the periapical region through the root canal, Preoperative

may cause chronic irritation to form a granu- ● Misdiagnosis is due to the lack of information –
loma. either clinical or radiographical.

● Treatment: Surgical removal of the irritant. ● Poor case selection.
(b) Cholesterol crystals l Predictable: Non-negotiable canal, resorption,
● These crystals are sclerogenic and induce unrestorable tooth

granulomatous lesion. They are formed from l Unpredictable: Secondary periodontal involve-
cholesterol released by: ment, occlusal trauma, transformation of an

l Dying lymphocytes, macrophages and apical abscess to cyst
plasma cells ● Poor prognosis: Avulsed tooth, unsuccessful peri-
l Disintegrating erythrocytes odontal treatment in endo-perio lesions.

l Circulating plasma lipids Operative
● These crystals attract more macrophages and Failure to obtain biologic objectives:
giant cells that are unable to degrade the crys- ● Improper removal of all potential irritants from
tals resulting in periapical periodontitis and the canal space.

stimulation of bone-resorptive mediators. ● Debris pushed beyond the apical foramen,
● Treatment: Surgical removal of the granulo- which acts as a constant irritant in the periapi-
matous tissue. cal area, delaying healing.
(c) True cyst Prevention:
● The failure of periapical radiolucency to re- ● Use appropriate irrigants.
solve in spite of a good obturation could be ● Avoid over instrumentation.
due to a true cyst. Radiolucency may be seen even in well-obturated

● A true cyst is self-sustaining and does not canals due to the presence of bacteria in the ac-
depend on the presence or absence of root cessory canals (use irrigants with low surface
canal infection. tension).
● Treatment: Surgical enucleation of the cyst. Failure to obtain mechanical objectives:
(d) Scar-tissue healing ● Mishaps during access cavity preparation
● The persistence of periapical radiolucency ● Mishaps during canal preparation
few months after surgery suggests that the ● Mishaps during obturation
lesion has healed by scar formation (without ● Miscellaneous causes
bone regeneration). Access-related mishaps treating the wrong

● Diagnosis: Radiograph shows persisting ra- tooth: This is due to inattention on the part of
diolucency in spite of a good orthograde the dentist. This could be either wrong diagno-
obturation. sis or access opening of the wrong tooth.
II. Interradicular factors Missed canals
● Persistent or reintroduced interradicular microor- Causes:
ganisms are one of the main causes of root canal ● Lack of knowledge of the pulp-space anatomy
failure. and its variations

● Persistent microorganisms are seen in the cases of ● Improper coronal access cavity preparation
iatrogenic mishaps like ledges, perforations, sepa- (too small or incomplete deroofing of the
rated instruments and improper shaping and cleaning. pulp)
● The microorganisms are reintroduced due to im- Sites:
proper apical or coronal seal. ● Mesiobuccal root of maxillary molars
● The bacteria are predominantly Gram-positive anaer- ● Distal root of mandibular molars
obes (Enterococcus faecalis) unlike the untreated ● Maxillary second premolars
necrotic pulp which is polymicrobial (mainly Gram- ● Mandibular incisors
negative anaerobes). Identifying an additional canal

Treatment plan ● During instrumentation, if the instrument is not
● Do nothing (if the cause is not definite). centred in the root, presence of an additional canal
● Extract the tooth (if the prognosis of the retreat- is indicated.
ment is poor). ● Using magnification glasses, head lamps and
● Nonsurgical retreatment. transilluminating devices.
● Surgical retreatment. ● Standard radiographs in two different horizontal
● Nonsurgical management of endodontic failure. angulations, radiovisuography (RVG), microscopes

and endoscopes can be used to locate additional ● Glass ionomer restorative cement (GIC)
canals. ● GP
● Ultrasonics. ● Tricalcium phosphate
● Microopeners. Prognosis: Depends on:

● Various dyes ● The location of the perforation
l Methylene blue ● The time lapse between the perforation and
l Ruddle’s solution repair

● Sodium hypochlorite: After shaping and cleaning, ● The ability to obtain a fluid-tight seal
the chamber is flooded with sodium hypochlorite ● Accessibility to the main canal
which reacts with the residual pulp tissues within Crown/root fractures
the missed canal to form bubbles. This is called Causes: A preexistent infraction that becomes a true
the champagne test. fracture when the patient chews on the tooth.
Prevention: Identifying an infraction line:
● Good illumination. ● Transillumination
● Radiographs with two different horizontal an- ● Dyes
gulations should be taken before the treatment Prevention:

is initiated. ● Deoccluding the tooth before working length
● Additional canal should be looked for in every determination.

tooth that is treated. ● Use of circumferential bands till the placement
● Proper access preparation (especially in teeth of a final restoration.

that are occlusally realigned with cast restora- Management:
tions). If the fracture involves a part of the crown, the
Prognosis: The prognosis will be poor unless loose fragment is removed and treatment is com-
the two canals open into a single foramen. pleted. If it is more extensive and nonrestorable,
Supracrestal perforation extraction of the involved tooth is indicated.
Causes: Prognosis:
● During access cavity preparation Prognosis is unpredictable as crown infraction
● Instrumentation may spread to the roots resulting in vertical frac-
● Postspace preparation tures.
Sites: Canal preparation-related mishaps: Ledge formation
● Above the periodontal attachment (an internal transportation)
● Into the periodontal ligament, e.g. furcation Causes:
perforation ● Inadequate access cavity preparation.
Identifying a perforation: ● Using straight or large instruments with active
● Direct observation cutting tip in curved canals.

● Presence of leakage-seepage of saliva into the Identifying a ledge:
cavity or sodium hypochlorite into the mouth ● When an instrument does not reach the full
(resulting in unpleasant taste) working length.

● Presence of bleeding in the access cavity ● Loss of normal tactile sensation of tensional
● Radiograph with a file placed in the perfora- binding (feels as if the instrument is hitting
tion site against a solid wall).
Prevention: ● The radiograph shows the instrument pointing
● Thorough knowledge of tooth anatomy. away from the lumen of the canal.
● Careful attention to radiographic information. Prevention:
● The access bur should be aligned along the ● Accurate radiographic interpretation.
long axis of the tooth. ● Use of stainless steel patency files to determine
Management of the perforation: The blood/fluid the canal curvature.

seepage is controlled using cotton pellets, paper ● Pre-curving the instruments.
points or haemostatic agents (Gelfoam). It is then ● Use of instruments with noncutting tip.
sealed effectively using one of these materials: ● Use of NiTi files.
● Cavity ● Instruments should be used in sequence for

● Amalgam canal preparation.
● Calcium hydroxide paste ● Canal should be irrigated and recapitulated
● Super ethoxybenzoic acid (EBA) frequently.

● Canal should be prepared in small increments ● A sudden appearance of haemorrhage in a

using the balanced-force technique. previously dry canal.
Management: ● Tactile resistance of the canal space is lost.
● The canal should be explored to the apex using ● Haemorrhage on a paper point placed in the
a small precurved file (no. 10/15). canal can confirm the presence and location
● The curve of the instrument should be pointed of the perforation.
towards the wall opposite the ledge. ● When post or root filling is seen beyond the
● The instrument is used in a ‘vaiven/watch confines of the canal space (periradicular

winding motion’ in the presence of lubricant or region) in the radiograph.
irrigant ethylenediamine tetraacetic acid ● Radiographs taken at different angulations.
(EDTA) should be avoided, as chelation may ● Presence of periodontal pockets in cervical
lead to perforation). and mid root perforations.

● Greater taper (GT) NiTi hand files can be used. Prevention:
The major advantage of using GT files to re- In cervical and mid root perforations: In a distally
move a ledge is the Do diameters are 0.20 mm, curved root, anticurvature filling should be done
their maximum flute diameter is 1.00 mm, and to avoid pressure on the distal wall (danger zone)
their tapers are three to six times the conven- maintaining the pressure on the mesial wall.
tional 0.02-mm tapered files. Management:
Prognosis: Nonsurgical (when periradicular periodontitis is
Prognosis is good if the ledge is bypassed and the not present).
canal is prepared to its full length. Advantages:
Root perforation ● Less invasive
Classification: ● Less destruction of periradicular tissue
Two types: ● Better isolation from microbes
● Point perforation ● Enhanced disinfection
● Strip perforation ● Surgical (when periodontal defect is present)
Sites: Materials used:

● Cervical perforation ● Mineral trioxide aggregate (MTA)
● Mid root perforation ● Geristore
● Apical perforation ● Cavity, etc.
Causes: Obturation-related mishaps

● Cervical third perforation occurs as a sequel to Over-under-extended root canal: The failure due
ledge formation (improper use of a file with to this mishap may be due to persistent or reintro-
cutting a tip) and stripping of the inner curva- duced microorganisms improper apical seal. The
ture of the curved canal (engine driven instru- causes of such a mishap are as follows:
ments such as Gates Glidden (GG) drills or 1. Under obturation:
Peeso reamers). l Due to loss of working length.
● Mid root perforations occur due to stripping, l Improper selection of master cone.
especially in distal wall of distally curved me- 2. Over obturation:

sial root in molars (mesial canal). Use of Peeso l Due to apical perforation.
reamers increases the chances of perforation. Overfilling: When the canal is totally obturated
● Apical perforation is the result of a file not with the excess material extruding beyond the apical
negotiating the curved canal or improper work- foramen.
ing length determination. Perforation in curved Overextension: When the canal is not filled properly
canal is because of ledge, apical transportation and material extrudes beyond the apical foramen.
or apical zipping, which is usually seen in Diagnosis:
maxillary lateral incisor, mesiobuccal roots ● Radiograph
and palatal root of maxillary molars and mesial ● Tooth is symptomatic
root of mandibular molars. It is the most com- Management: The three types of management are
mon site of perforation. ● Semisolids
Identifying a perforation: ● Solids

Cervical, mid root and apical perforation can be ● Pastes
detected by the following methods: ● Semisolids (GP)
● The patient suddenly complains of pain dur- Seen as a pink material in the orifice. The root
ing treatment. canal filling may or may not have a solid core.
Removal of GP without core: Difficulty in remov- The tissue reaction depends on the following:
ing GP depends on: The type of solution
● Canal length. Its concentration
● Density of the filling. The amount of exposure
● Curvature of the canal. Prevention:
● It is best removed progressively in a crown ● Use needles with closed end and lateral vents.
manner (first coronally, then middle third and ● While using a Monoject needle, the tip of the
finally from apical third). needle should be 1–2 mm short of the apex.
Technique: The GP is softened either by heat or ● The needle should not bind to the canal walls
chemically. (should allow back flow of the irrigant).

Heat-softening is done by the following: Treatment:
● Rotary file be used passively in the canal at ● Since the infection (due to tissue destruction)
a speed of 1200–1500 rpm to soften the GP, could spread, antibiotics, analgesics and anti-
e.g. GG, automated GPx (not flexible), Beu- histamines should be prescribed.
telrock reamer (flexible). ● Icepack should be placed initially followed by
● Ultrasonic without a coolant. warm saline soaks (next day) to decrease the
● Controlled heating systems like Touch ‘n swelling. Incision and drainage may be neces-
Heat or system B. sary to decrease the pain.
● Hand files (H files, C1 files) heated over a ● In severe cases, steroid (IM) and hospitaliza-
flame. tion (for surgical wound debridement) may be

Chemical softening is done using solvents like: indicated.
1. Methyl chloroform (best) ● If NaOCl is accidentally injected into the max-
2. Halothane illary sinus, 30 mL of sterile water of or saline

3. Xylene (toxic) should be injected to prevent damage to the
4. Chloroform (toxic) sinus lining.
5. Eucalyptus oil Tissue emphysema
l The softened GP is removed with a hand It is the collection of gas or air in tissue spaces/facial
file and finally wicked with paper point. planes which occurs during apical surgery when air
l The canal is negotiated till the apical from high-speed drill is directed towards the exposed
constriction using precurved files and soft tissue. It can also occur when a blast of air is
working length is confirmed with a ra- used to dry the canal. This leads to swelling, ery-
diograph. thema and crepitus (crepitus is pathognomonic of
l Canal is irrigated with NaOCl and all the tissue emphysema and is distinguished from angio-
remnants of GP and sealer are removed edema). Unlike irrigant extrusion reactin, emphy-
(GIC sealer is removed using ultrasonic). sema remains in the subcutaneous connective tissue
l When the canal is overfilled, the GP is and does not spread to deep anatomic spaces.
removed till the middle third using ro- Treatment: Antibiotics are given to prevent second-
tary files in the presence of solvents. A ary infection. If the airway or mediastinum is com-
new H file is then heated and inserted promised, immediate medical attention is advised.
into the GP (in the apical third of the Prevention: While using air syringe, do not direct
canal). The file is withdrawn gently after the air periapically, instead blow at a horizontal di-
the GP cools, which brings the overex- rection against the walls of the canal or use paper
tended GP along with it. points to dry canals. During surgery, use low-speed
Miscellaneous or high-speed impact handpiece that does not direct
Irrigant-related mishaps. All irrigants that are used jets of air into the surgical site.
in chemomechanical preparation of the root canal Postoperative causes: Trauma, fracture, superim-
are tissue irritants if they extrude into the perira- posed nonendodontic lesion and poorly designed
dicular tissues. When NaOCl or alcohol contacts final restorations including posts are few causes of
the periradicular tissue, inflammatory reaction is postoperative mishaps.
followed by tissue destruction. There could be in- Q.2. What are the causes of endodontic failures?
terstitial haemorrhage and ecchymosis. Injection Explain each cause?
of hydrogen peroxide causes tissue emphysema
(the patient complains of severe pain and violent Ans.
swelling). [Same as LE Q.1]
Q.3. What are the procedural problems during end- Management of separated instruments within root
odontic therapy? Discuss their management. canal:
● Instrument breakage is a common problem in endodon-
Ans. tic treatment which occurs by improper or over instru-
[Same as LE Q.1] mentation.
Factors influencing broken instrument removal
Q.4. What are the complications encountered during 1. The ability to nonsurgically gain access and remove
routine endodontic treatment? Give aetiology and man- a broken instrument will be influenced by several
agement of broken instrument in root canal. factors like cross-sectional diameter, length and cur-
Ans. vature of the canal.
2. A general rule that, if one-third of the overall length
[Same as LE Q.1] of an obstruction can be exposed, it can be usually
removed.
Surgical indications
SHORT NOTES: 1. Broken file is behind the curve.
2. File fragment is not visible because of curved roots.
Q.1. Ledge formation. 3. Much of dentine has to be removed to allow file
removal.
Ans.
4. Instrument is in the apical part of the canal and is
Definition difficult to retrieve it.
● Ledge is an internal transportation of the canal which Surgical grasping devices
prevents positioning of an instrument to the apex in 1. Instrument Removal system (IRS) option
an otherwise patent canal. 2. Masserann kit
Causes 3. Endo Excavator
● Failure to make access cavities that allow direct ac- 4. Wire loop technique
cess to the apical part of the canals or from using Techniques for removal of broken instruments
straight or too-large instruments in curved canals. Before beginning instrument-retrieval efforts:
Treatment 1. Inform the patients.
1. Locate the position of the ledge by inserting an in- 2. Take radiograph to check the location of the
strument until it is blocked and verify the depth of instrument.
insertion by taking a radiograph. 3. Use operating microscope and ultrasonics (Micro-
2. Irrigate the canal with sodium hypochlorite solution. sonics).
3. Use a small file, No. 10 or 15 with a distinct curve at 4. Attention should be given to thickness of dentinal
the tip to explore the canal to the apex, in vaiven or walls and root surface concavities.
watch winding motion. Procedure
4. When the ledge is reached, the file is slightly re- 1. Coronal access using high-speed friction-grip,
tracted, rotated and advanced again until it bypasses surgical length burs.
the ledge. 2. Radicular access using either rotary or hand files
5. Once the ledge is bypassed, do not remove the instru- used serially to gain access to the broken frag-
ment instead, do circumferential instrumentation of ments.
the canal before withdrawal of the instrument. 3. GG drill is introduced and is used like ‘brushes’ to
6. Repeat this with larger instruments until the ledge is create additional space and maximize visibility
filed away. coronal to the obstruction.
Prevention 4. Increasingly larger GG is stopped out of the canal
1. Accurate interpretation of diagnostic radiographs to create a smooth flowing funnel that is largest at
before the placing of first instrument the orifice and narrowest at the obstruction.
2. Awareness to canal morphology 5. If greater access is required lateral to the most
3. Using precurving instruments coronal aspect of the obstruction, then the bud-
4. Using instruments with noncutting tips shaped tip of GG can be modified and used to
create a circumferential ‘staging platform’.
Q.2. Management of separated instruments within the
root canal. 6. ‘Staging platform’ is made by selecting a GG with
a maximum cross-sectional diameter that is
Ans. slightly larger than the visualized instrument. The
bud of GG is altered by cutting it perpendicular Prevention of instrument separation

to the long axis at its maximum cross-sectional 1. Never use instruments in dry canals.
diameter. 2. Never force the instruments into the canals.
7. Before starting the radicular removal, it is wise to 3. Use smaller number of instruments only once.
keep cotton pellets over the other canal orifices to 4. Always use the instruments in sequential order.
prevent the re-entry of the fragment into the 5. Clean the instrument before placing it into the
nearby canal system. canal.
8. Ultrasonic instrument is activated at low inten- 6. Instead of using carbon steel, use stainless steel
sity and dry conditions. Continuous airstream is files.
applied. The CPR is moved in counterclockwise 7. Examine each instrument before placing into the
direction. This will finally loosen the instru- canal.
ment, and wedging the energized tip between 8. Do not give excessive rotation to instrument while
tapered file and the canal wall often causes the working with it.
broken instruments to abruptly ‘jump-out’ of the
canal.
Topic 14
Treatments of Traumatized Teeth
LONG ESSAYS:
1 . A boy, aged 8, comes to clinic with fractured central incisor due to an impact outline the treatment plan.
2. Classify traumatic injuries. Write about management of avulsed upper incisor tooth in a 10-year-old patient.
3. How will you treat a young boy of 14 years coming to you with a recently fractured central incisor involving
pulp? [Same as LE Q.1]
4. Give step-by-step management of traumatically fractured central incisor in a 9-year-old child. [Same as LE Q.1]
5. A boy, aged 8 years, comes to your clinic with a fractured central incisor due to sports injury. Outline and de-
scribe your line of treatment. [Same as LE Q.1]
6. Classify traumatic injuries of anterior teeth. How will you manage Ellis Class III fracture in maxillary central
incisor? [Same as LE Q.1]
7. Classify the tooth fracture. Discuss the treatment of avulsed tooth. [Same as LE Q.2]
SHORT ESSAYS:
1 . Types of root fracture and management.
2. Classification of injuries of teeth. [Ref LE Q.2]
3. Management of avulsed tooth. [Ref LE Q.2]
4. Vertical root fractures. [Same as SE Q.1]
SHORT NOTES:
1 . Ellis classification of fractured teeth. [Ref LE Q.2]
2. Methods of immobilization of traumatized teeth.
3. Resorption.
4. Define avulsion.
5. Root fracture. [Ref SE Q.1]
6. Replacement resorption.
7. Classify traumatic injuries of anterior tooth. [Same as SN Q.1]
8. Classification of injuries of teeth. [Same as SN Q.1]
9. Internal resorption. [Same as SN Q.3]
10. Mention various storage media for avulsed tooth transport. [Same as SN Q.4]
11. Treatment of coronal root fracture. [Same as SN Q.5]
SOLVED ANSWERS
LONG ESSAYS: inadvertently exposed due to excavation of caries or
traumatic injury.
Q.1. A boy, aged 8, comes to clinic with fractured cen-
Indications for direct pulp capping
tral incisor due to an impact outline the treatment plan.
● Pinpoint exposure (,0.5 mm)
Ans. ● Controlled haemorrhage
● Crown fractures involving enamel, dentine and pulp are ● No pulpal necrosis
called complicated crown fractures. ● Absence of swelling and tenderness
The diagnosis of the patient depends on: Pulp-capping agents used
● Patient’s history ● Calcium hydroxide
● Clinical examination ● MTA
● Radiographs ● Emdogain (enamel matrix derivative)
● Vitality tests ● Tricalcium phosphate
Factors determining the choice of treatment plan ● Bone morphogenic proteins
I. Stage of the development of tooth Procedure
● For an immature vital tooth, vital pulp therapy ● Anaesthesia is administered followed by rub-
like pulp capping, partial pulpotomy or full ber dam placement.
pulpotomy is done till apex is completely ● Bleeding is controlled with a sterile moist cot-
formed (apexogenesis). ton pellet then the exposure site is covered by
● For an immature nonvital tooth, apexification is a pulp capping agent followed by a bacteria
done using calcium hydroxide or mineral triox- seal restorative material.
ide aggregate (MTA) followed by obturation. ● Patient should be recalled after 6 weeks to
● In a mature tooth, root canal therapy (RCT) is evaluate the formation of hard tissue barrier.
the treatment of choice. II. Pulpotomy
II. Time between the accident and treatment (i) Shallow pulpotomy/partial pulpotomy
● If the pulp is exposed for less than 48 h, then ● It is also known as modified pulpotomy pro-
pulpotomy is performed. cedure or Cvek’s pulpotomy.
● If the pulp is exposed for more than 48 h, then ● Materials used are calcium hydroxide and
pulpectomy/RCT is preferred. MTA.
III. Associated periodontal injury Indications for partial pulpotomy:
● Pulpectomy is indicated in cases when the sur- ● Pulp exposure is less than 1 mm in
rounding periodontium is damaged and the nu- diameter.
tritional supply to the tooth is affected. ● Pulp has been exposed for less than 24 h.
IV. Restorative treatment plan ● Pulp responds positively to vitality tests.
● For composite treatment partial pulpotomy is ● Absence of infection.
decided, however, to receive a complex restora- Procedure:
tion pulpectomy is the treatment of choice. ● Anaesthesia is administered followed by
A. Apexogenesis rubber dam placement.
● For an immature vital tooth, vital pulp therapy like ● 1–2 mm of pulp is removed with a sterile
pulp capping, partial pulpotomy or full pulpotomy is diamond bur and copious water coolant
done till apex is completely formed known as apexo- with the help of intermittent light strokes.
genesis. ● The lost tooth structure is then replaced
I. Direct pulp capping with acid-etched composite resin.
Direct pulp capping involves the placement of bio- Treatment is considered to be successful when
compatible agent on healthy pulp tissue that has been there is
● No evidence of periradicular pathologic ● The canal is disinfected using calcium hydroxide

changes mixed in a creamy consistency or by placing
● No evidence of resorption medicated gutta-percha points.
● Evidence of continued root formation ● At the recall visit after 1 week, the debridement
(ii) Full pulpotomy (cervical pulpotomy) procedure is repeated followed by placing a thick
Indications for full pulpotomy are paste of pure calcium hydroxide mixed with ster-
● Traumatic pulp exposure beyond 72 h. ile saline/anaesthetic solution with the help of a
● Carious exposure. plugger. The canal is back filled to provide a bac-
● Pulp responds positively to vitality tests. teria seal canal.
● Absence of infection. ● The access cavity is then restored with a tempo-
● Primarily indicated if root apex is not yet rary filling.

completely developed. ● Patient is recalled after 3 months to evaluate the
Materials used: hard-tissue barrier formation with a radiograph.

● Calcium hydroxide ● If the apical barrier is not formed, the procedure
● MTA is repeated.
Procedure: ● If the apical barrier is formed, it gives a ‘Swiss
● Anaesthesia is administered followed by cheese’ consistency; the thickness of the hard-tissue

rubber dam placement. barrier formation is confirmed radiographically,
● The entire coronal pulp up to the level of while a hand file is used with light pressure to probe
root orifice is removed with a sterile bur or the apical stop.
electrosurgical pulpotomy or laser pulpot- ● The calcium hydroxide is removed using NaOCl
omy, it is then rinsed with sterile saline and along with ultrasonics followed by obturation.
bleeding is controlled with sterile cotton The following obturation techniques can be em-
pellet. ployed:
● Calcium hydroxide dressing is placed, fol- i. Inverted gutta-percha technique
lowed by zinc phosphate/glass ionomer ii. Roll cone technique
used as a base; it is then restored to provide iii. Thermoplasticized gutta-percha:
a bacterial tight seal. ● Retrograde filling during periapical sur-
B. Apexification gery (if all the above-mentioned meth-

Indications for apexification ods fail).
● Necrosed pulp in a developing tooth with incom- ● The obturating material is removed to
plete root formation. below the marginal bone level, and a

● Open apices with thin dentinal walls in which in- bonded resin restoration is placed to
strumentation techniques cannot create an apical strengthen the endodontically treated
stop to facilitate effective root canal obturation. teeth and increase their resistance to
Materials used fracture.
● Calcium hydroxide Disadvantages of calcium hydroxide apexification
● MTA are as follows:
● Tricalcium phosphate ● Multiple sittings.
● Bone morphogenic proteins ● Calcium hydroxide on long-term use disrupts
Shortcomings the bond between the hydroxyapatite and col-

● The canal is wider apically than coronally. lagen thus weakening the tooth structure.
● Extrusion of the obturating material due to lack of ● Requires patient cooperation.
apical stop. Apexification using MTA:

● Underfilled canal is susceptible to leakage. ● MTA can be used to obtain a hard tissue barrier
● Thin dentinal walls are prone to fracture. against which obturation can be completed.
Procedure Most of the steps are similar to that of calcium
● The affected tooth is isolated using a rubber dam. hydroxide.
● An access opening is made and the pulpal rem- ● At the recall visit, calcium sulphate is pushed
nants are removed using barbed broaches and a beyond the apex which provides a resorbable
file is then placed in the root canal to determine barrier against which MTA is condensed into
the working length. the apical 3–4 mm of the canal.
● The canal is irrigated using 0.5% NaOCl and then ● Moisture from the canal and a wet cotton pellet
dried with paper points. placed in the canal facilitates setting of the MTA.
● The cotton pellet is removed after 6 h and the avulsion results in damage to the periodontal ligament
canal is obturated till the marginal bone level, (PDL) and pulp necrosis.}
followed by a resin restoration. Aetiology of tooth fracture
III. Pulpectomy ● Fall
● Pulpectomy is defined as the complete removal ● Accidents
of the pulp to the level of the apical foramen. ● Acts of violence
Indications ● Sports
● If the exposure is longer than 72-h duration

Incidence
or the pulp is damaged beyond recovery
● 7–12 years are the most accident prone age.
● When the pulp is degenerated or of question-
● Boys tend to injure their teeth more frequently than girls
able vitality
(2:1 to 3:1).
Procedure
● It occurs primarily in the maxillary anterior region than
● The affected tooth is isolated using a rubber
the mandibular.
dam.
● An access opening is made, and the pulpal Examination
remnants are removed using barbed broaches. ● Clinical examination is done to check for the fracture of
● A file placed in the root canal to establish the alveolar socket wall or any hard-tissue fragment lodged
working length and radiograph is taken. in the soft tissue, which is confirmed radiographically
Shaping and cleaning are done along with and soft tissue is examined for lacerations.
copious irrigation with NaOCl.
● The canal is then dried with paper points and
[SE Q.3]
a suitable intracanal medicament is placed. {Treatment objectives
● The access cavity is restored with a tempo- Treatment is directed at minimizing the damage and
rary filling that provides a bacteria-tight seal. treating pulp space at appropriate time.}
● At the next visit, the canal is checked for any Factors that affect the prognosis of avulsion after
drainage. If the canal is dry, obturation is replantation
completed and the access cavity is restored i. Extraoral time (the most important factor)
with resin restoration. ii. Treatment of the root surface
Q.2. Classify traumatic injuries. Write about manage- iii. The storage or transport media
ment of avulsed upper incisor tooth in a 10-year-old iv. Splinting
patient. v. Endodontic treatment
Ans. [SE Q.3]
(SE Q.2 and SN Q.1) {Management of avulsed tooth

● Replantation of the tooth in the socket is the emergency
{(Classification of traumatic injuries treatment done at the accident site or placed it in an ap-
According to Ellis and Davey propriate storage medium as quickly as possible (15–20
1 . Ellis class I: Enamel fracture min) to avoid drying and subsequent damage to the
2. Ellis class II: Dentine fracture without pulp exposure PDL.
3. Ellis class III: Crown fracture with pulp exposure ● Steps followed before replacing the tooth are
4. Ellis class IV: Root fracture i. Rinse the tooth (do not scrub the tooth).
5.
Ellis class V: Tooth avulsion ii. Replace the tooth.
6.
Ellis class VI: Fracture of the root, with or without the iii. Refer the patient to dentist.}
loss of crown structure
7 . Ellis class VII: Displacement of a tooth, without the The various storage media:
fracture of crown or root ● Teeth are placed in: Saliva (effective for 2 h) buccal
8. Ellis class VIII: Fracture of the crown en masse and its vestibule.
● Milk (effective for 6 h).
displacement
● Water (least effective as water, being a hypotonic solu-
9. Ellis class IX: Traumatic injuries to deciduous teeth)}
tion, causes cell lysis).
[SE Q.3] ● Storage media: Hank’s balanced salt solution.
{Avulsion ● Propolis (resinous beehive product).
Avulsion is defined as the complete displacement of a ● Viaspan (transplant organ storage medium recom-
tooth from its socket, also known as exarticulation. Tooth mended for the storage of avulsed tooth). They provide
the best environment to maintain the vitality of the v. Endodontic treatment

avulsed tooth. ● When extraoral dry time is less than 60 min.
RCT is initiated within 7–10 days after reimplanta-

[SE Q.3] tion. Calcium hydroxide intracanal dressing is placed
{Management in the dental office (7–14 days) and then obturated with gutta-percha.
i. Management of socket The only exception to the rule of RCT is when tooth
● Light irrigation is done followed by aspiration to
is still developing with open apical foramen.
● When extraoral dry time is more than 60 min.
avoid any blood clots.
● Curettage is completely avoided.
Endodontic treatment is carried out in vitro and then
ii. Management of the root surface replanted. In open apex, canal is debrided in vitro,
● If the root surface is dirty, it is rinsed with saline.
replanted and apexification procedure is initiated.
● Scrubbing, brushing or removing any of the root
Canal is obturated after a calcific barrier is formed. An
surface is avoided to prevent any further damage to appropriate permanent access cavity restoration, usu-
PDL.} ally composite resin with a minimum depth of 4 mm
● Preparation of the root depends on the:
should be placed (to prevent any coronal leakage).
● Maturity of the tooth (open versus closed apex).
vi. Instructions to be given to the patient
● Home-care instructions
● Dry time of the tooth before it is placed in a stor-
● Soft diet
age medium.
● Administer antibiotics for 5–7 days (tetracycline is
A dry time of 60 min is considered as a point at which
survival of root PDL cells is unlikely. the best)
● Analgesics
Extraoral dry time less than 60 min:
● Tetanus injection (within 48 h)}
● Closed apex: The root should be rinsed of de-
bris with water or saline and replanted in a Replantation resorption:

● The major cause of failure in the replantation of
gentle manner as soon as possible.
● Open apex: The tooth is soaked in doxycycline
avulsed teeth is resorption of root, frequently
as it causes revascularization or covered with followed by ankylosis.
● Three types of resorption include surface re-
minocycline for 5 min, debris is gently rinsed
off and tooth is replanted. sorption, inflammatory resorption and replace-
Extraoral dry time more than 60 min: ment resorption.
● On follow-up if resorption occurs, nonsurgical
Closed apex:
● The PDL is removed by placing it in acid
retreatment should be done.
for 1 min, followed by soaking the tooth in Q.3. How will you treat a young boy of 14 years coming
2% stannous fluoride for 5 min (prevents to you with a recently fractured central incisor involving
resorption) or covering the root with Em- pulp?
dogain (an enamel–matrix protein) and then
replanting. Ans.
Open apex: [Same as LE Q.1]
● If replantation is to take place, the open-
Q.4. Give step-by-step management of traumatically
apex tooth is treated same as the closed-
fractured central incisor in a 9-year-old child.
apex tooth.
Ans.
[SE Q.3]
[Same as LE Q.1]
{iii. Splinting
Q.5. A boy, aged 8 years, comes to your clinic with a
● Physiological or semirigid splint is used.
fractured central incisor due to sports injury. Outline
● The tooth splinted for 7–10 days.
and describe your line of treatment.
● Splints used are acid-etched resin, soft arch wire,
orthodontic brackets, Ribbond fibre splint and tita- Ans.

nium trauma splint.
[Same as LE Q.1]
● Patient is put on a soft food and advised not to bite
on the splinted teeth. Q.6. Classify traumatic injuries of anterior teeth. How
● The avulsed tooth is relieved of premature occlusal will you manage Ellis Class III fracture in maxillary
contact. central incisor?
iv. Management of soft tissues Ans.
● Clean the wound at the site of lacerations, and, if
required, sutures are placed. [Same as LE Q.1]

Q.7. Classify the tooth fracture. Discuss the treatment of ● Splinting is done by using: composite, orth-
avulsed tooth. odontic brackets, acrylic or cast splint cementa-
tion and fibre splint.
Ans.
(ii) Most often, the pulp in the coronal segment is ne-
[Same as LE Q.2] crosed leaving the apical segment vital.
● In these cases, pulpectomy/RCT/apexification
of coronal segment is done.

SHORT ESSAYS: ● Apical segment is kept under observation.
(iii) When both the segments contain necrotic pulp

Q.1. Types of root fracture and management.
within:
Ans. An endodontic treatment is performed in the coro-
nal segment followed by surgical removal of apical
segment.
{SN Q.5} Q.2. Classification of injuries of teeth.
● Fracture of root can be defined as vertical, oblique or Ans.
horizontal fracture of the cementum, dentine and [Ref LE Q.2]
pulp.
● Fractures of the root can be complete or incomplete. Q.3. Management of avulsed tooth.
Fractures of root can occur at three levels: Ans.
i. Coronal/cervical fracture
ii. Mid root fracture [Ref LE Q.2]
iii. Apical root fracture Q.4. Vertical root fractures.
Ans.
Clinical features
● Tenderness to percussion and palpation [Same as SE Q.1]
● Tooth mobility
● Displacement SHORT NOTES:
● Bleeding from the gingival sulcus
● Negative response of tooth to vitality tests Q.1. Ellis classification of fractured teeth.
Ans.
[Ref LE Q.2]
{SN Q.5}
Q.2. Methods of immobilization of traumatized teeth.
Treatment
i. Coronal root fracture Ans.
● If the fracture line is above the crest of the alveo-
● Immobilization is done by the surgeon to rest an organ
lar bone, the coronal fragment is extracted. to decrease pain or promote healing.
● The apical portion is orthodontically extruded for
● Immobilizing the affected tooth, i.e. relieving tooth
post/core restoration. from occlusal stress when it is in occlusion.
● If the fracture line is below the crest of the alveo-
● It also reduces the possibility of traumatizing the PDL.
lar bone, it is splinted as for mid root fracture. ● Methods of immobilization:
Splinting, figure of eight wiring or arch bar fixation.

Q.3. Resorption.
ii. Mid-apical root fracture
(i) Splinting Ans.
● When the tooth exhibits normal mobility with-
● An idiopathic slow or fast progressive resorptive pro-
out displacement, no splint is required.
cess occurring in the dentine of the pulp chamber or root
● When the tooth exhibits displacement and mo-
canal of teeth.
bility, the fracture is reduced and a rigid splint is
placed for a period of 4–8 weeks. Aetiology
● This promotes healing which is verified radio- ● Unknown
graphically. ● May be history of trauma
Clinical features Q.6. Replacement resorption.

● Asymptomatic.
Ans.
● Pink spot: Internal resorption is manifested in the crown
as a reddish area. ● The act or process of resorbing is called resorption.

● It represents the granulation tissue showing through the ● The major cause in failure of replantation of avulsed
resorbed area of the crown. teeth is resorption of root.
● Three types of resorption seen are
Diagnosis
i. Surface resorption
During routine radiographic examination. It is seen as a round
ii. Inflammatory resorption
or ovoid radiolucent area in the root canal or pulp chamber.
iii. Replacement resorption
Treatment
Q.7. Classify traumatic injuries of anterior tooth.
● Pulp extirpation,
● RCT with plasticized gutta-percha, Ans.
● If root perforation occurs seal it with calcium hydroxide,
[Same as SN Q.1]
Q.4. Define avulsion.
Q.8. Classification of injuries of teeth.
Ans.
Ans.
● Avulsion is defined as the complete displacement of a
[Same as SN Q.1]
tooth from its socket and is also referred to as exarticu-
lation. Q.9. Internal resorption.
● Tooth avulsion results in damage to the PDL and pulp
Ans.
necrosis.
Various storage media used in transporting avulsed teeth [Same as SN Q.3]
that provide the best possible environment to maintain
Q.10. Mention various storage media for avulsed tooth
vitality of the root surface in an avulsed tooth are:
transport.
i. Patients own saliva (effective for 2 h) buccal
vestibule. Ans.
ii. Milk (effective for 6 h).
[Same as SN Q.4]
iii. Hank’s balanced solution (NaCl, D-glucose,
KCl, NaOH, CaCl2, KOH and MgCl2). Q.11. Treatment of coronal root fracture.
iv. Propolis (resinous beehive product).
Ans.
v. Viaspan.
[Same as SN Q.5]
Q.5. Root fracture.
Ans.
[Ref SE Q.1]
Topic 15
Endodontic Surgery and Replantation
and Transplantation
LONG ESSAYS:
1 . Define intentional replantation. Write indications, contraindications and techniques of intentional replantation.
2. Give indications, contraindications for periapical surgery. Add a note on wound healing.
3. Classify different flap designs used in surgical endodontics and add a note on Luebke-Ochsenbein flap.
4. Discuss apicoectomy and the postoperative complication of apicoectomy.
5. Describe the outline of technique for immediate root resection. [Same as LE Q.4]
SHORT ESSAYS:
1. Replantation. [Ref LE Q.1]
2. Incision and drainage.
3. Radisection.
4. Indications and contraindications for endodontic surgery.
5. Flap design for endodontic surgeries. Add a note on Luebke-Ochsenbein flap design and advantages.
6. Hemisection.
7. Retrograde amalgam filling.
8. Reimplantation. [Same as SE Q.1]
9. Intentional replantation. [Same as SE Q.1]
10. Indications and contraindications for intentional reimplantation. [Same as SE Q.1]
11. Replantation of avulsed tooth. [Same as SE Q.1]
12. Luebke-Ochsenbein flap. [Same as SE Q.5]
SHORT NOTES:
1. Bicuspidization.
2. Semilunar incision. [Ref LE Q.3]
3. Luebke-Ochsenbein flap design. [Ref SE Q.5]
4. Replantation.
5. Apicoectomy. [Ref LE Q.4]
6. Hemisection. [Ref SE Q.6]
7. Trapezoidal flap. [Ref LE Q.3]
8. Splinting.
9. Flaps for endodontic surgery.
10. Periapical curettage.
11. Retrograde fillings. [Ref SE Q.7]
12. Intentional replantation. [Same as SN Q.4]
13. Sequelae of replantation. [Same as SN Q.4]
14. Flap designs in endodontics surgery. [Same as SN Q.9]
SOLVED ANSWERS
LONG ESSAYS: iv. Perforations in inaccessible areas.
v. When apical surgery creates defect.
Q.1. Define intentional replantation. Write indications, vi. Deciduous teeth needs as space maintainers.
contraindications and techniques of intentional replan- vii. Accidental avulsion unintentional replantation.
tation.
Contraindications
Ans. i. Nonrestorable teeth
ii. Curved and flared canals
[SE Q.1]
iii. Missing interseptal bone
l {Replacement of a tooth in its socket, with the objec- iv. Persistent moderate to severe periodontal diseases}
tive of attaining reattachment when the tooth has been
Management of avulsed tooth by intentional replan-
completely avulsed from its socket by an accident.
tation
l Intentional replantation is defined as an act of deliber-
● An avulsed tooth is a tooth that has been totally dis-
ately removing a tooth and following examination, diag-
placed out of its socket.
nosis, endodontic manipulation and repair returning the
● If the tooth is replanted soon after avulsion, the peri-
tooth to its original socket.
odontal ligament (PDL) has a good chance of healing.
Indications ● The avulsed tooth should be brought immediately as
i. Failed apical surgery. soon as possible to maintain the viability of root surface
ii. Persistent chronic pain. and PDL.
iii. Anatomical limitations. ● It can be stored in special media.
Storage media ● Stabilization may also be achieved by the use of a flex-

i. Saline ible wire with acid etching and bonding with composite
ii. Bovine milk resin to an adjacent tooth.
iii. Water least preferable ● The patient should be seen 7–14 days following inten-
iv. Hank’s balancing solution tional replantation surgery to remove any stabilization
v. Patients saliva: Under the tongue or buccal vestibule- that was placed and to evaluate tooth mobility.
most preferable ● Postsurgical evaluation is recommended at the end of 2,
6, 9 and 12 months following surgery.

Intentional replacement technique
Three factors that directly affect the outline of the Q.2. Give Indications, contraindications for periapical
procedure: surgery. Add a note on wound healing.
i. Out-of-the-socket time should be as short as possible. Ans.
ii. PDL cells on the root surface should be kept moist in
storage media during the time the tooth is out of the ● Periapical surgery is mainly performed to remove a por-
socket. tion of the root with undebrided canal space or to seal
iii. Minimizing the damage to the cementum and PDL the canal apically when a complete seal cannot be ac-
cells by gentle elevation and extraction of the tooth. complished with a nonsurgical root canal treatment
The forceps beaks should not touch the cement if at all through the crown approach.
possible. Indications
● Anatomic problems
Steps in replantation ● Procedural accidents
● Before extraction/replantation, orthograde endodontic ● Irretrievable material in the root canal
treatment should be completed. ● Symptomatic cases
● The pulp chamber and the coronal access should be
● Horizontal apical fracture
restored. ● Biopsy and corrective surgery
● Incision of the periodontal fibres is made using No. 15
blade and is gently elevated with an appropriate surgical Contraindications

elevator until class III mobility is achieved. ● Anatomic factors
● Medical or systemic complications
● The beaks of an appropriate forceps are wrapped with a
● Indiscriminate use of surgery
sterile gauze sponge then saturated with normal saline
● An unidentified cause of treatment failure
or Hanks’ balanced salt solution to minimize damage to
the cementum during the extraction process. Wound healing
● The roots of the tooth should be thoroughly examined Postoperative assessment of healing: Given by Andreasen
with fibreoptic illumination and magnification to evalu- and Rud (1972).
ate for the presence of root fracture or radicular defects Group 1: Complete healing
such as perforations or resorption. Group 2: Incomplete healing (scar tissue)
● If root-end resection is indicated, it should be done with Group 3: Uncertain healing
a plain fissure bur in a high-speed handpiece under con- Group 4: Unsatisfactory healing (failure)
stant irrigation (2–3 mm). An appropriate root-end fill- Wound healing after periradicular surgery
ing is placed. ● The main goal of periradicular surgery is to facilitate
● Following the repair of any root defects, the extraction regeneration of tissues rather than repair, i.e. scar tissue
socket should be irrigated with normal saline and gen- formation.
tly suctioned to remove any blood clot that may have ● These tissues include free gingiva, attached gingiva,
formed; the tooth is then carefully returned to its periosteum, alveolar mucosa, PDL and cementum and
socket. the healing occurs by primary and secondary intentions.
● Reinsertion of the tooth into the socket may be difficult Healing following periradicular surgery is dealt under fol-
at times, especially if there is a critical path of insertion. lowing headings:
● After the tooth has been inserted into the socket, a rolled A. Soft-tissue healing
gauze sponge should be placed on the occlusal aspect of B. Hard-tissue healing
the tooth and the patient be instructed to bite down so A. Soft-tissue healing
that the interocclusal force will seat the tooth into its Three phases of healing:
socket. i. Inflammatory phase
● The patient should be instructed to maintain interocclu- a. Clot formation
sal pressure for approximately 5 min. b. Early inflammation
● If excessive mobility is evident, splinting is suggested. c. Late inflammation
ii. Proliferative phase and later type-I collagen as the wound

iii. Maturation phase matures.
● Myofibroblast plays a significant role in
i. Inflammatory phase wound contraction, particularly in inci-
a. Clot formation begins with three events: sional-type wounds.
● Blood vessel contraction ● Myofibroblasts align themselves parallel
● Intravascular platelet aggregation with the wound surface and then con-
(platelet plug) tract, drawing the wound edges together.
● Extrinsic and intrinsic clotting mecha- ● These cells are eliminated by apoptosis
nism after wound closure.
● The result is coagulum consisting of b. Endothelial cells (angiogenesis):
fibrin strands with serum exudates, ● These cells help in the formation of cap-
erythrocytes, tissue debris and inflam- illary buds from the blood vessels around
matory cells the wound.
b. Early inflammation: ● This occurs concurrently with fibroblast
● Polymorphonuclear leucocytes proliferation and begins as early as 48–72 h
(PMNLs) organization. after the injury.
● PMNLs begin to enter the wound site ● Without angiogenesis, the wound would
by pavementing, emigration and mi- not have the blood supply needed for
gration within 6 h of clot stabilization. further active healing.
● It decontaminates the wound by the ● Potent stimulator of angiogenesis in-
means of phagocytosis. cludes VEGF, BFGF, aFGF, TGF-0 and
● The number reaches its peak at about TGF-13 and interleukin-l.
24–48 h after injury and drops rapidly c. Epithelium:
after the third day (PMNLs are short ● It helps in the formation of an epithelial
lived). seal on the surface of the fibrin clot.
c. Late inflammation: ● This process begins at the edge of the
● Macrophages organization. wound, where the basal and suprabasal
● Macrophages enter the wound site by prickle cells rapidly undergo mitosis.
48–96 h after injury and reach a peak ● The cells then migrate across the fibrin clot
concentration at the third or the fourth at a remarkable rate (0.5–1 mm per day).
day and remain in the wound until ● In the wound healing by primary inten-
healing is complete. sion formation of epithelial seal, it takes
● They secrete cytokines that initiate 21–28 h after the reapproximation of the
proliferative phase. wound margins.
● Macrophages play a major role in iii. Maturation phase
wound decontamination through ● The transition to this phase of healing be-
phagocytosis and digestion of micro- gins at 5–7 days after the injury with a re-
organisms and tissue debris. duction in fibroblast, vascular channels and
● They ingest and process the antigens extracellular fluids.
for presentation to T lymphocytes ● Initially the wound matrix consists of fibro-
which enter the wound after the mac- nectin and hyaluronic acid.
rophages. ● As healing progresses, the collagen gradually
ii. Proliferative phase remodels and reorganizes, decreasing the cel-
● This phase is characterized by the for- lularity and vascularity of the reparative tissue.
mation of granulation tissue. The cells ● Maturation of the epithelial layer quickly
involved are follows the formation of the epithelial seal.
a. Fibroblasts (fibroplasias): ● The epithelial seal differentiates and under-
● It migrates to the wound site on the goes mitosis and maturation to form a de-
third day after the injury, peaks on finitive layer of stratified squamous epithe-
the seventh day and forms granulation lium (forms by 36–42 h after suturing).
tissue. B. Hard-tissue healing
● They play a major role in the reconstruc- ● The inflammatory and the proliferative phases are
tion by initially laying type-III collagen similar to that as seen in soft-tissue healing,
i.e. clot formation followed by a formation of A. Full mucoperiosteal flaps

granulation tissue in the bony crypt. i. Triangular flap
● Maturation phase differs from that of the soft tis- ● It is formed by a horizontal, intrasulcular inci-
sue as the tissues involved are cortical bone, can- sion and one vertical releasing incision.
cellous bone, alveolar bone proper, endosteum, Indications
PDL, cementum, dentine and inner mucoperios- ● In mid root perforation repair and with short
teal tissue. roots

Hard-tissue healing includes: ● In periapical surgery
Osteogenesis (osteoblasts) ● Mandibular posterior teeth
● Once haematoma is formed in the bony Advantages:

crypt, inflammation begins as in soft-tissue ● Can be easily repositioned and result in good
and progresses with the eradication of de- wound healing.

bris and the proliferation of granulation tis- ● Maintain integrity of blood supply.
sue (2–4 days). Disadvantages:

● Along with the cells seen in the soft-tissue ● Limited access and visibility in long roots.
healing, preosteoblasts and osteoblasts mi- ● Tension is created and vertical incision pen-
grate into this region to form woven bone etrates alveolar mucosa.
(matrix vesicle-based process) and lamellar ii. Rectangular flap
bone (osteoblast–secretion process). ● Rectangular flap is formed by an intrasulcular,
● The osteoblasts secrete collagen rich ground horizontal incision and two vertical releasing
substance along with alkaline phosphatase incisions.
(which helps in mineralization). Indications
● New bone formation takes place in about ● Periapical surgery
6 days after surgery and the defect (ap- ● Mandibular anterior teeth and long roots
proximately 10 mm) is filled by 16 weeks. such as maxillary canines

Cementogenesis (cementoblasts) Advantages:
● Precementoblasts derived from ectomesen- ● Provides maximum access and visibility and
chymal cells in the tooth germ attach to the reduces retraction tension
periphery of the resected root and help in Disadvantages:
cementogenesis, which begins 10–12 days ● Reduces blood supply to flap
after root resection. ● Increased incision and reflection time
● The cementum covers the resected root end ● Difficulty in the reapproximation of the flap
in approximately 28 days to form a double margins

seal (mechanical closure and cementum ● Gingival attachment violated
closure of the root). ● Gingival recession
● The PDL fibres realign to extend from cemen- ● Crestal bone loss
tum to the newly formed bone in 8 weeks. ● May uncover dehiscence
● Suturing is more difficult

Q.3. Classify different flap designs used in surgical end-
● Not recommended for posterior teeth
odontics and add a note on Luebke-Ochsenbein flap.
Ans.
Classification of surgical flaps (according to Gutmann {SN Q.7}
and Harrison) iii. Trapezoidal flap
A. Full mucoperiosteal flaps (sulcular full-thickness flap) ● It is similar to the rectangular flap except that the
i. Triangular flaps (one vertical releasing incision) two vertical releasing incisions intersect the hori-
ii. Rectangular flaps (two vertical releasing incisions) zontal, intrasulcular incision at an obtuse angle.
iii. Trapezoidal flaps (broad-based rectangular) not ● The design was assumed to provide a better blood
used supply to the flapped tissues.
iv. Horizontal flaps (no vertical releasing incision) ● Since the blood vessels and collagen fibres in the
B. Limited mucoperiosteal flaps mucoperiosteal tissues are oriented in a vertical di-
i. Submarginal curved (semilunar) rection, the angled vertical releasing incisions will
ii. Submarginal scalloped rectangular (Luebke- sever more of these vital structures. This will result
Ochsenbein) in more bleeding and shrinkage of the tissue and
iii. Free rectilinear submarginal flap (mucogingival hence is contraindicated in periradicular surgery.
flap)
iv. Horizontal/envelope flap ● Enhanced visibility and access

● Formed by a horizontal, intrasulcular incision ● Ease in repositioning
with no vertical releasing incisions. ● Maintains integrity of gingival attachment
● It has limited surgical access and hence limited ● Prevents gingival recession
applications. ● Prevents crestal bone loss
Indications Disadvantages:
● Repair of cervical defects such as root perfo- ● Horizontal component disrupts blood supply.
rations, resorption and caries ● Vertical component crosses mucogingival
● Hemisections and root amputations junction and may enter muscle tissue.
. Limited mucoperiosteal flaps
B ● Difficult to alter if the size of the lesion is
misjudged.
iii. Free-form rectilinear submarginal flap (muco-
{SN Q.2} gingival flap)
i. Semilunar flap or submarginal curved flap ● This flap design is similar to Luebke-Ochsenbein.
● It is formed by a curved incision, beginning in ● It has parallel vertical releasing incisions.
the alveolar mucosa, extending into the attached Q.4. Discuss apicoectomy and the postoperative compli-
gingiva and then curves back into the alveolar cation of apicoectomy.
mucosa.
● This flap design is not recommended for perira- Ans.
dicular surgery. Apicoectomy means surgical resection of the apex of
Indications the root.
l In the presence of aesthetic crowns
Indications
l Trephination
l When the anatomy of canal system has not been
Advantages: conductive to the nonsurgical treatment.
l Reduces incision and reflection time thereby
l When root tip is resorbed or fractured or when iatro-
reducing operating time genic perforation or ledges prevent apical sealing.
l Maintains integrity of gingival attachment
l If a root canal filling fails and retreatment cannot be
l Eliminates potential crestal bone loss
effected by orthograde means.
Disadvantages: l When a retrograde filling must be placed in an apex
l Limited access and visibility
because of unremovable obstruction in root canal.
l Tendency for increased haemorrhage
l In cases of deficient apical seal where root canal fill-
l Crosses root eminences
ing may extrude through the apical foramen.
l May not include the entire lesion
l The presence of necrotic material at the apex between
l Predisposed to stretching and tearing
the interface of root canal filling and canal wall.
l Poor healing associated with scarring
{SN Q.5}
ii. Luebke-Ochsenbein flap or submarginal scal-
loped rectangular flap Steps
● Radiograph is taken to determine the level at
● It is a modification of the rectangular flap.
● The horizontal incision is not placed in the gin-

which the root should be amputated.
● Cleaning of the area involved with antiseptic
gival sulcus but in the buccal or labial attached
gingival and the base of the incision is wider. solution.
● Administering local anaesthesia.
● The horizontal incision is scalloped and follows
● Design of mucoperiosteal flap and reflection of
the contour of the marginal gingiva above the
free gingival groove. mucoperiosteal flap.
● The mucoperiosteal flap is raised to make an
Indications
● Presence of crowns
opening into the periapical region.
● Extend the opening in the labial plate to obtain
● Periapical surgery
● Anterior region
good access to the limits of the defect.
● Bone removal is done for access to root tip, then
● Teeth with longer roots
● Wide band of attached gingiva

with a fissured cylindrical bur amputate the root at
Advantages: the appropriate level.
● Root tip resection and curettage.
● Ease in incision and reflection
● To establish drainage, an I-shaped or ‘Christmas tree’

● Retro preparation and retrograde filling done to
drain cut from a rubber dam or a piece of iodoform
seal the root apex.
gauze can be placed (suturing is optional) in the incision.
● Debridement.
● The drain should be removed after 2–3 days and if it is
● Suture the mucoperiosteal flap and maintain firm
not sutured, the patient may remove the drain at home.
pressure over the area for 10 min.
● Follow-up the case and obtain a postoperative ra- Q.3. Radisection.
diograph to check the level of root amputation and Ans.
future comparison.
● Radisection means the removal of one or more roots of
a molar.
Postoperative complications Indications
● Excessive bone cutting can cause mobility of the ● When endodontic treatment of one root is technically
tooth. impossible or when such treatment has failed
● Loss of bone support to the adjacent tooth. ● When untreatable furcation involvement is present and
● Haemorrhage – granulation tissue tends to bleed removal of the root will facilitate oral hygiene in that area
profusely and can be controlled by complete curet- ● When extensive loss of bone has occurred around one
tage and by packing the cavity with wet gauze. root of an upper molar
● Perforation in the nasal cavity leading to oroantral/ ● In a fractured root of an upper molar
nasal fistula. ● Root perforation which cannot be treated endodontically
● Damage to mental nerve or to inferior alveolar canal ● When a root has been destroyed by extensive decay
if the tooth is in that region.

Contraindications
Q.5. Describe the outline of technique for immediate ● When loss of bone involves more than one root and the
root resection. remaining root would have inadequate support
● When the bridge span is long and the abutment tooth
Ans.
would lend inadequate support
[Same as LE Q.4] ● When the roots are fused
Technique of root resection

SHORT ESSAYS: ● Administer local anaesthesia and probe the area to de-
termine the extent and outline of alveolar bone destruc-
Q.1. Replantation.
tion around the root to be removed.
Ans. ● Elevate the mucoperiosteal flap and with the contraan-
gle handpiece and cross-cut bur severe the root where it

[Ref LE Q.1]
joins the crown and remove the root.
Q.2. Incision and drainage. ● With a stone or diamond point smooth the resected root
stumps and contour the tooth.
Ans.
● Scale and plane the root surface area.
Incision ● Clean the area and replace the flap and suture and cover
● After anaesthesia, the incision is made vertically with a it with a periodontal pack.
No. 11 scalpel. ● Remove the pack and suture after 1 week.
● Vertical incisions are parallel with the major blood ves-

Q.4. Indications and contraindications for endodontic
sels and nerves and leave very little scarring.
surgery.
● The incision should be made firmly through periosteum
to bone. Ans.
● If the swelling is fluctuant, pus usually flows immedi-
Indications of endodontic surgery
ately, followed by blood.
i. Need for surgical drainage
● If the swelling is nonfluctuant, the predominant drain-
ii. Failed nonsurgical endodontic treatment, e.g. irre-
age is blood.
trievable root canal filling material or an intrara-
Drainage dicular post
● After the initial incision, a small dosed haemostat may iii. Calcific metamorphosis of the pulp space
be placed in the incision and then opened to enlarge the iv. Procedural errors like instrument fragmentation,
draining tract and this procedure is indicated with more nonnegotiable ledging, perforation of root or symp-
extensive swellings. tomatic overfilling
v. Anatomic variations like root dilacerations or api- Advantages:

cal root fenestration ● Ease in incision and reflection
vi. Biopsy ● Enhanced visibility and access
vii. Corrective surgery, e.g. root resorptive defects, root ● Ease in repositioning
resection and hemisection ● Maintains integrity of gingival attachment
viii. Replacement surgery ● Prevents gingival recession
Contraindications of endodontic surgery ● Prevents crestal bone loss
i. Anatomic factors, e.g. proximity to nerve bundle or
Disadvantages:
maxillary sinus
● Horizontal component disrupts blood supply
ii. Periodontal status
● Vertical component crosses mucogingival junction and
● Medical factors
may enter muscle tissue
● Leukaemia or neutropenia
● Difficult to alter if the size of the lesion is misjudged
● Uncontrolled diabetes
● Recent heart surgery Q.6. Hemisection.

● Cancer, etc
iii. Postponement of surgery Ans.

● Patients on anticoagulants
● Radiation therapy of jaw

{SN Q.6}
● Surgeon’s skill Hemisection is a procedure in which one root and its
Q.5. Flap design for endodontic surgeries. Add a note on corresponding crown portion are cut and removed.
Luebke-Ochsenbein flap design and advantages. Indications
● Periodontal involvement of one root is severe.
Ans. ● Bone loss is extensive in the furcation area.
● When caries involves much of the roots.

Classification of surgical flaps (according to Gutmann
and Harrison) Technique
● In this procedure, half of the crown is removed alone
A. Full mucoperiosteal flaps (sulcular full-thickness flap)
i. Triangular flaps (one vertical releasing incision) with one of roots of mandibular molar.
● The retained mesial and distal halves serve as abut-
ii. Rectangular flaps (two vertical releasing incisions)
iii. Trapezoidal flaps (broad-based rectangular) not ment for prosthesis or restoration.
used
iv. Horizontal flaps (no vertical releasing incision). Bicuspidization/bisection
● Molar is cut into two separate mesial and distal portions
B. Limited mucoperiosteal flaps
i. Submarginal curved (semilunar) without the removal of any part of the root or crown.
● It is done when the mandibular molars exhibit proper
ii. Submarginal scalloped rectangular (Luebke-
Ochsenbein) anatomic features and stability.
● Molar with divergent roots and bone loss restricted to
iii. Free rectilinear submarginal flap (mucogingival flap) furcation areas are ideal for bicuspidization.
● The tunnel-like effect of the furcation involvement is elimi-
{SN Q.3} nated by creating two separate teeth from single molar.
● The portion of the teeth will require crowns.
Luebke-Ochsenbein flap or submarginal scalloped
rectangular flap Q.7. Retrograde amalgam filling.
● It is a modification of the rectangular flap.
Ans.
● The horizontal incision is not placed in the gingival
sulcus but in the buccal or labial attached gingival

{SN Q.11}
and the base of the incision is wider.
● The horizontal incision is scalloped and follows the ● A retrograde filling is placed in the apically resected
contour of the marginal gingiva above the free gingi- root when the canal is poorly sealed from the sur-
val groove. rounding tissue.
● The technique depends on the accessibility of the
Indications
root tip in the operative site, the presence of hazard-
● Presence of crowns
ous anatomic structures surrounding the surgical site.
● Periapical surgery
● Anterior region Materials used

● Teeth with longer roots ● Zinc and zinc-free amalgam – widely used
● Wide band of attached gingiva ● ZOE cements
● Cavity SHORT NOTES:

● Polycarboxylate cement Q.1. Bicuspidization.
● Glass ionomer cement
Ans.
● Composite fillings
● Zinc phosphate cement ● Molar is cut into two separate mesial and distal
● Silver cones portions without the removal of any part of the root or
● Gold foil crown.
● It is done when the mandibular molars exhibit proper
anatomic features and stability.

● Molar with divergent roots and bone loss restricted to
Technique
● The cavity in the bevelled surface of the root is prepared furcal areas are ideal for bicuspidization.
● The tunnel-like effect of the furcation involvement is
for a retrograde filling with small, round burs followed
by inverted cone burs. eliminated by creating two separate teeth from single
● The ideal preparation has the smallest exposed surface
molar.
● The portion of the teeth will require crowns.
at the apex.
● Debride the operative site, wipe and dry the root tip and Q.2. Semilunar incision.
isolate the root tip with sterile cotton pellets to prevent
any seepage into the cavity. Ans.
● Place a varnish over the prepared cavity. [Ref LE Q.3]
● Pack the amalgam into the cavity using a retrofilling
amalgam carrier or a plastic instrument and condense Q.3. Luebke-Ochsenbein flap design.
amalgam with a retro fill amalgam plugger. Ans.
● Wipe and adapt the margins of amalgam to dentine/with
a moist cotton pellet. [Ref SE Q.5]

● Remove all the cotton pellets surrounding the root apex, Q.4. Replantation.
cautiously.
● Irrigate the wound with sterile saline or anaesthetic so-
Ans.
lution and aspirate the solution thoroughly to debride ● Replantation is replacement of a tooth in its socket,
the wound site. with the object of attaining reattachment when the tooth
● Examine the root tip, filling and surrounding tissue, has been completely avulsed from its socket by an
both visually and radiographically to that the canals accident.
have been properly sealed.
Intentional replantation
Q.8. Reimplantation. ● Intentional replantation is defined as an act of deliber-
Ans. ately removing a tooth and following examination, diag-
nosis, endodontic manipulation and repair returning the
[Same as SE Q.1] tooth to its original socket.
Q.9. Intentional replantation. Sequelae of replantation
● Surface resorption
Ans.
● Inflammatory (infection-related) resorption
[Same as SE Q.1] ● Replacement (ankylosis-related) resorption
● Root canal treatment
Q.10. Indications and contraindications for intentional
reimplantation. Q.5. Apicoectomy.
Ans. Ans.
[Same as SE Q.1] [Ref LE Q.4]
Q.11. Replantation of avulsed tooth. Q.6. Hemisection.
Ans. Ans.
[Same as SE Q.1] [Ref SE Q.6]
Q.12. Luebke-Ochsenbein flap. Q.7. Trapezoidal flap.
Ans. Ans.
Q.8. Splinting. Periradicular curettage:

● Removal of pathologic soft-tissue surrounding the apex
Ans.
● It provides access and visibility of the apex
● Physiological or semirigid splint is used. ● It removes inflamed tissue
● Tooth is splinted for 7–10 days. ● Provides a biopsy specimen for histological exami-
● Splints used are acid etch resin, soft arch wire, orth- nation
odontic bracket, Ribbond fibre splint and titanium ● Reduces haemorrhage
splint. ● The tissue should be carefully peeled out, ideally in
● Patient should be advised to eat soft food and not to bite one piece, with a suitably sized sharp curette and
on splinted tooth. process should leave a clean bony cavity
● Avulsed tooth is relieved of premature occlusal contact.
Q.11. Retrograde fillings.
Q.9. Flaps for endodontic surgery.
Ans.
Ans.
[Ref SE Q.7]
Classification of surgical flaps (according to Gutmann
Q.12. Intentional replantation.
and Harrison):
A. Full mucoperiosteal flaps (sulcular full-thickness flap) Ans.
● Triangular flaps
[Same as SN Q.4]
● Rectangular flaps
● Trapezoidal flaps Q.13. Sequelae of replantation.

● Horizontal flaps
Ans.
B. Limited mucoperiosteal flaps
● Submarginal curved or semilunar [Same as SN Q.4]
● Luebke-Ochsenbein flap
Q.14. Flap designs in endodontics surgery.
Q.10. Periapical curettage.
Ans.
Ans.
[Same as SN Q.9]
Topic 16
Endodontic Periodontal Inter-relationships
LONG ESSAYS:
1. Classification of endodontic–periodontic lesions.
SHORT ESSAYS:
1 . Write in detail about hemisection and radisection.
2. Classification of endo-perio lesions. [Ref LE Q.1]
SHORT NOTES:
1. Perioendodontic therapy. [Ref LE Q.1]
SOLVED ANSWERS
LONG ESSAYS: III. Lesions that require combined endodontic–
periodontic treatment procedures
Q.1. Classification of endodontic–periodontic lesions. i. Any lesion in group I that results in irre-
Ans. versible reactions in the attachment appara-
tus and requires periodontal treatment
Stock et al. in 2004 defined endo-perio lesion as ‘a lo- ii. Any lesion in group II that results in irre-
calized periodontal probing depth of pulpal or periodontal versible reactions in pulp tissue and also
origin’. requires endodontic treatment}
Classifications of endodontic–periodontal lesions B. Simon’s classification
A. Grossman’s classification ● Classification proposed by Simon et al. is most
B. Simon’s classification widely followed and is as follows:
C. Weine’s classification According to Simon et al. (1972), Classification Based
[SE Q.2] on Aetiology, Diagnosis, Prognosis and Treatment:
I. Primary endodontic lesion
{A. Grossman’s classification II. Primary periodontal lesion
Grossman proposed a classification based on treat- III. Primary endodontic lesion with secondary peri-
ment needs and categorized them broadly as men- odontal involvement
tioned below: IV. Primary periodontal lesion with secondary end-
I. Lesions that require endodontic treatment pro- odontic involvement
cedures only V. True combined lesions
II. Lesions that require periodontal treatment pro-
cedures only I. Primary endodontic lesion
III. Lesions that require combined endodontic– Causes:
● Caries, restorations and traumatic injuries
periodontic treatment procedures
associated with pulpal involvement.
I. Lesions that require endodontic treatment ● The above causes lead to endodontic pa-
procedures only will include thology. The lesions resorb bone apically
i. Any tooth with necrotic pulp and apical and laterally, which result in the destruction
granulomatous tissue with or without sinus of attachment process adjacent to the nonvi-
tract tal tooth.
ii. Chronic periapical abscess with sinus tract ● A sinus tract may be present that opens
iii. Root fractures – longitudinal and horizontal through periodontal ligament on to the gin-
iv. Root perforations – pathologic and iatro- giva or gingival sulcus.
genic Clinical features:
v. Endodontic implants ● Pain, tenderness on percussion, swelling in
vi. Replants – intentional or traumatic the marginal gingiva and periodontal abscess
vii. Transplants – autotransplant or allotrans- Diagnosis:
plant ● Negative vitality test and absence of prob-
viii. Teeth that require hemisection ing confirm a primary endodontic lesion
II. Lesions that require periodontal treatment pro- Treatment:
cedures only include ● Endodontic treatment alone is sufficient
i. Occlusal trauma, causing reversible pulpitis II. Primary periodontal lesions
ii. Occlusal trauma as well as gingival inflam- ● Periodontal disease is progressive in nature
mation resulting in pocket formation and Causes:
reversible pulpitis ● Local factors such as plaque and calculus
iii. Suprabony or infra bony pocket formation initiate gingivitis, when untreated this leads
treated with overzealous root planning and to destruction of the bone, periodontal liga-
curettage leading to pulpal sensitivity ment and cementum.
iv. Extensive infrabony pocket formation ex- Clinical features:
tending beyond the root apex and some- ● The epithelial attachment migrates apically
times coupled with lateral or apical resorp- leading to broad-base pocket formation,
tion yet with pulp that responds within mobility of teeth, widespread bone loss.
normal limits to clinical testing ● Patient usually has generalized periodontitis.
Diagnosis: ● Mild periodontitis when not treated can

● Increased probing depth, widespread lesion, progress to advanced periodontitis, apical
generalized involvement, mobility, furca- progression of periodontal pocket may con-
tion involvement, purulent discharge with tinue until apical tissues are involved and
positive vitality test confirms periodontal pulp may become necrotic.
lesion. Clinical features:
Treatment: ● Deep pocket
● Exclusive periodontal treatment. ● History of periodontal disease
● Prognosis depends on the extent of lesion and ● Pain due to pulpal involvement
patients ability to comply with potential long- Diagnosis:

term treatment and maintenance therapy. ● Radiograph reveals radiolucency at the root
III. Primary endodontic lesions with secondary apex

periodontal involvement ● Vitality test
Causes:
● Long-standing endodontic lesion left un-
{SN Q.1}
treated progresses to chronic stage with
destruction of periodontal tissues to the Treatment:
level of gingival sulcus. ● Endodontic treatment followed by periodontal treat-
● Simultaneous accumulation of plaque and ment.
calculus in the deepened sulcus, i.e. ● Prognosis may be poor in single rooted teeth com-
pocket, leads to an apical shift of the epi- pared to multirooted teeth like molars.
thelial attachment. ● Root resection may be considered as treatment option.
● This type of lesions can also occur in case
of root perforation during endodontic

treatment and misplaced pins and posts V. True combined lesions
during restoration of the crown. Causes:
● In this condition pulpal and periodontal dis-
Clinical features:
● Acute state presents abscess formation
ease may occur together in the same tooth.
● When both the lesions combine, they may
associated with swelling, pain, mobility,
exudates and pocket formation to a become clinically indistinguishable.
chronic state with no symptoms and sud- Clinical features:
● Pulpitis.
den appearance of a pocket with bleeding
● Periodontitis.
on probing.
● Prognosis of the teeth depends on the extent
● Root fractures may also present as pri-
mary endodontic lesions with secondary of destruction caused by periodontal com-

periodontal involvement. ponent.
Diagnosis: Treatment:
● Endodontic treatment is done. Periodontal
● There is a radiographic evidence of peri-
apical pathology and angular bone loss. treatment is done after a month so that end-
Treatment: odontic lesion would have healed to some
● Endodontic treatment followed by peri-
extent.
● Root resection or regenerative approaches
odontal treatment.
● Prognosis depends on the severity of peri-
are treatment options leading to better prog-
odontal involvement and efficacy of peri- nosis in multirooted teeth.
odontal treatment. C. Weine’s classification
IV. Primary periodontal lesions with secondary According to Weine (1972), classification based on
endodontic involvement aetiology and treatment plan:
● Class I: Tooth that clinically and radiographically
Causes:
● The influence of primary periodontal dis-
simulates the periodontal involvement, but it is
ease on the pulp is through: due to pulpal inflammation or necrosis
● Class II: Tooth that has both pulpal and periodon-
a. Dentinal tubules
b. Accessory canals and lateral canals tal disease occurring concomitantly
● Class III: Tooth that has no pulpal problem but
c. Apical foramen
d. Congenital absence of cementum requires endodontic therapy with root amputation
e. Developmental deep grooves, etc. to achieve periodontal healing
● Class IV: Tooth that clinically and radiographi- ● It is preferable to complete endodontic therapy before
cally simulates pulpal or periapical disease but, in resection of the root.
fact, has periodontal disease
Root resection depends on several criteria as follows:
● Ideally, the root with the greatest amount of bone loss
SHORT ESSAYS: and attachment loss is removed since after surgery suf-
ficient periodontal attachment must remain for the tooth
Q.1. Write in detail about hemisection and radisection.
to withstand the functional demands placed on it.
Ans. ● The root with the greatest number of anatomic problems
such as severe curvature, developmental grooves, root

Hemisection
flutings or accessory and multiple root canals would be
● Hemisection is the splitting of a two-rooted tooth into
decided upon for removal first.
two separate parts. Here, both the root and the associ-
● The root that is easiest for periodontal maintenance is
ated part of the crown are removed.
retained.
● Bicuspidization also involves splitting of a two-rooted
tooth into two sections, but it does not involve removal Procedure of root resection:
of the root. Each portion is restored with crowns. ● The procedure involves making a cut on the surface of
the root to be resected using a high-speed, surgical
Procedure of hemisection:
length fissure or crosscut fissure carbide bur.
● After the elevation of both buccal and lingual flap, a verti-
● A through and through cut is made before an elevator is
cally oriented cut is made faciolingually through the buccal
placed to remove the fragment, complete separation of
and lingual developmental grooves of the tooth, through
it should be verified.
the pulp chamber and through the furcation, in case of a
● The root should move independent of the crown. The
hemisection, the sectioned root along with its crown por-
area is well irrigated and inspected. Overhangs and sharp
tion is removed from the socket and any overhangings on
edges should be eliminated, and the tooth surface and the
the adjacent retained fragment are then smoothened.
bone surface are shaped to provide a cleanable area.
● The flaps are then sutured back with or without the use
● Root resection is a predictable treatment option that
of bone grafts.
may help maintain a portion of a strategic tooth.
● As the removal of a portion of the tooth or just the root
in case of root resection alters the load-bearing capacity Q.2. Classification of endo-perio lesions.
of the tooth, it is essential to adjust the occlusion. Cen-
Ans.
tric contacts should be maintained but eccentric contacts
should be eliminated. [Ref LE Q.1]
● Temporary splinting of the retained fragment to the ad-
jacent teeth may also help in the distribution of the oc-

clusal forces. SHORT NOTES:
Root resection (radisection) Q.1. Perioendodontic therapy.
● Root resection or amputation may be considered when
Ans.
severe isolated bone loss occurs around an individual root.
● It can also be done in other situations like root resorp- [Ref LE Q.1]
tion, vertical root fracture and root perforation during
endodontic therapy.
Topic 17
Lasers and Endodontic Implants
SHORT ESSAYS:
1 . Endodontic implants.
2. Lasers.
3 . Endodontic endo-osseous implants. [Same as SE Q.1]

4. Applications of lasers in endodontics. [Same as SE Q.2]
SHORT NOTES:
1 . Endo-osseous implants. [Ref SE Q.1]
2. Classification of lasers.
3. Mention advantages and disadvantages of lasers.
4. Applications of lasers in endodontics.
5. Mention few hazards of lasers in endodontics.
6. Uses and indications of endodontic implants. [Same as SN Q.1]
SOLVED ANSWERS
SHORT ESSAYS: 40 mm in sequential sizes and implants of corresponding
size.
Q.1. Endodontic implants.
Steps
Ans. ● Anaesthetize the tooth and involved area.
● Application of rubber dam.
● Access preparation wider and larger in the clinical

{SN Q.1} crown to accommodate rigid implant.
An endodontic implant is a metallic extension of the root ● Enlargement of the root canal up to 60 size reamer/file.
with the objective of increasing the crown root ratio to ● Irrigation of the root canal.
give the tooth better stability. ● Set a marker on the 40 mm reamer/file at a level equiva-
Uses and indications lent to the length of the tooth plus the distance in mil-
● Periodontally involved teeth requiring stabilization. limetres the implant will extend beyond the root apex.
● Transverse root fracture involving loss of the apical ● The first 40 mm reamer used to perforate the root apex
fragment or the presence of two fragments that can- should be several sizes smaller than the last sized instru-
not be self-aligned. ment used to complete the preparation of the root canal.
● Pathologic resorption of the root apex due to a ● The last 40 mm reamer is used and the bone is reamed
chronic infection. to the desired length.

● A nonvital tooth with an unusually short root. ● Irrigate the canal with saline or anaesthetic solution
● Internal resorption affecting the integrity and strength rather than sodium hypochlorite which may irritate the
of the root. periapical tissues.
● Dry the canal with sterile absorbent points.
● Select an implant of equivalent size to the last instru-
ment used and insert it into the root and bone.

Disadvantage
● The implant must fit tightly and must penetrate the bone
● Poor apical seal leading to periapical rarefaction around
to the prepared length.
the root apex.
● Extrusion of excessive sealer through the apical fora- Q.2. Lasers.
men into the periapical tissues with resulting irritation.
Ans.
● Limitation in the length of the osseous portion of implant
by local anatomic factors in the maxilla or mandible. ● The term LASER is an acronym that stands for ‘light
● Perforation of the lateral root surface or perforation of a amplification by simulated emission of radiation’. A
curved root near the root apex. laser is a device that produces and amplifies light.
● A structurally weakened tooth biomechanically pre- ● In 1971, Weichman and Johnson reported the first laser
pared to a much larger size than usual, to receive an use in endodontics.

inflexible implant, which may fracture during function.
Applications of lasers in endodontics are as follows:
Technique i. Dentinal hypersensitivity
● Chrome cobalt implants and titanium implants are ii. Indirect pulp capping
available. iii. Direct pulp capping
● Equipment required are same as for endodontic treat- iv. Access cavity preparation and enlargement of root
ment, with the addition of a series of extra-long reamers, canal orifice
v. Sterilization and disinfection of infected root canals ● Er:YAG and ErCr:YSGG lasers are indicated
vi. Obturation of the root canals for vital extirpation of the infected root canals
vii. Apicoectomy and periapical curettage as well as in cases with limited mouth opening
viii. Photoactivated disinfection (PAD) where instrument insertion is difficult and also
in cases where it is difficult to locate the root
i. Dentinal hypersensitivity
canal orifice.
● The LASERS used in the treatment of dentinal hy-
● Only straight and slightly curved canals are in-
persensitivity are divided into two groups:
dicated for applying lasers.
a. Low-output power lasers
● The laser tip must slide gently from apical to the
Examples: Helium–Neon (He–Ne) and Gallium–
coronal portion, while pressing the laser tip to
Aluminium–Arsenide (Ga–Al–As).
the root canal wall under water spray.
b. Middle-output lasers: Nd:YAG and CO2 lasers.
v. Sterilization and disinfection of infected root canals
● The laser-induced reduction in dentinal hypersensi-
● Because of their energy and wavelength character-
tivity is based on two mechanisms that differ greatly
istics, the laser is an effective tool for killing micro-
from each other as follows:
organisms.
The first mechanism:
● Various lasers tested are Pulsed Nd:YAG, argon,
● It implies the direct effect of laser irradiation on
semiconductor diode, CO2 and Er:YAG.
the electric activity of nerve fibres within the
● 38% silver ammonium solution, 5.25% sodium hy-
dental pulp.
pochlorite or 17% EDTA can be placed in the canal
The second mechanism:
before laser irradiation, to increase the effect of
● Involves modification of the tubular structure of
sterilization in the infected root canal.
the dentine by melting and fusing of the hard
vi. Obturation of the root canals
tissue or smear layer followed by sealing of the
● Laser can be used as a heat source to soften the
dentinal tubules.
gutta-percha and used in the root canals.
ii. Indirect pulp capping
● Studies have shown that it is possible to obturate
● The discovery of closure of dentinal tubules by la-
root canals using gutta-percha segments and a
ser energy and the sedative effects on pulpitis has
pulsed Nd:YAG laser as gutta-percha is thought to
led to the development of several new treatments
be melted by laser energy.
that are soon to be put into practice.
vii. Apicoectomy and periapical curettage
● Lasers commonly used are pulsed Nd:YAG and
● A new laser Er, Cr:YSGG laser has been developed
CO2 lasers.
which can be used to carry out apicoectomy, retro-
● It is indicated in deep cavities, hypersensitive cavi-
grade endodontic apical root end cavity preparation
ties and cavities that require sedative treatment.
and periapical curettage. The laser parameters
● The outcome of pulp capping procedure is unpre-
should be determined based on the size and length
dictable.
of the root apex that is to be cut.
iii. Direct pulp capping
Indications:
● A laser treatment has advantage with respect to the
● Root canals with fractured instruments.
control of haemorrhage.
● Cases with continuing clinical symptoms like
● Lasers which can be used are CO2 laser, pulsed
nonhealing sinus tracts with pus discharge.
Nd:YAG, argon, semiconductor diode and Er:YAG.
viii. PAD
● When using CO2 laser, calcium hydroxide paste
● Low-power laser energy in itself is not particularly
should be placed on the exposed pulp after laser
lethal to bacteria, but is useful for photochemical
treatment.
activation of oxygen-releasing dyes.
Indications of direct pulp capping are
● The released oxygen causes damage to the mem-
● Pulp exposure must be 2 mm or less.
brane and DNA of the microorganisms.
● There should not be any infection in the pulp.
● The PAD technique can be undertaken with a range
● A success rate of around 89% has been reported.
of visible red and near infrared lasers, and systems
iv. Access cavity preparation and enlargement of root
using low-power (100 mW) visible red semicon-
canal orifice
ductor diode lasers and tolonium chloride (toluidine
Laser systems used for root canal preparation are as
blue) dye.
follows:
● Initially PAD used He–Ne laser, over a period
● Thin optical fibre: Nd:YAG, Er, Cr:YSGG,
of time they have been substituted with high-
argon and diode.
efficiency diode lasers, which operate at the same
● Hollow tube: CO2 and Er:YAG.
wavelength.
● Photoactivated dyes can be applied effectively for Q.3. Mention advantages and disadvantages of lasers.
killing Gram-positive bacteria, Gram-negative bac-
Ans.
teria, fungi and viruses.
● Major clinical application of PAD includes disin- The various advantages and disadvantages of lasers are
fections of root canals, deep carious lesions, peri- as follows:
odontal pocket and sites of periimplantitis.
Advantages:
Q.3. Endodontic endo-osseous implants. i. Provides more sterilized environment
ii. Minimal bleeding and pain
Ans.
iii. Reduced risk of infection
[Same as SE Q.1] iv. Faster healing
Q.4. Applications of lasers in endodontics. Disadvantage:
i. Expensive
Ans.
ii. Specially trained personnel required
[Same as SE Q.2] iii. Chances of explosion
Q.4. Applications of lasers in endodontics.
SHORT NOTES: Ans.
Q.1. Endo-osseous implants. Soft tissue applications:
● Pulp capping, pulpotomy, apicoectomy, curettage, hae-
Ans.
mostasis and incision and drainage of abscesses
[Ref SE Q.1]
Hard tissue applications:
Q.2. Classification of lasers. Caries removal, access cavity preparation, biomechanical
preparation, root canal debridement and cleaning
Ans.
Various types of lasers used in several endodontic pro-
● LASER stands for light amplification by stimulated cedures are
emission of radiation.
● Lasers are devices that produce beams of coherent and Endodontic procedure Lasers used
very high intensity light. ● Vitality tests ● He–Ne
● Various types of lasers are used in dentistry; they have
● Sterilization of root canal ● CO2, Nd:YAG
been classified as follows:
● Root canal preparation ● Excimer, Nd:YAG
Classification
● Sealing the apical delta ● CO2, Nd:YAG
Based on application
i. Soft tissue lasers
ii. Hard tissue lasers Q.5. Mention few hazards of lasers in endodontics.
Based on type of medium used Ans.

i. Solid A few hazards caused by lasers are as follows:
ii. Liquid ● Tissue damage
iii. Gas ● Ocular injury/retinal burn if there is no protection
● Aerosols contamination – leading to respiratory hazards
Based on type of interaction with surface
● Fire and explosion hazards
i. Contact lasers
● Electric hazards
ii. Noncontact lasers
Based on level of energy emission Q.6. Uses and indications of endodontic implants.
i. Soft lasers Ans.
ii. Hard lasers
[Same as SN Q.1]
Based on wavelength
i. Long wavelength, e.g. infrared laser
ii. Short wavelength, e.g. ultraviolet laser
Topic 18
Single-Visit Endodontics
SHORT NOTES:
1. Single-visit endodontics.
SOLVED ANSWER
SHORT NOTES: Guidelines recommended for single-visit endodontics
● Accurate diagnosis and treatment planning.
Q.1. Single-visit endodontics. ● Proper case selection.
Ans. ● Well-trained, skilled and experienced clinicians should
undertake this procedure.

● Single-visit endodontics may be described as a conser- ● The procedure should be completed within 60 min.
vative nonsurgical treatment of an endodontically in- ● The dental assistant should be quick and well trained,
volved tooth, which comprises all the steps in root canal which saves the treatment time.
treatment starting from access opening and biomechan-
ical preparation till obturation of the root canal in one
visit.
Topic 19
Bleaching of Discoloured Tooth
LONG ESSAYS:
1. Mention the causes of discolouration of teeth.
2. Describe the procedures of bleaching nonvital endodontically treated tooth.
3. Describe in detail the classification and various treatment options of discoloured anterior teeth. [Same as LE Q.1]
4. What are the causes for discolouration of teeth? Describe walking bleach technique. [Same as LE Q.1]
5. Mention the various causes for discolouration of teeth. Describe the techniques of bleaching vital discoloured
teeth. [Same as LE Q.1]
6. Discuss the management of a case with an injury to upper central incisor tooth without pulp exposure but with
subsequent history of discolouration of the tooth? [Same as LE Q.1]
7. Describe the causes of discolouration of anterior teeth. How will you proceed to restore the aesthetics of these
teeth? [Same as LE Q.1]
8. Enumerate the cause of discolouration of tooth. Discuss the various methods of bleaching and procedure to
prevent the recurrences of discolouration. [Same as LE Q.1]
9. How will you manage a case of discoloured nonvital central incisor? [Same as LE Q.2]
10. Describe the rational of bleaching a discoloured nonvital tooth. Describe extracoronal bleaching procedure in
a tetracycline stained tooth. [Same as LE Q.2]
SHORT ESSAYS:
1 . Describe briefly bleaching of fluorosis stains.
2. Describe briefly one technique of bleaching of vital teeth. [Ref LE Q.1]
3. Superoxol.
4. Night guard bleaching. [Same as SE Q.2]
SHORT NOTES:
1. Thermocatalytic technique of bleaching.
2. Bleaching.
3. Causes of intrinsic discolouration of teeth.
4. Indications of ‘night guard bleaching’. [Ref LE Q.1]
5. Hydrogen peroxide.
6. Procedures of bleaching a nonvital maxillary central incisor after endodontic treatment.
7. Classification of tetracycline discoloured teeth.
8. Matrix bleaching. [Ref LE Q.1]
9. Bleaching agents. [Same as SN Q.2]
10. Nonvital bleaching. [Same as SN Q.6]
11. Home bleaching. [Same as SN Q.8]
SOLVED ANSWERS
LONG ESSAYS: ● Amelogenesis imperfecta or dentinogenesis imper-
fecta are intrinsic stains that are impossible to
Q.1. Mention the causes of discolouration of teeth. eliminate because they originate from developmen-
Ans. tal defects of the enamel and dentine.
● Stains due to pulp necrosis can usually be removed
Discolouration of tooth is classified as follows: by bleaching procedures.
1. Extrinsic discolouration Causes of tooth discolouration
● It is found on the outer surface of the teeth or ac-
I. Local causes:
quired pellicle and is usually of local origin such as ● Decomposition of pulp tissue
tobacco stains. ● Excessive haemorrhage following pulp removal
The origin of stain may be due to following substances: ● Trauma
i. Metallic: ● Medicaments
● Occupational exposure to metallic salts
● Filling materials
● Medicines containing metal salts
II. Systemic causes:
ii. Nonmetallic: ● Congenital porphyria – red or purple discolou-
● Dietary components.
ration is seen
● Beverages.
● Hereditary opalescent dentine – violaceous dis-
● Tobacco.
colouration
● Mouth rinses.
● Endemic fluorosis – mottled brown discoloura-
● Medicaments.
tion
● Chromatogenic bacteria.
● Erythroblastosis fetalis – greyish-brown discol-
● Green colour discolouration is seen with the
ouration
Nasmyth’s membrane in children. ● Jaundice brown discolouration
● Silver nitrate stains are other types of extrinsic
● Tetracyclines – cause yellow to grey or brown
stains that are almost impossible to eliminate discolouration
without grinding as these stains penetrate the According to ingle causes of tooth discolouration
surface of the crowns. A. Patient-related causes
2. Intrinsic discolouration i. Pulp necrosis
● These are stains within the enamel and dentine
ii. Intrapulpal haemorrhage
caused by the deposition or incorporation of sub- iii. Dentine hyper calcification
stances with in these structures, such as tetracycline iv. Age
stains.
v. Tooth formation defects Contraindications

vi. Developmental defects i. Severe enamel loss
vii. Drug-related defects ii. Hypersensitive teeth
B. Dentist-related causes iii. Caries affected teeth
1. Endodontically related iv. Defective coronal restorations
i. Pulp tissue remnants v. Allergy to bleaching gels
ii. Intracanal medicaments vi. Bruxism
iii. Obturating materials Properties of mouthguard
2. Restoration related ● It should be strong enough to avoid damage by
i. Amalgam the patient during wear.

ii. Pins and posts ● It should be made of a bioinert material.
iii. Composites ● It should not cause irritation to the soft tissues,
Prevention of tooth discolouration gingivae, mucosa, tongue or teeth.

Discolouration of pulpless teeth can be prevented by ● It should be thin, smooth and polished to be
proper debridement. well tolerated in the mouth.

● All traces of blood should be removed by thor- ● It should fit comfortably with freedom of
ough irrigation. movement for the frenum attachments if the

● Any defective restorations should be replaced. ‘full vestibule’ design is used.
● Nonstaining medicaments and materials should ● It should have good retention and should be
be used. easy to clean and rinse.

● Root canal sealer and obturating materials should
be removed from the pulp chamber beyond a level [SE Q.2]

1–3 mm apical to the free gingival margin. {Technique
Various techniques of bleaching Natural teeth shade is determined with the help
●
Techniques for bleaching of vital teeth: of a shade guide then clinical photographs
A. Mouthguard bleaching should be taken before starting and as well as
B. In-office power bleaching during the procedure.
Techniques for bleaching endodontically treated teeth: ● The alginate impression is taken and a cast is
A. Internal (intracoronal) bleaching prepared. On the cast, plastic night guard of
B. ‘Walking bleach’ technique 2 mm thickness is fabricated that covers all the
C. Thermocatalytic bleaching teeth.
D. Ultraviolet (UV) photooxidation ● Patient is instructed to put two to three drops of
Other methods of bleaching: solution in the space in which the teeth to be
● Intentional and intracoronal bleaching bleached.
● Insert the night guard in the mouth and allow
(SE Q.2 and SN Q.8)
the excess material to extrude out.
{(Bleaching procedures for vital teeth ● Patient is asked to wear night guard during the
A. Night/mouth guard bleaching (matrix bleaching) sleep until the treatment is completed.
● It is also known as home bleaching and it is a re- ● Instruct the patient about the using of the
cently introduced outside dental office bleaching bleaching agent and the wearing of the guard.
procedure. The procedure is usually performed 3–4 h a
● It is safe and effective procedure for mildly disco- day, and the bleaching agent is replenished
loured teeth with high success rate and low cost. every 30–60 min.
● Employs l.5%–10% hydrogen peroxide (H2O2) or ● The guard should not be worn while eating. It
10%–15% carbamide peroxide that degrades may be worn while sleeping for better long-
slowly to release H2O2. The carbamide peroxide term aesthetic results.
products are more commonly used.)} ● Treatment should be for a period between 4
and 24 weeks.
● Recall the patient every 2 weeks to monitor
{SN Q.4}
stain lightening.
Indications Complications
i. Superficial enamel discolourations ● Systemic effects such as irritation of gastric
ii. Mild yellow discolourations and respiratory mucosa
iii. Brown fluorosis discolourations ● Dental hard tissue damage, pulpal damage and
iv. Discolourations related to ageing mucosal damage
● Tooth sensitivity v. Diode laser light:

● Damage to restorations} ● A true laser light produced from a solid-
B. In-office power bleaching state source. This type of laser produces no

● It is also known as thermocatalytic or thermopho- heat.
tocatalytic bleaching technique. ● It is ultra-fast taking 3–5 s to activate the
● This technique basically involves application of bleaching agent.

30%–35% H2O2 and heat or a combination of heat Procedure
and light or UV rays to the enamel surface. The steps involved in procedure of power bleach-
● Heat is applied either by electric heating devices ing are as follows:
or heat lamps. ● Make radiographs to detect the presence of
Advantages of power bleaching caries, defective restorations and proximity

● It saves time for the dentist. to pulp horns.
● It enables the patient’s preference to have their ● With the help of a shade guide evaluate
teeth bleached in one visit rather than spend tooth colour and take clinical photographs
several weeks on home bleaching techniques. before and throughout the procedure.
● It enables the option to isolate areas, such as ● Protect the gingival tissues with Orabase or
abfractions or erosions, with bonding agents to Vaseline and isolate the teeth with a rubber
prevent sensitivity. dam.
Light sources for power bleaching ● Do not inject a local anaesthetic.
i. Conventional bleaching light: ● Both patient and operator should wear pro-
● The conventionally used bleaching light tective sunglasses.

supplies energy simply by adding heat to ● Following thorough oral prophylaxis, apply
enhance the bleaching action of H2O2. 30%–35% H2O2 liquid on the labial surface
● The heat caused a more vigorous release of of the teeth using a small cotton pellet or a
oxygen and facilitated the dissolution of piece of gauze. A bleaching gel containing
the pigments. H2O2 may be used instead of the aqueous
● It was slow and often uncomfortable to the solution.
patient. ● Apply heat with a heating device or a light
ii. Tungsten–halogen curing light: source. The temperature should be main-

● The standard curing light provides heat tained between 125°F and 140°F (52–60°C).
and stimulates the initiation of the chemi- ● Do not exceed 30 min of treatment even if
cal reaction by activating the light sensitive the result is not satisfactory. Remove the
chemicals in the bleaching agent. heat source and allow the teeth to cool down
● This is a time-consuming process (i.e. for at least 5 min.
40–60 s per application per tooth). ● Remove the bleaching agent and irrigate
iii. Argon laser: thoroughly. Dry the teeth and gently pol-
● A true laser light is delivered to the chemi- ish them with a composite resin polishing
cal agent to stimulate the catalyst in the cup. Apply neutral sodium fluoride gel for
chemical. 3–5 min.
● There is no thermal effect; therefore, there ● Instruct the patient to use a fluoride rinse
will be less dehydration of the enamel and daily for 2 weeks.

subsequent rebound effect. ● Vitamin E is a powerful antioxidant; vita-
● The rapid treatment time of 10 per applica- min E capsules should be cut open and the
tion per tooth is an advantage for the clini- oil should be used if the clinician notices
cian and the patient. blanching of the tissues caused by the H2O2.
iv. Xenon plasma arc light: ● The vitamin E oil if immediately applied
● This nonlaser, high-intensity light produces to the area, it can reverse the soft tissue
a great amount of heat; hence, it is applied damage.
only for 3 s at a time. The action is thermal
and stimulates the catalyst in the chemical. Q.2. Describe the procedures of bleaching nonvital end-
● Compared to other sources, it is very fast; odontically treated tooth.
there is a greater potential for thermal trauma
for the pulp and surrounding soft tissues. Ans.
The various techniques involved in bleaching of pulp- B. Thermocatalytic bleaching technique

less teeth or endodontically treated teeth are as follows: ● It involves the placement of the oxidizing chemical,
A. Walking bleach technique generally 30%–35% H2O2 (Superoxol), in the pulp

B. Thermocatalytic technique chamber followed by heat application either by elec-
C. UV photooxidation/heat and light bleaching tric heating devices or specially designed lamps.
D. Intentional endodontics and intracoronal bleaching ● External cervical root resorption by thermocatalytic
approach caused by irritation to the cementum and

A. Walking bleach technique
periodontal ligament. This is possibly attributed to
● This technique involves intracoronal bleaching tech-
the oxidizing agent combined with heat.
nique along with home bleaching techniques.
● It is not indicated routinely.
Composition of bleaching agent
C. UV photooxidation
i. Superoxol
● After preparation of the tooth, a loose mat of cotton
ii. Sodium perborate
is placed on the labial surface and another is placed
Mechanism of action
in the pulp chamber of the tooth to be bleached.
● When the paste is sealed into the pulp chamber, it
● The loose cotton mats are saturated with Superoxol.
oxidizes and discolours the stain slowly, continu-
The solution is activated by exposing it to UV light
ing its activity over a longer period.
for 2 min.
Procedure
● The tooth is subject to several (equally 5–6 min) ex-
● The tooth is prepared by polishing the enamel
posures and replenishes the bleaching solution at
with prophylactic paste to remove debris. Petro-
frequent intervals.
leum jelly is applied to protect the gingiva against
● This causes oxygen release similar thermocatalytic
tissue irritation.
bleaching technique.
● Adapt the rubber dam and reestablish the access
D. Intentional endodontics and intracoronal bleaching
cavity. Remove any gutta-percha root canal filling
● It was advocated mainly for treating intrinsic tetra
that extends into the pulp chamber.
cycline discolouration which is difficult to treat from
● Seal the orifice of the root canal with at least 1 mm
the external enamel surface.
cavity over the gutta-percha to prevent percolation
● The technique involves standard endodontic therapy
of the bleaching agent into the apical area.
(pulpectomy, cleaning, shaping and obturation) fol-
● Remove the smear layer; open the tubule by apply-
lowed by an intracoronal walking bleach technique.
ing a 25% solution of citric acid or 30% solution
Preferably, only intact teeth without coronal defects,
of orthophosphoric acid to the dentinal surface.
caries or restorations should be treated.
● Flush the surface with sodium hypochlorite or
● This prevents the need for any additional restoration,
water to remove the acid. Flush the pulp chamber
thereby reducing the possibility of coronal fractures
with 95% alcohol and dry with air to dissociate
and failures.
the dentine.
● The most discoloured tooth should be selected for
● Mix sodium perborate powder with Superoxol to
trial treatment.
a thick paste in a dappen dish.
● Carry the thick paste into the pulp chamber and Q.3. Describe in detail the classification and various
the entire facial surface of the pulp chamber is treatment options of discoloured anterior teeth.
covered with the paste.
● Now place a small cotton pellet slightly moist-
Ans.
ened with Superoxol over the bleaching paste. [Same as LE Q.1]
● Seal the access cavity with IRM or zinc phosphate
cement. Patient should return in 3–7 days for the Q.4. What are the causes for discolouration of teeth?
evaluation of the result. Describe walking bleach technique.
Advantages: Ans.
● The procedure is safe.
● It requires less chair side time. [Same as LE Q.1]

● More comfortable for the patient.
Q.5. Mention the various causes for discolouration of
Disadvantages: teeth. Describe the techniques of bleaching vital discol-
● Noncomplaint patients.
oured teeth.
● Overbleaching may result by overzealous ap-
plication. Ans.
● Slight chances for cervical resorption though it is
[Same as LE Q.1]
reduced.
Q.6. Discuss the management of a case with an injury to ● The solution should be freshly mixed and applied
upper central incisor tooth without pulp exposure but directly to the enamel surface for 5 min at 1 min
with subsequent history of discolouration of the tooth? intervals.
● On completion of the bleaching, the solution is neutral-
Ans.
ized with a backing soda solution and copious irrigation
[Same as LE Q.1] with water.
● The bleached surface should be polished with cuttle
Q.7. Describe the causes of discolouration of anterior
discs and a prophylactic paste.
teeth. How will you proceed to restore the aesthetics of
● In order obtain the desired shade, this procedure may
these teeth?
have to be repeated two to three times.
Ans.
Q.2. Describe briefly one technique of bleaching of vital
[Same as LE Q.1] teeth.
Q.8. Enumerate the cause of discolouration of tooth. Ans.
Discuss the various methods of bleaching and procedure
to prevent the recurrences of discolouration. [Ref LE Q.1]
Ans. Q.3. Superoxol.

Q.9. How will you manage a case of discoloured nonvital ● Superoxol is a 30% solution of H2O2 by weight and
central incisor? 100% by volume in pure distilled water.
Ans. Characteristics
● It is clear, colourless, odourless liquid.
[Same as LE Q.2] ● Should be stored in light-proof amber bottles.
Q.10. Describe the rational of bleaching a discoloured ● It is unstable and should be kept away from heat which
nonvital tooth. Describe extracoronal bleaching proce- could cause it to explode.

dure in a tetracycline stained tooth. Uses
Ans. ● It can be used alone or mixed with sodium perborate
into a paste for use in the walking bleach technique.
[Same as LE Q.2]
Disadvantages:
It has ischaemic effect on skin and mucous membrane.
SHORT ESSAYS: ●
● It is painful if it comes in contact with the nail bed or
Q.1. Describe briefly bleaching of fluorosis stains. the soft tissue under the finger nail.
Ans. Q.4 Night guard bleaching.
● Teeth that have been discoloured as a result of ingestion Ans
of a high amount of fluoride such as 5 ppm in natural
drinking water do not respond well to ordinary methods [Same as SE Q.2]
of bleaching.
● Fluoride stained teeth are difficult to bleach and require SHORT NOTES:
longer and repeated sessions to decolourize them. Q.1. Thermocatalytic technique of bleaching.
● In cases of endemic fluorosis (mottled enamel), the fol-
lowing solution is used: Ans.

1 part anaesthetic ether (0.2 mL) ● Thermocatalytic bleaching technique involves the place-
5 parts hydrochloric acid (36%) (1.0 mL) ment of the oxidizing chemical, generally 30%–35%
5 parts H2O2 (30%) (1.0 mL) H2O2 (Superoxol), in the pulp chamber followed by heat
● The anaesthetic ether removes surface debris, while
application either by electric heating devices or spe-
hydrochloric acid etches the enamel and the H2O2 cially designed lamps.
bleaches the enamel. ● External cervical root resorption by thermocatalytic ap-
Technique proach caused by irritation to the cementum and periodon-

● Teeth should be polished with a prophylactic paste. tal ligament. This is possibly attributed to the oxidizing
● The gingiva is protected with petroleum jelly and the agent combined with heat.
teeth to be bleached with a rubber dam. ● It is not indicated routinely.
Q.2. Bleaching. ● Should be stored in light-proof amber bottles.

● The average pH found in various strengths of H2O2 is
Ans.
approximately 4 and that of buffered H2O2 is in the
Bleaching is defined as ‘whitening of a tooth through range of 9.5–10.8.
the application of chemical agents to oxidize/reduce the
Q.6. Procedures of bleaching a nonvital maxillary cen-
organic pigmentation in the tooth’.
tral incisor after endodontic treatment.
Aetiology
● Decomposition with remnants of pulp tissue Ans.
● Excessive haemorrhage following pulp removal
Techniques for bleaching endodontically treated teeth:
● Trauma
. Internal (intracoronal) bleaching
A
● Intracanal medicaments
B. ‘Walking bleach’ technique
● Obturating materials
C. Thermocatalytic bleaching
Bleaching materials D. UV photooxidation
● The most commonly used are H2O2, sodium perborate
Other methods of bleaching:
and carbamide peroxide.
● Intentional and intracoronal bleaching
● H2O2 and carbamide peroxide are mainly indicated for
extracoronal bleaching, whereas sodium perborate is Q.7. Classification of tetracycline discoloured teeth.
used for intracoronal bleaching.
Ans.
Q.3. Causes of intrinsic discolouration of teeth.
According to Jordan and Boksman (1984), tetracycline
Ans. stains are classified as follows:
i. First degree:
Discolouration of tooth is classified as
Light yellow to light grey staining without banding
i. Extrinsic discolouration
ii. Second degree:
ii. Intrinsic discolouration
Darker and more extensive yellow-grey staining with-
Causes of intrinsic discolouration of teeth: out banding
● These are stains within the enamel and dentine caused iii. Third degree:
by the deposition or incorporation of substances with in Severe staining characterized with dark grey or blue
these structures, such as tetracycline stains. discolouration with banding
● Amelogenesis imperfecta or dentinogenesis imperfecta
Q.8. Matrix bleaching.
are intrinsic stains that are impossible to eliminate be-
cause they originate from developmental defects of the Ans.
enamel and dentine.
[Ref LE Q.1]
● Stains due to pulp necrosis can usually be removed by
bleaching procedures. Q.9. Bleaching agents.

Q.4. Indications of ‘night guard bleaching’. Ans.
[Ref LE Q.1] Q.10. Nonvital bleaching.
Q.5. Hydrogen peroxide. Ans.
● H2O2 is a colourless, odourless and unstable (high con- Q.11. Home bleaching.
centration solutions of H2O2 must be handled with care Ans.
as they are thermodynamically unstable and may ex-
plode unless refrigerated). [Same as SN Q.8]
● Caustic and burns tissues on contact, releasing toxic
free-radicals, perhydroxyl anions or both.

Section I

of Previous Years
PART I: ORAL MEDICINE

Topic 1 Ulcerative, Vesicular and Bullous Lesions 247
Topic 2 Red and White Lesions 259
Topic 3 Pigmentation of the Oral Tissues 274
Topic 4 Benign Tumours of the Oral Cavity
Including Gingival Enlargements 281
Topic 5 Oral Cancer 296
Topic 6 Diseases of the Tongue and Lips 305
Topic 7 Salivary Glands Diseases 316
Topic 8 Disorders of TMJ and MPDS 327
Topic 9 Ionizing Radiation and Regressive Alterations
of the Oral Cavity 345
Topic 10 Odontologic Diseases 348
Topic 11 Orofacial Pain 357
Topic 12 Bacterial, Viral and Infectious Diseases
of the Oral Cavity Including AIDS 369
Topic 13 Diseases of the Endocrine and Respiratory
System: CVS and GIT 383
Topic 14 Metabolic Disorders 391
Topic 15 Haematologic Diseases 396
Topic 16 Diagnostic Laboratory Procedures 406
Topic 17 Miscellaneous 415
Section I

of Previous Years
Part I
Oral Medicine
Topic 1
Ulcerative, Vesicular and Bullous Lesions
LONG ESSAYS:
1. Define vesicle. Write the pathogenesis, clinical features, investigations and management of primary herpetic
infection.
2. Classify vesiculobullous lesions. Write briefly about aetiology, clinical features and treatment of erythema
multiforme.
3. Classify the ulcerative and vesiculobullous lesions of oral cavity. Describe in detail recurrent aphthous stomatitis.
4. What are the bullous lesions of oral mucosa? Describe clinical features, differential diagnosis and treatment of
pemphigus vulgaris (PV).
5. List the common viral infections that may involve the oral cavity. Discuss in detail the differential diagnosis of
herpes simplex. [Same as LE Q.1]
6. Discuss in detail the aetiology, clinical features and management of erythema multiforme. [Same as LE Q.2]
7. Enumerate various vesiculobullous lesions of oral cavity and describe erythema multiforme in detail.
[Same as LE Q.2]
8. Classify vesiculobullous lesions. Write briefly about aetiology, clinical features and treatment of erythema
multiforme. [Same as LE Q.2]
9. Classify oral ulcerations with a suitable example of each condition. Describe the clinical features and
management of recurrent aphthous ulcers. [Same as LE Q.3]
10. Classify ulcerative and vesiculobullous lesions of oral cavity. Describe the aetiology, clinical features and
treatment plan for recurrent aphthous stomatitis. [Same as LE Q.3]
11. Classify oral ulcerations with a suitable example of each condition. Describe clinical features and management
of recurrent aphthous ulcer. [Same as LE Q.3]
247
12. Classify ulcerative and vesiculobullous lesion of oral cavity. Describe the aetiology, clinical features and
treatment plan for recurrent aphthous stomatitis. [Same as LE Q.3]
13. Enumerate the various bullous lesions and describe aetiology, clinical features differential diagnosis and
management of pemphigus. [Same as LE Q.4]
14. Classify vesiculobullous lesions. Discuss in detail aetiopathogenesis, clinical features and management of PV.
[Same as LE Q.4]
15. What are the bullous lesions of oral mucosa? Describe clinical features, differential diagnosis and treatment of
PV. [Same as LE Q.4]
16. Define an autoimmune disease and enumerate autoimmune disease that has indirect and direct effect on the
oral cavity. Give the clinical features and investigations of PV. [Same as LE Q.4]
SHORT ESSAYS:
1. Classification and treatment of recurrent aphthous stomatitis. [Ref LE Q.3]
2. Describe clinical features of acute necrotizing ulcerative gingivitis (ANUG).
3. Give treatment plan for ANUG.
4. Give treatment plan for pemphigus vulgaris (PV). [Ref LE Q.4]
5. Describe clinical features of Stevens–Johnson Syndrome (SJS).
6. Investigations and management of primary herpetic gingivostomatitis. [Ref LE Q.1]
7. Classify vesiculobullous lesions of oral cavity. [Ref LE Q.2]
8. Clinical features of erythema multiforme. [Ref LE Q.2]
9. Herpes zoster.
10. Enumerate four differences between pemphigus vulgaris and benign mucous membrane pemphigoid (BMMP).
11. Write a note on the management of oral mucous membrane pemphigoid.
12. Aphthous ulcer. [Same as SE Q.1]
13. Recurrent aphthous stomatitis. [Same as SE Q.1]
14. Describe briefly about erythema multiforme. [Same as SE Q.8]
SHORT NOTES:
1. ANUG.
2. Patch test.
3. Tzank test.
4. Name two clinical features of discoid lupus erythematosus.
5. Nikolsky sign.
6. Target lesions.
7. Lipschutz bodies.
8. LE cells.
9. Define macule, papule and vesicle. Also give two examples of each.
10. Define postherpetic neuralgia.
11. Smoker’s palate.
12. Tzank smear. [Same as SN Q.3]
SOLVED ANSWERS
LONG ESSAYS: Vesicles

Primary herpetic infection
Q.1. Define vesicle. Write the pathogenesis, clinical
l Elevated blisters containing clear fluid that are
features, investigations and management of primary
under 1 cm in diameter are called vesicles. ‘Her-
herpetic infection.
pes’ is a Greek word which literally means creep,
Ans. it tells its nature of spreading.
l Although 80 herpes viruses are noted in humans, HSV lesions can be scraped and smeared for
l
herpes 1–8 are mainly infectious. Among them cytologic studies and Giemsa, Wright and Pa-
herpes I and II are called herpes simplex. panicolaou, H&E staining is done, which may
Pathogenesis identify viral particles and multinucleated epi-
l Primary herpetic gingivostomatitis is caused by thelial cells.
herpes simplex virus (HSV) I infection. l The murine monoclonal antibody immunohis-
l The herpes simplex virus gains access to the tochemistry can also identify the presence of
patient via: intracellular HSV.
a. Direct or airborne (humans are only natural Treatment
reservoirs) l The two drugs most effective against HSV are
b. Water-droplet transmission from an infected systemic acyclovir and ganciclovir.

individual l Primary herpetic gingivostomatitis is self-limiting
Clinical presentation and should require only supportive care consisting

l Common incubation period is 5–7 days; first proof hydration, antipyretics, nutrition and possibly
dromal symptoms will appear for 2 days before antibiotics if secondary bacterial infections arise.
appearance of oral lesions. l In immunocompromised patients, topical 5% acy-
l Primary herpetic gingivostomatitis develops clovir is used.

mostly in children and young adults. l Immunocompromised patients may also require
l The mucous membrane lesions represent direct intravenous therapy, usually in divided dosages
viral infection at the site of inoculation. for a total of 30 mg/kg per day.
l Painful vesicular lesions develop on all mucosal l In acyclovir-resistant strains, foscarnet (Foscavir)
surfaces; because of their thin nature they rupture is used as a substitute to acyclovir or as an addition
to produce foul-smelling ulcers. to it at dose of 40–60 mg/kg, i.v. thrice a day.}
l The patient is usually febrile, drools, has significant
Q.2. Classify vesiculobullous lesions. Write briefly about
malaise, feels miserable and will have tender cervi-
aetiology, clinical features and treatment of erythema
cal lymphadenopathy especially submandibular.
multiforme.
l It will appear as generalized acute marginal
gingivitis. Ans.
l The lesions and acute illness last about 10 days
[SE Q.7]
and resolve with scar formation.
Differential diagnosis {Classification of vesiculobullous lesions
l The painful vesicular ulcerative lesions of acute I. Acute and chronic vesiculobullous
herpetic gingivostomatitis may resemble necrotiz- A. Acute vesiculobullous lesions
ing ulcerative periodontitis, pemphigus vulgaris i. Herpesvirus infections
(PV); these lesions will have systemic signs and a. Primary herpes simplex virus infection
symptoms. ii. Coxsackievirus infections
l Erythema multiforme mainly occurs on lips, the a. Herpangina
oral lesions by themselves might be suggestive of b. Acute lymphonodular pharyngitis
erythema multiforme, but without concomitant c. Hand, foot and mouth disease
skin lesions true erythema multiforme is not iii. Varicella zoster virus infection
likely. iv. Erythema multiforme
l Aphthous ulcers and focal atrophic candida v. Contact allergic stomatitis
lesions are other prime considerations. vi. Oral ulcers secondary to cancer chemotherapy
l Early herpes zoster is also possible. vii. Acute necrotizing ulcerative gingivitis (ANUG)
B. Chronic vesiculobullous lesions
[SE Q.6]
i. Pemphigus vulgaris
{Investigations ii. Pemphigus vegetans
a . Cytology iii. Subepithelial bullous dermatoses
b. Virus isolation iv. Bullous pemphigoid
c. Antibody titres v. Cicatricial pemphigoid
l In children with suspected primary herpetic vi. Erosive lichen planus
gingivostomatitis, circulating HSV antibodies II. Based on the clinical presentation
are used for investigation; however, it is not A. Predominantly vesicular
reliable in recurrent lesions. i. HSV infection
ii. Varicella infection immune complexes in the superficial micro-

iii. Hand, foot and mouth disease vasculature of skin and mucosa or cell medi-
iv. Herpangina ated immunity.
v. Dermatitis herpetiformis Types
B. Predominantly bullous a. EM minor or erythema multiforme minor: It rep-
i. Pemphigus vulgaris resents the localized eruptions of skin with mild
ii. Bullous pemphigoid or no mucosal involvement.}
iii. Benign mucous membrane pemphigoid b. EM major or erythema multiforme major or
iv. Bullous lichen planus Stevens–Johnson syndrome (SJS): It is more se-
v. Erythema multiforme vere mucosal and skin disease and is potentially
vi. Stevens–Johnson syndrome life-threatening disorder.
vii. Epidermolysis bullosa Clinical manifestations
III. Histopathological classification
General features
Intraepithelial vesiculobullous lesions
i. HSV infection
[SE Q.8]
ii. Varicella infection
iii. Herpangina l {Occurs chiefly in children and young adults be-
iv. Hand, foot and mouth disease tween the ages of 15 and 40 years and males are
v. Pemphigus more commonly affected than females.
vi. Familial benign chronic pemphigus l Characterized by the occurrence of asymptomatic
vii. Epidermolysis bullosa vividly erythematous discrete macules, papules or
viii. Erythema multiforme (mucosal) occasionally vesicles and bullae that appear sym-
Subepithelial vesiculobullous lesions metrically distributed over hands and arms, legs and
i. Bullous pemphigoid feet, face and neck.
ii. Cicatricial pemphigoid l It is a self-limiting form of disease.
iii. Epidermolysis bullosa l The classical dermal lesions of erythema multiforme,
iv. Dermatitis herpetiformis which often appear on extremities are concentric ring
IV. Based on whether the lesions are infectious or non- like resulting from varying shades of erythema giv-
infectious ing rise to terms ‘target’, ‘iris’ or ‘bull’s eye’ lesions.
Infectious vesiculobullous lesions l The palms of the hands will show target-like lesions
i. Herpes simplex infections more than any other skin surface.
ii. Varicella infections l The vesicles of mucosal surface develop rapidly and
iii. Herpangina are short lived and become eroded or ulcerated and
iv. Hand, foot and mouth disease bleed profusely.
Noninfectious vesiculobullous lesions l Recurrence is common; patient also develops tra-
i. Pemphigus cheobronchial ulceration and pneumonia.}
ii. Bullous pemphigoid l Erythema multiforme major or SJS is a variant of ery-
iii. Cicatricial pemphigoid thema multiforme that represents a life-threatening
iv. Erythema multiforme and debilitating hypersensitivity.
v. Dermatitis herpetiformis} l Patients presented with ‘ocular-genital lesions’. Skin
lesions involve necrosis of scrotal skin, penile skin or
[SE Q.8]
vulval and labial surfaces.
{Erythema multiforme l The ocular component is epithelial necrosis of the cor-
Erythema multiforme is an acute self-limiting, inflamma- nea and conjunctiva, which develop prominent ulcer-
tory dermatological disorder that involves skin, mucus ation and necrosis, often leading to blindness directly
membrane and sometimes, internal organs. or to visual loss caused by secondary infection.
Aetiology l Oral lesions are severely painful large, haemor-
i. Infectious agents: Mycoplasma pneumonia, rhagic, crusting ulcers, especially of the lips and
herpes simplex, etc. labial mucosa.
ii. Drug hypersensitivity: Oxicam NSAIDs, anticon- l The pain prevents oral intake of fluids or solids.
vulsants like carbamazepine, phenobarbital, etc., l The oral lesions will secondarily produce drooling,
sulpha drugs, salicylates, allopurinol and penicillin. resulting in excess fluid and electrolyte loss and
iii. Hyperimmune reaction: It is an immune- leads to secondary infection, ultimately resulting in
mediated disease initiated by the deposition of cervical lymphadenitis.
l The progression from the initial emergence of lesions l The necrosed skin is treated as a burn with topical
to a full debilitating clinical picture with skin and antimicrobial creams (1% silver sulphadiazine;
mucous membrane necrosis often occurs within 24 h. Silvadene, Aventis), and the eyes are irrigated and
Oral findings patched.
l Oral lesions tend to be haemorrhagic ulcers that crust l Erythema multiforme major (SJS), however, requires
and may be seen on any portion of the oral mucosa, systemic corticosteroids.
with predilection for lip vermilion. l Topical steroid therapy coupled with antibiotics may
l Oral lesions will occur in only 50% of cases with be considered whereas systemic steroid therapy is
skin lesions and will emerge concurrently. controversial.}
l Oral lesions suggestive of erythema multiforme with- l Once the intensity of the disease resolves and no
out concomitant skin lesions probably do not repre- new skin lesions are developing, corticosteroids are
sent true erythema multiforme; they often represent a discontinued.
lichenoid drug eruption or an immune-based disease.
Q.3. Classify the ulcerative and vesiculobullous lesions
[SE Q.8] of oral cavity. Describe in detail recurrent aphthous
stomatitis.
{Histopathology
l The microscopic appearance of erythema multiforme Ans.
is not diagnostic as it depends in part on the stage of
the lesion and the area of the biopsy. Classification of vesiculobullous lesions
l It usually consists of changes such as intercellular or I. Acute and chronic vesiculobullous
intracellular oedema and necrosis of epithelium. A. Acute vesiculobullous lesions
l Necrosis of prickle cells is a significant finding. Epi- i. Herpesvirus infections
thelial necrosis is also very prominent within the a. Primary herpes simplex virus infection
centre of ‘iris’ lesions. ii. Coxsackievirus infections
l Vesicles may form within epithelium or at epithelial– a. Herpangina
connective tissue junction. b. Acute lymphonodular pharyngitis
l Subepithelial connective tissue shows oedema and c. Hand, foot and mouth disease
perivascular infiltration of lymphocytes and macro- iii. Varicella zoster virus infection
phages.} iv. Erythema multiforme
Diagnosis v. Contact allergic stomatitis
l Both types of erythema multiforme are clinical vi. Oral ulcers secondary to cancer chemotherapy
diagnoses. vii. Acute necrotizing ulcerative gingivitis (ANUG)
l A mucosa or skin biopsy is recommended to rule out B. Chronic vesiculobullous lesions
identifiable immune-based and viral diseases. i. Pemphigus vulgaris
Differential diagnosis ii. Pemphigus vegetans
l The main differential lesion is toxic epidermal iii. Subepithelial bullous dermatoses
necrolysis. iv. Bullous pemphigoid
l Severe cases of pemphigus or cutaneous pemphigoid v. Cicatricial pemphigoid
may also mimic erythema multiforme major, but the vi. Erosive lichen planus
progression of signs and symptoms is not nearly as II. Based on the clinical presentation
rapid. A. Predominantly vesicular
i. HSV infection
[SE Q.8]
ii. Varicella infection
{Treatment iii. Hand, foot and mouth disease
l Cause should be identified and withdrawn. iv. Herpangina
l Erythema multiforme minor usually requires no treat- v. Dermatitis herpetiformis
ment. It is self-limiting, will improve after 5–8 days, B. Predominantly bullous
and will completely resolve within 2–4 weeks. i. Pemphigus vulgaris
l In some cases, antibiotics are required to treat sec- ii. Bullous pemphigoid
ondary skin or oral infections appropriately. iii. Benign mucous membrane pemphigoid
l For all the forms of erythema multiforme, symptom- iv. Bullous lichen planus
atic treatment including oral antihistamines, analge- v. Erythema multiforme
sics, local skin care and soothing mouthwashes is of vi. SJS
great importance. vii. Epidermolysis bullosa
III. Histopathological classification l The third or ulcerative stage: The classic ulcer
Intraepithelial vesiculobullous lesions appears, measuring between 3 and 10 mm and
i. HSV infection may last 7–14 days.
ii. Varicella infection l The fourth stage: It is the healing stage in
iii. Herpangina which granulation tissue followed by epithelial
iv. Hand, foot and mouth disease migration incurs healing without scar.
v. Pemphigus b. Recurrent aphthous major
vi. Familial benign chronic pemphigus l The major ulcers are over 1 cm in diameter and
vii. Epidermolysis bullosa take longer to heal with often scars.
viii. Erythema multiforme (mucosal) l Most individuals with major aphthous ulcers har-
Subepithelial vesiculobullous lesions bour at least one or two lesions at all times.
i. Bullous pemphigoid l Major aphthous ulcers are identical to minor aph-
ii. Cicatricial pemphigoid thous ulcers in their developmental stages and
iii. Epidermolysis bullosa their general appearance except that they are
iv. Dermatitis herpetiformis larger (.10 mm), deeper and long-lasting almost
IV. Based on whether the lesions are infectious or up to 6 weeks.}
noninfectious Pathogenesis
Infectious vesiculobullous lesions l The pathogenesis of aphthous stomatitis is unknown.
i. Herpes simplex infections l The current concept is that Recurrent Apthous Stomati-
ii. Varicella infections tis (RAS) is a clinical syndrome with several possible
iii. Herpangina causes: the major factors identified are heredity, haema-
iv. Hand, foot and mouth disease tologic deficiencies, immunologic abnormalities and
Noninfectious vesiculobullous lesions nutritional deficiencies.
i. Pemphigus l Other factors include trauma, psychological stress, anx-
ii. Bullous pemphigoid iety and allergy to foods such as milk, cheese, wheat-
iii. Cicatricial pemphigoid flour and detergent, i.e. sodium lauryl sulphate (SLS),
iv. Erythema multiforme present in toothpaste.
v. Dermatitis herpetiformis Histopathology
Clinical presentation l Histologic examination is not usually indicated for aph-
thous ulcers, although it is sometimes helpful for diffi-
[SE Q.1] cult clinical cases. The findings are rather nonspecific.
l {Aphthous ulcers are also commonly known as ‘canker Diagnosis
sores’. l No specific diagnosis is required. It is a clinical-recognition
l According to their clinical characteristics, aphthous diagnosis.
ulcers are divided into two types: Differential diagnosis
a. Recurrent aphthous minor l Minor aphthae will often be confused with recurrent
b. Recurrent aphthous major herpes lesions.
a. Recurrent aphthous minor l The lesions of Behcet syndrome will look very much
l Minor ulcers comprise over 80% of cases and are like those of major aphthous stomatitis.
less than 1 cm in diameter. l The oral lesions of hand, foot and mouth disease will
l They appear as single discrete ulcers or in groups also resemble aphthae.
of two or more and they heal without scar.
[SE Q.1]
l They are characteristically found on the free
movable oral mucosa rather than the attached {Treatment

mucosa. l As there is no known single effective treatment for aph-
l The formed ulcers are discrete with a white yel- thous stomatitis, there is a plethora of published and un-
low base, which is a fibrinous slough, and a dis- published treatment schedules and drugs. They include
tinct irregular border with a red halo. antibiotics; vitamins; zinc; levamisole as an immune
l The lesions emerge in four stages: stimulant; and either topical, intralesional or systemic
l The first or prodromal stage: The individual corticosteroids. In addition, chlorhexidine gluconate 0.12%
will experience a tingling or burning pain in a and iron therapy.
clinically normal-appearing site. l Minor aphthous ulcers are few and of short duration,
l The second or preulcerative stage: Red oval hence no specific therapy is required. It is reasonable to
papules appear and the pain intensifies. simply reassure the patient.
l Pain relief of minor lesions can be obtained by using Aetiology

topical anaesthetic agent or topical diclofenac. l PV is an autoimmune disorder that is characterized
l Single or small groups of ulcers that are uncomfortable by the appearance of intraepithelial bullae on unin-
may be directly cauterized with silver nitrate (AgNO3) flammed skin surface or mucous membranes.
or phenol, thereby avoiding systemic side effects. Mechanism of bullae formation
l In more severe cases, the use of a high-potency topical l PV is a B cell–mediated autoimmune disease in
steroid preparation, such as fluocinonide, betametha- which autoantibodies develop to antigens within the
sone or clobetasol, placed directly on the lesion shortens desmosome–tonofilament junction of the intercellu-
healing time and reduces the size of the ulcers. lar bridges. Such autoantibodies fix complement and
l For aphthous ulcers that are numerous, frequent enough initiate inflammation, which causes a suprabasilar
to debilitate patients, the three most effective antibiotic split as the primary pathogenesis causing an intraep-
regimens are ithelial blister to form.
l Erythromycin, 250 mg by mouth four times daily. Clinical features
l Tetracycline 250 mg by mouth four times daily. l PV is commonly seen in people of 50–60 years age
l A mixture often called ‘tetranydril elixir’, which group.

consists of 250 mg tetracycline and 12.5 mg diphen- l It is insidious in its onset and can often be fatal.
hydramine hydrochloride (Benadryl) per 5 mL of l Men and women are equally affected. Jewish people
kaopectate. The patient is instructed to use 1 tsp at a are more commonly affected.
time and swish, hold the solution in their mouth as l PV usually presents with painful skin and/or oral
long as possible, and swallow, three times daily. ulcers. The lesions actually begin as short-lived ves-
l The above regimens have been variably useful in con- icles that rapidly rupture because of their suprabasi-
trolling the number, frequency and duration of lesions. lar position.
l If these antibiotic regimens fail, systemic corticoste- l The characteristic feature of PV is rapidly appearing
roids are the treatment of choice.} multiple vesicles and bullae which vary in diameter
Prognosis from a few millimetres to several centimetres.
l Aphthous stomatitis is most active in young adulthood. l The lesions (bullae) appear on a perfectly normal ap-
With time and advancing age, the condition becomes pearing mucosa, although a large area of the skin
less intense and usually remits altogether. surface may be affected, the eye is not involved. The
bullae could be rubbed with fingers.
Q.4. What are the bullous lesions of oral mucosa? l PV can be fatal in several cases as the appearance of
Describe clinical features, differential diagnosis and large bullae all over the skin surface can lead to rapid
treatment of pemphigus vulgaris (PV). fluid loss just like a case of severe burns.
l The bullae are flaccid, fragile, regular and nonin-
Ans.
flammatory. They contain a thin watery fluid initially,
The various types of vesiculobullous lesions that affect the which may soon become purulent or sanguineous.
oral cavity have been categorized as follows: l Intraorally, the bullae, if seen sufficiently early, ap-
A. Viral diseases pear as vesicles on the palate, oropharynx or inside
l Herpes gingivostomatitis of the cheeks.
l Primary varicella zoster l When the affected epithelium ruptures, it leads to the
l Secondary varicella zoster formation of shallow painful ulcers that are covered
l Herpes labialis with a whitish ‘skin’, which is the original roof of the
l Measles bulla. These oral lesions may persist for months be-
B. Immunologic conditions fore the skin becomes involved.
l Pemphigus vulgaris l The oral mucosa may be affected 2–3 months before
l Bullous form of lichen planus the skin. Cheeks and vermilion border of the lips are
C. Hereditary conditions the common sites for the bullae.
l Epidermolysis bullosa l Nikolsky sign is positive, that is the loss of epithe-
l Familial benign pemphigus (Hailey–Hailey disease) lium occasioned by rubbing apparently unaffected
l Keratosis follicularis (Darier disease) skin is termed as Nikolsky sign.
D. Miscellaneous Histological features
l Impetigo l The pemphigus is characterized microscopically by
Pemphigus vulgaris the formation of a vesicle or bulla entirely intraepi-
l Pemphigus vulgaris (PV) is the most common form thelially just above the basal layer producing a dis-
of pemphigus, accounting for over 80% of cases. tinctive suprabasilar ‘split’.
l The suprabasal separation of epithelium (i.e. float- lesions, and if the individual is older than 50 years,
ing epithelium) is the most important diagnostic pemphigoid becomes a realistic consideration.
feature of PV. l Bullous-erosive lichen planus: It is another pos-
l Disappearance of intercellular bridges results in loss sibility, but they are rare and more pruritic than
of cohesiveness or acantholysis because of which painful. They are also violet-red, not the pale grey
clumps of epithelial cells are found lying free within vesicles seen in PV.
the vesicular space; these cells are called ‘Tzanck Q.5. List the common viral infections that may involve
cells’. Tzank cells have large nuclei and hyper chro- the oral cavity. Discuss in detail the differential diagno-
matic staining. sis of herpes simplex.
l Bulla is filled with acantholytic multinucleated
epithelial cells known as ‘Tzank cells’, which are Ans.

diagnostic feature of this condition. [Same as LE Q.1]
l Immunofluorescent testing is considered to be of
great importance in establishing the diagnosis of PV, Q.6. Discuss in detail the aetiology, clinical features and
especially when the clinical or microscopic findings management of erythema multiforme.
are inconclusive. Ans.
[Same as LE Q.2]
[SE Q.4]
Q.7. Enumerate various vesiculobullous lesions of oral
{Treatment cavity and describe erythema multiforme in detail.
The mainstay of treatment remains high doses of
l
Ans.
systemic corticosteroid, usually given in dosages of
1–2 mg/kg/day. [Same as LE Q.2]
l Taking into account the pre-existing and coexisting
Q.8. Classify vesiculobullous lesions. Write briefly about
conditions, therapy may be tailored for each patient. aetiology, clinical features and treatment of erythema
l Various other therapies that have been reported as
multiforme.
beneficial are parenteral gold therapy, dapsone, tetra-
cycline and plasmapheresis and administration of Ans.
8-methoxypsoralen. [Same as LE Q.2]
l Patient may continue to experience mild disease
activity while under optimal treatment. Q.9. Classify oral ulcerations with a suitable example of
l When steroids must be used for long periods of time, each condition. Describe the clinical features and man-
adjuvants such as azathioprine or cyclophosphamide agement of recurrent aphthous ulcers.
are added to the regimen to reduce the complications Ans.
of long-term corticosteroid therapy.
[Same as LE Q.3]
l One new immunosuppressive drug, mycophenolate,
has been effective when managing patients resistant Q.10. Classify ulcerative and vesiculobullous lesions of
to other adjuvants.} oral cavity. Describe the aetiology, clinical features and
Differential diagnosis treatment plan for recurrent aphthous stomatitis.
The oral-only pemphigus presentation will include a Ans.
subset of diseases as follows:
[Same as LE Q.3]
l Erosive lichen planus: Has similar presentation;
however, lichen planus targets the dorsum of the Q.11. Classify oral ulcerations with a suitable example
tongue, buccal mucosa and attached gingiva. of each condition. Describe clinical features and man-
l Pemphigoid: Mild forms of PV may closely re- agement of recurrent aphthous ulcer.
semble but it does not usually produce a conjunc- Ans.
tivitis, which is frequently present in pemphigoid
cases. [Same as LE Q.3]
The PV that expresses vesicular skin lesions in addition Q.12. Classify ulcerative and vesiculobullous lesion of
to painful oral lesions includes a subset of following oral cavity. Describe the aetiology, clinical features and
diseases: treatment plan for recurrent aphthous stomatitis.
l Erythema multiforme.
Ans.
l Bullous pemphigoid: If the oral lesions are not es-
pecially painful and more prominent than the skin [Same as LE Q.3]
Q.13. Enumerate the various bullous lesions and de- subsequently involving marginal gingival and
scribe aetiology, clinical features differential diagnosis rarely attached gingival.
and management of pemphigus. l Craters are covered by greyish pseudo-membranous
slough with a marked demarcation of linear ery-

Ans.
thema from the normal mucosa.
[Same as LE Q.4] l Spontaneous bleeding from gingival tissue, fetid
odour and increased salivation.

Q.14. Classify vesiculobullous lesions. Discuss in detail ae- Symptoms
tiopathogenesis, clinical features and management of PV. l Extremely tender with radiating pain on eating
Ans. hot and spicy foods.

l Metallic foul taste.
[Same as LE Q.4] Extraoral and systemic signs and symptoms
Q.15. What are the bullous lesions of oral mucosa? Mild-to-moderate stages:
l Local lymphadenopathy
Describe clinical features, differential diagnosis and
l Slight elevation of temperature
treatment of PV.
Severe cases:
Ans. l High fever with increased pulse rate
l Loss of appetite and general lassitude

[Same as LE Q.4]
Systemic reactions
Q.16. Define an autoimmune disease and enumerate l They are severe in children.
autoimmune disease that has indirect and direct effect l Rarely gangrenous stomatitis, fusospirochetal men-
on the oral cavity. Give the clinical features and investi- ingitis, peritonitis, toxemia and fatal brain abscess
gations of PV. may occur.
Ans. Q.3. Give treatment plan for ANUG.
l Treatment of ANUG generally consists of local debride-
ment and irrigation coupled with oral antibiotics.
SHORT ESSAYS: l The conservative treatment is superficial cleaning of
oral cavity and irrigation with a solution of 3% hydro-

Q.1. Classification and treatment of recurrent aphthous gen peroxide mixed 1:1 with saline or chlorhexidine or
stomatitis. warm salt water.
l Initially, the teeth should undergo a light scaling to
Ans.
remove superficial plaque and calculus under local or
[Ref LE Q.3] topical anaesthesia.
l In addition, home plaque control instructions should be
Q.2. Describe clinical features of ANUG.
provided, and oral rinses with either the same hydrogen
Ans. peroxide solution or 0.12% chlorhexidine should be
used.
l It is an inflammatory and destructive endogenous
l Oral antibiotics are effective, and penicillin remains the
oral infection, which is characterized by the necrosis of
drug of choice.
gingival tissue.
l In the nonpenicillin allergic patient, oral phenoxy-
l It is also known as trench mouth, Vincent infection,
methyl penicillin 500 mg four times daily for 7–10 days
acute ulceromembranous gingivitis and acute ulcerative
is recommended.
gingivitis.
l For the penicillin allergic patient, erythromycin ethyl
Clinical features
succinate, 400 mg twice a day for 7–10 days, and
l It is identified as an acute disease characterized by sud-
ordoxycycline, 100 mg once daily for 7–10 days, are
den onset, sometimes followed by an episode of de-
good second choices.
bilitating diseases or acute respiratory tract infections.
l Nutritional supplements like vitamins B and C.
l It is seen commonly in age group 16–30 years.
Oral signs and symptoms Q.4. Give treatment plan for pemphigus vulgaris (PV).
Signs
l Characterized by punched out, crater-like de-
Ans.
pressions at the crest of the interdental papillae, [Ref LE Q.4]
Q.5. Describe clinical features of Stevens–Johnson Q.7. Classify vesiculobullous lesions of oral cavity.
syndrome (SJS).
Ans.
Ans.
[Ref LE Q.2]
i. SJS is a very severe bullous form of erythema multi-
Q.8. Clinical features of erythema multiforme.
forme with widespread involvement typically includ-
ing skin, oral cavity, eyes and genitalia. It manifests as Ans.
generalized vesicles and bullae involving the skin,
[Ref LE Q.2]
mouth, eyes and genitals.
ii. It is characterized by the abrupt appearance of symp- Q.9. Herpes zoster.
toms such as fever, photophobia, malaise and erup-
Ans.
tions over the oral mucosa, skin and the genitalia.
iii. Widespread involvement of different regions like the l Varicella zoster virus (VZV) is responsible for two ma-
skin and the eyes are also noted which are commonly jor clinical infections of humans: chickenpox (varicella)
haemorrhagic and are often vesicular or bullous. and shingles (herpes zoster, HZ).
iv. The oral mucosal lesions are extremely painful and l Chickenpox is a generalized primary infection, analo-
mastication is usually impossible. In many cases, the gous to the acute herpetic gingivostomatitis of herpes
oral lesions may be the chief complaint. simplex virus. After the primary disease is healed, Vari-
v. The lips may exhibit ulceration with bloody crusting cella zoster virus (VZV) becomes latent in the dorsal
and are painful. root ganglia of spinal nerves or extramedullary ganglia
vi. Genital lesions include nonspecific urethritis, balanitis of cranial nerves. VZV becomes reactivated, causing
and vaginal ulcers. lesions of localized HZ.
vii. Some of the other complications may include tracheo- l The incidence of HZ increases with age or immunosup-
bronchial ulcerations and pneumonia patients usually pression and these lesions may be deepseated and dis-
recover unless they are secondarily infected. seminated, causing pneumonia, meningoencephalitis
viii. Treatment and hepatitis.
l Cause should be identified and withdrawn and in- l HZ commonly has a prodromal period of 2–4 days, when
fections should be appropriately treated. shooting pain, paraesthesia, burning and tenderness ap-
l Symptomatic treatment including oral antihista- pear along the course of the affected nerve. Unilateral
mines, analgesics, local skin care and soothing vesicles on an erythematous base then appear in clusters,
mouthwashes is of great importance. chiefly along the course of the nerve, giving the charac-
l Topical steroid therapy coupled with antibiotics teristic clinical picture of single dermatome involvement.
may be considered, whereas systemic steroid ther- Some lesions spread by viraemia outside the dermatome.
apy is controversial. l The vesicles turn to scabs in 1 week, and healing takes
l Mild cases of oral EM may be treated only with place in 2–3 weeks.
supportive measures, including topical anaes- l The nerves most commonly affected with HZ are C3,
thetic mouthwashes. Adults treated with short- T5, L11, L2 and the first division of the trigeminal
term systemic steroids, patients with severe cases nerve.
of recurrent EM have been treated with dapsone, l HZ may also occasionally affect motor nerves. HZ of
azathioprine, levamisole or thalidomide. the sacral region may cause paralysis of the bladder. The
l The most severe form of the disease is TEN (toxic extremities and diaphragm have also been paralysed
epidermal necrolysis or Lyell disease), which is during episodes of HZ.
usually secondary to a drug reaction and results in l The most common complication of HZ is postherpetic
sloughing of skin and mucosa in large sheets. Pa- neuralgia (PHN), which is defined as pain remaining for
tients with this form of the disease are most suc- over a month after the mucocutaneous lesions have
cessfully managed in burn centres, where necrotic healed.
skin is removed under general anaesthesia and heal- l Involves one of the branch of trigeminal nerve generally
ing takes place under sheets of porcine xenografts. but ophthalmic branch is most commonly involved.
l HZ has been associated with dental anomalies and severe
Q.6. Investigations and management of primary her- scarring of the facial skin when trigeminal HZ occurs
petic gingivostomatitis. during tooth formation. Pulpal necrosis and internal root
resorption have also been related to HZ.
Ans.
l Although the histopathology is not specific, two major
[Ref LE Q.1] histologic patterns have been described: an epidermal

pattern characterized by lichenoid vasculitis and intraepi- day for 6 months with slow tapering, may be helpful in
dermal vesicles, and a dermal pattern characterized by controlling the disease.
lymphocytic vasculitis and subepidermal vesiculation.
Q.12. Aphthous ulcer.
l The most accurate method of diagnosis is viral isolation
in tissue culture. [Same as SE Q.1]

l Acyclovir or famcyclovir accelerate healing and reduce
Q.13. Recurrent aphthous stomatitis.
acute pain, but they do not reduce the incidence of PHN.
The use of systemic corticosteroids to prevent PHN in [Same as SE Q.1]
patients over 50 years of age is controversial.
Q.14. Describe briefly about erythema multiforme.
l Effective therapy for PHN includes application of cap-
saicin tricyclic antidepressant, or gabapentin can also [Same as SE Q.8]

be used.
Q.10. Enumerate four differences between pemphigus SHORT NOTES:
vulgaris and benign mucous membrane pemphigoid
(BMMP). Q.1. ANUG.
Ans. Ans.
l The classical lesion of pemphigus is a thin-walled bulla l Acute necrotizing ulcerative gingivitis (ANUG) became
arising on otherwise normal skin or mucosa. The bulla known popular as ‘trench mouth’ during World War I
rapidly breaks but continues to extend peripherally, because of its prevalence in the combat trenches.
eventually leaving large areas denuded of skin. In BMMP Aetiology
lesions appear as blisters, which turn out into ulcer. l The fusiform bacillus and spirochetes.
l In BMMP, subepithelial blisters remain intact for a lon- Clinical features

ger time period compared to PV, due to a thicker blister l Sudden in onset with pain, tenderness, profuse saliva-
wall. tion, a peculiar metallic taste and spontaneous bleed-

l Routine histopathology shows subbasilar cleavage and ing from the gingival tissues, loss of the sense of taste.
no acantholysis, whereas acantholysis is commonly l The typical lesions of ANUG consist of necrotic
seen in PV. punched-out ulcerations, developing most commonly

l In PV, Tzanck cells (clumps of epithelial cells often on the interdental papillae and the marginal gingiva.
found lying free within the vesicular space, have swol- Treatment
len nuclei and hyperchromatic staining) are common l Local debridement.
histologic feature. l Complete gingival curettage and root planning.
l The conjunctiva is the second most common site of in- l Antibiotics are required in patients with extensive
volvement in BMMP. gingival involvement, lymphadenopathy or other

systemic signs. Metronidazole and penicillin are the
Q.11. Write a note on the management of oral mucous
drugs of choice.
membrane pemphigoid.
Q.2. Patch test.
Ans.
Ans.
Management of oral mucous membrane pemphigoid
l There is no single treatment for mucous membrane l Patch test is the only test used to distinguish contact
pemphigoid it differs according to patient condition. allergy from other lesions. It is also used in diagnosis
l If extensive lesions involving the oral cavity are present, of lichenoid reactions.
systemic prednisone may be indicated. l The technique is that, suspected allergen is placed on
l Normally, a short course of prednisone is prescribed normal nonhairy skin, usually upper portion of the back,
(40 mg per day for 7 days without tapering). it is covered and allowed to remain in contact with the
l Topical steroids may be prescribed either alone or in skin for 48 h the patch is removed and the area is exam-
addition to systemic steroids, as ointments or oral rinse ined for persistent erythema 2–4 h later.
solutions. l The patch testing directly on oral mucosa has been at-
l If lesions are extensive, immunosuppressive medica- tempted by incorporating the test substance in orabase,
tions such as azathioprine, mycophenolate and cyclo- by use of prosthetic appliance to hold the substance in
phosphamide may be necessary to manage. place or by use of a rubber cup attached to the teeth.
l Also, a combination of tetracycline and niacinamide l The patch testing of the skin may not be reliable in di-
(niacin flush free), 500 mg taken three or four times a agnosis of hypersensitive reactions of oral mucosa.
Q.3. Tzank test. l The size of the iris lesion varies from a few mm to about
2 cm in diameter. These lesions usually resolve in about
Ans.
3–5 weeks.
l In pemphigus, on histological examination, disappear-
Q.7. Lipschutz bodies.
ance of intercellular bridges results in acantholysis be-
cause of which clumps of epithelial cells are found lying Ans.
free within the vesicular space, these cells are called
l The Lipschutz bodies are characteristic findings of her-
‘Tzanck cells’.
pes infection.
l Cytology smears taken from freshly opened vesicles are
l The presence of multinucleated giant cells and intranu-
usually preferred as ‘Tzanck cells’ can be seen. These
clear viral inclusion bodies such as Lipschutz bodies or
are characterized particularly by degenerative changes,
Cowdry Type A (ovoid, amorphous and eosinophilic
which include swelling of the nuclei and hyperchro-
bodies that exhibit peri-inclusion halo that is caused by
matic staining. This is also referred to as Tzanck test.
the peripheral displacement of the nucleolus and the
Q.4. Name two clinical features of discoid lupus erythe- nuclear chromatin). The cells exhibit ballooning degen-
matosus. eration of the nucleus.
Ans. Q.8. LE cells.
l Discoid lupus erythematosus (DLE) is a relatively com- Ans.
mon disease and occurs predominantly in females in the
l Lupus erythematous cells (LE cells) are characteristi-
third or fourth decade of life.
cally found in patients suffering from acute systemic
l It can present in both localized and disseminated forms
form of lupus erythematosus.
and is confined to the skin and oral mucous membranes
l The cells consist of rosette of neutrophils surrounding a
and has a better prognosis than SLE.
pale nuclear mass derived from lymphocytes.
l Typical cutaneous lesions appear as red and somewhat
scaly patches that favour sun-exposed areas such as the Q.9. Define macule, papule and vesicle. Also give two
face, chest, back and extremities. The oral mucosal le- examples of each.
sions of DLE frequently resemble reticular or erosive
Ans.
lichen planus.
Macules
Q.5. Nikolsky sign.
Well-circumscribed, flat lesions that are noticeable
Ans. because of their change from normal skin colour. They
may be red due to the presence of vascular lesions or
l Gentle retraction of unaffected mucosa or application of
inflammation, or pigmented due to the presence of
minimal pressure over unaffected skin or mucosa results
melanin, haemosiderin and drugs.
in blisters, producing a classical clinical sign known as
Papules
Nikolsky sign (named after Pyotr Vasilyewich Nikolsky
Solid lesions raised above the skin surface that are
who described it in 1896).
smaller than 1 cm in diameter. Papules may be seen
l The Nikolsky sign is positive if slight pressure or
in a wide variety of diseases including erythema mul-
rubbing of the skin produces lateral movement of the
tiforme simplex, rubella, lupus erythematosus and
upper layers of the epidermis.
sarcoidosis.
l Nikolsky sign is generally positive in PV and benign
Vesicles
oral mucous membrane pemphigoid.
Elevated blisters containing clear fluid that are under
Q.6. Target lesions. 1 cm in diameter.
Q.10. Define postherpetic neuralgia.
Ans.
Ans.
l The typical dermal lesions of EM are target, iris or
bull’s eye lesion. Spontaneous pain, pain provoked by trivial stimuli and al-
l These are asymptomatic, discrete, and erythematous tered sensation accompany herpes zoster which may con-
macules or papules set in a concentric ring pattern usu- tinue long after its characteristic rash has healed is known
ally comprising a central bulla. The iris lesion has three as postherpetic neuralgia.
concentric zones: a central dusky or darker red area
Q.11. Smoker’s palate.
(central bulla or area of necrosis), a paler pink or oede-
matous zone and a peripheral erythematous zone. Ans.
l Smoker’s palate or nicotine stomatitis or stomatitis papules with punctate red centres that represent in-
nicotina palati, refers to a specific white lesion that de- flamed and metaplastically altered minor salivary gland
velops on the hard and soft palate in heavy cigarette, ducts are noted.
pipe and cigar smokers. l Nicotine stomatitis is completely reversible once the
l The lesions are restricted to areas that are exposed to a rela- habit is discontinued.
tively concentrated amount of hot smoke during inhalation. l The lesions usually resolve within 2 weeks of cessation
l Nicotine stomatitis also develops in individuals with a of smoking.

long history of drinking extremely hot beverages. This
suggests that heat, rather than toxic chemicals in to- Q.12. Tzank smear.
bacco smoke, is the primary cause. Ans.
l Due to the chronic insult, the palatal mucosa becomes
diffusely grey or white. Numerous slightly elevated [Same as SN Q.3]
Topic 2
Red and White Lesions
LONG ESSAYS:
1. Describe the clinical features and differential diagnosis of oral lichen planus (OLP).
2. Classify white lesions of the oral cavity. Describe the aetiology, clinical features and management of leukoplakia.
3. Enumerate oral precancerous lesions and conditions. Describe clinical features and management of oral
submucous fibrosis (OSMF).
4. Write an essay on oral candidiasis.
5. Describe briefly and give the differential diagnosis of psoriasis.
6. Discuss in detail clinical features, differential diagnosis and treatment of erythroplakia.
7. Describe the aetiology, clinical features, differential diagnosis and treatment of oral lichen planus (OLP).
[Same as LE Q.1]
8. Name some of the white lesions of oral mucosa. Describe the clinical features, differential diagnosis and treat-
ment of leukoplakia of hard palate. [Same as LE Q.2]
9. What are the keratinizing lesions of the oral cavity? Write about oral leukoplakia. [Same as LE Q.2]
10. Define leukoplakia. Discuss the aetiopathogenesis, clinical features and treatment of oral leukoplakia.
[Same as LE Q.2]
11. Enumerate the ‘white lesions’ of the oral cavity. Describe leukoplakia in detail, giving differential diagnosis.
[Same as LE Q.2]
12. What conditions may produce trismus? Describe in detail the predisposing factors, clinical features, treatment
of oral submucous fibrosis. [Same as LE Q.3]
13. Write the clinical features, differential diagnosis and management of oral submucous fibrosis. [Same as LE Q.3]
14. Describe in detail aetiology, clinical features and management of oral submucous fibrosis. [Same as LE Q.3]
15. Describe in detail the aetiology, clinical features, treatment plan and prognosis of submucous fibrosis.
[Same as LE Q.3]
16. Classify oral mucosal candidiasis. Write the aetiopathogenesis, clinical features, investigations and manage-
ment of chronic atrophic candidiasis. [Same as LE Q.4]
17. Enumerate the various white lesions that can be scrapped. Describe the clinical features, differential diagnosis
and treatment of candidiasis. [Same as LE Q.4]
18. Enumerate predisposing factors of candidiasis. Mention the various types and discuss in detail the treatment
plan. [Same as LE Q.4]
19. Classify candidiasis. Write in detail about the aetiology, clinical features and management of oral thrush.
[Same as LE Q.4]
20. Classify candidiasis and give clinical features, laboratory diagnosis tests and treatment of oral candidal infec-
tion. [Same as LE Q.4]
21. Treatment of acute pseudomembranous moniliasis. [Same as LE Q.4]
SHORT ESSAYS:
1. Predisposing factors and smear examination for Candida albicans.
2. Aetiology and management of oral leukoplakia. [Ref LE Q.2]
3. Aetiology and management of oral submucous fibrosis (OSMF). [Ref LE Q.3]
4. Lichenoid reactions.
5. Lupus erythematosus.
6. Management of oral lichen planus (OLP).
7. Erythroplakia – clinical features and management. [Ref LE Q.6]
8. White spongy nevus.
9. Oral hairy leukoplakia.
10. Mention any four predisposing factors of candidiasis. [Same as SE Q.1]
11. Predisposing factors of moniliasis. [Same as SE Q.1]
12. Leukoplakia. [Same as SE Q.2]
13. Mention the treatment plan for submucous fibrosis. [Same as SE Q.3]
14. Systemic lupus erythematosus. [Same as SE Q.5]
15. Write briefly clinical and histologic features of discoid lupus erythematosus. [Same as SE Q.5]
SHORT NOTES:
1. Define vesicle and papule. Give two examples of each.
2. Behcet syndrome.
3. Candidiasis – aetiology.
4. Auspitz sign.
5. White spongy nevus.
6. Mention various types of lichen planus.
7. Grinspan syndrome.
8. Civatte bodies.
9. Oral manifestations of ectodermal dysplasia.
10. Systemic lupus erythematosus. [Ref SE Q.5]
11. Stevens–Johnson syndrome.
12. Target lesions.
13. Moniliasis. [Same as SN Q.3]
SOLVED ANSWERS
LONG ESSAYS: l Such cases are common following severe psychological

Q.1. Describe the clinical features and differential diag- stress such as death of a close friend or relative, marital
nosis of oral lichen planus (OLP). or sexual problems, failure in a career, loss of job and
security or exam tensions.
Ans.
Clinical features
l Lichen planus is a common chronic, dermatologic dis- l Lichen planus commonly occurs among the middle aged
ease of the skin and mucous membranes. and elderly people with slight predilection for females.
Aetiology l Oral lichen planus can involve several areas of oral cav-
l Lichen planus is primarily an immune-related disorder, ity including the buccal mucosa, vestibule, tongue, lips,
which may also be caused due to other factors. floor of mouth, palate and gingiva.
l One of the major factors that can cause exacerbations or l Patients may often report with burning sensation of oral
remission of the condition is emotional trauma. mucosa.

l The oral lesion is generally characterized by radiating include glandular enlargement and Treponema pallidum
white and grey velvety thread-like papules in linear, found in oral lesions.
angular or retiform arrangement. Tiny white elevated iv. Candidiasis (thrush)
dots are usually present at the intersection of these white The white patches of candidiasis can be easily scraped
lines and are known as ‘Wickham striae’. off and microscopically spores and mycelia can be
l Types or patterns of lichen planus in the oral cavity: seen from the collected specimens.
i. Linear pattern v. Recurrent aphthae (ulcer)
ii. Papular pattern They are usually associated with trauma.
iii. Reticular vi. Pemphigus
iv. Annular pattern, i.e. circular Is characterized by bullous lesions resulting on a nor-
v. Vesicular or bullous mal looking mucosa and histologically presence of
vi. Erosive or atrophic acantholytic cells is diagnostic.
vii. Hypertrophic vii. Lupus erythematosus
Is characterized by the area of atrophy and scarring
Histopathology
remains stationary over many months or years and is
The following histopathological changes may be noted
firm on palpation.
that are suggestive of lichen planus:
viii. Erythema multiforme
l The overlying surface epithelium exhibits hyperortho-
Can be differentiated by history and biopsy, its acute
keratosis or parakeratosis.
nature and severe involvement of labial mucosa.
l Thickening of granular cell layer.
Treatment
l Acanthosis of spinous cell layer and ‘saw-tooth’ appear-
l There is no known cure for OLP. Hence, the manage-
ance of rete pegs.
ment of symptoms guides therapeutic approaches.
l There is presence of necrosis or liquefaction degenera-
l Corticosteroids have been the most predictable and suc-
tion of basal cell layer of epithelium.
cessful medications for controlling signs and symptoms.
l Band-like subepithelial mononuclear infiltrate consist-
Topical and/or systemic corticosteroids are prescribed
ing of T cells and histiocytes.
electively for each patient.
l Chronic inflammatory cell infiltration is present in
l Topical medications include high-potency corticoste-
juxta-epithelial region.
roids, the most commonly used are as follows:
l Degenerating basal keratinocytes form rounded or
l 0.05% fluocinonide (Lidex), 0.05% clobetasol
ovoid, amorphous eosinophilic bodies known as ‘civatte,
(Temovate) and triamcinolone acetonide 0.1 % in
hyaline, cytoid’ bodies.
orabase, oral suspension of triamcinolone, high-
l Degeneration of basal keratinocytes and disruption of
potency steroid mouthwashes like betamethasone
anchoring elements of epithelial basement membrane
valerate 0.1%, fluocinolone acetonide 0.1% and clo-
weakens the epithelial connective tissue interface re-
betasol propionate 0.05% have been used effectively.
sulting in histological clefts known as Max–Joseph
l The topical forms are applied daily to meet each pa-
spaces.
tient’s needs. Topical corticosteroids reduce pain and
Differential diagnosis inflammation.
Lichen planus must be differentiated from the lesions, l In addition, extensive erosive lesions of OLP on the gin-
which may present a similar clinical appearance, they are as giva (desquamative gingivitis) may be treated effectively
follows: by using occlusive splints as carriers for the topical steroid.
i. Lichenoid reactions l Candida overgrowth with clinical thrush may develop,
Some of the varieties of medications may induce lesions requiring concomitant topical or systemic antifungal
that appear clinically very similar to lichen planus. therapy. It has been shown that the use of an antibacte-
ii. Leukoplakia rial rinse such as chlorhexidine before steroid applica-
Some of the distinguishing features of leukoplakia tion helps prevent fungal overgrowth.
from lichen planus are that it is more common in men, l Systemic steroids are rarely indicated for brief treat-
found in slightly younger age group, may have a fam- ment of severe exacerbations or for short periods of
ily history, has no history of remission and recurrence, treatment of recalcitrant cases that fail to respond to
usually involves commissures of the mouth, surround- topical steroids.
ing mucosa is normal in appearance and symptom like l Systemic administration of prednisone tablets may be
soreness is felt. done with dosages varying between 40 and 80 mg daily

iii. Mucous patches of secondary syphilis for less than 10 days without tapering. The time and
They are distinguished from lichen planus by the ten- dosage regimens are determined individually, based on
dency for the papules to ulcerate in the centre, favour the patient’s medical status, severity of disease and pre-
commissure of lips and tonsils. Other manifestations vious treatment responses.
l Consultation with the patient’s primary care physician is ii. Acute atrophic candidiasis (antibiotic sore mouth)
important when underlying medical problems are present. iii. Chronic atrophic candidiasis (denture sore mouth
l Retinoids are also useful, usually in conjunction with and angular cheilitis)
topical corticosteroids as adjunctive therapy for OLP. iv. Median rhomboid glossitis
l Systemic and topically administered b all-trans retinoic v. Chronic hyperplastic candidiasis
acid, vitamin A acid, systemic etretinate and systemic IV. Keratotic white lesions with no increased potential for
and topical isotretinoin are all effective, and topical the development of oral cancer
application of a retinoid cream or gel will eliminate i. Stomatitis nicotina
reticular and plaque-like lesions in many patients. ii. Traumatic keratosis
However, following withdrawal of the medication, the iii. Intraoral skin grafts
majority of lesions recur. iv. Focal epithelial hyperplasia
l Topical retinoids are usually favoured over systemic v. Psoriasiform lesions (psoriasis, Reiter syndrome
retinoids since the latter may be associated with ad- and geographic tongue ‘ectopic geographic tongue’)
verse effects such as liver dysfunction, cheilitis and V. Red and white lesions with defined or uncertain pre-
teratogenicity. cancerous potential
l A new systemically administered retinoid, temarotene, i. Leukoplakia (homogenous, nodular or speckled
is reported to be an effective therapy for OLP and to be and verrucous)
free of side effects other than a slight increase in liver ii. Erythroplakia
enzymes. iii. Oral lesions are with use of tobacco and alcohol
l Other topical and systemic therapies reported to be use- (cigarette, cigar and pipe smoking, snuff clipping
ful, such as dapsone, doxycycline and antimalarials, tobacco and betel nut chewing and reverse smoking)
require additional research. iv. Carcinoma in situ
l Topical application of cyclosporine appears to be help- v. Bowen disease
ful in managing recalcitrant extensive and otherwise vi. Oral submucous fibrosis (OSMF)
intractable oral lesions of OLP. vii. Actinic keratosis
l When lesions have been confined to the mucosa just viii. Discoid lupus erythematosus
opposite amalgam restorations and when patients have ix. Dyskeratosis congenita
been positive for patch tests to mercury or other metals, x. Lichen planus
complete removal of the amalgam restorations has been xi. Oral lichenoid reactions (erythema multiforme,
curative in most patients. lupus erythematosus, dermatomyositis, drug-induced
l Surgical excision is indicated for the treatment of OLP lichenoid reactions, secondary syphilis and graft
only in cases where concomitant dysplasia has been vs. host reactions)
identified. This grouping provides a practical scheme for the clini-
cian faced with for making decisions about particular lesions.
Q.2. Classify white lesions of the oral cavity. Describe
the aetiology, clinical features and management of [SE Q.2]
leukoplakia.
{Leukoplakia
Ans. l Leukoplakia is defined as ‘a white patch or plaque that
cannot be characterized clinically or pathologically as
Classification of white lesions
any other disease’.
I. Variations in structure and appearance of the normal
l Leukoplakia is a keratotic plaque occurring on mucous
oral mucosa
membranes and is considered as a premalignant lesion.
i. Leukoedema
ii. Fordyce granules Aetiologic factors
iii. Linea alba and other areas of frictional cornifica- i. Tobacco products
tion ii. Ethanol
II. Nonkeratotic white lesions iii. Hot, cold, spicy and acidic foods and beverages
i. Habitual cheek biting iv. Alcoholic mouth rinse
ii. Burns (thermal, aspirin, dental medicaments, ra- v. Occlusal trauma
diation mucositis and uraemic stomatitis) vi. Sharp edges of prostheses or teeth
iii. Caused by specific infectious agents (Koplik spots, vii. Actinic radiation
and syphilitic patches) viii. Syphilis
III. Candidiasis ix. Presence of Candida albicans
i. Acute pseudomembranous candidiasis (oral thrush) x. Presence of viruses}
Classification v. The typical homogenous leukoplakia is characterized

Clinical types of leukoplakia are as follows: as white, well-demarcated plaque with an identical
a. Homogenous type reaction pattern throughout the lesion.
b. Speckled type vi. The surface texture can vary from smooth thin surface
c. White and red patches to leathery appearance with surface fissures referred to
d. Verrucous type as ‘cracked mud’.
a. Homogenous leukoplakia vii. The nonhomogeneous type of oral leukoplakia also
Homogenous white plaques have no red component but known as erythroleukoplakia or speckled leukoplakia
have a fine, white, grainy texture or a more mottled, may have white patches or plaque intermixed red tis-
rough appearance. sue elements.
b. Speckled leukoplakia viii. Verrucous or verruciform leukoplakias are the lesions
Composed of fine or coarse variety of white and red in which white component is dominated by papillary
flecks. projections similar to oral papillomas.
c. Combination of white and red patches This variety of leukoplakia with more aggressive
Basically erythroleukoplakic lesions demonstrating seg- proliferation pattern and recurrent rate are designated
regation of red and white components. as proliferative verrucous leukoplakia (PVL). This is
d. Verrucous leukoplakia more common in older women and lower gingiva is
Has red and white components of which the white com- the predilection site.
ponents are much thicker and protrude above the sur- ix. Malignant potential: Those lesions situated in the
face mucosa. high-risk areas, such as floor of the mouth, ventral
surface of tongue, margins of the tongue and retro
Histological types
molar regions, have high risk for malignant trans-
Leukoplakia is mainly categorized into two types:
formation.
i. Those that show no atypia (dysplasia).
ii. Those that show different degrees of atypia: Differential diagnosis
l A leukoplakia lesion may show severe atypia with i. Lichen planus
malignant change throughout the depth of epithelial ii. Leukoedema
layer, but its basement membrane may still be intact, iii. Cheek-biting lesions
such lesion is referred to as carcinoma in situ or in- iv. Smokeless tobacco lesion
traepithelial carcinoma. When intraepithelial carci- v. Lupus erythematosis
noma breaks through the basement membrane, it vi. Hyperplastic or hypertrophic candidiasis
becomes an invasive SCC. vii. Verrucous or squamous cell carcinoma
viii. Verruca vulgaris
Leukoplakia is also divided into two types according to ix. White sponge nevus (WSN)
its spontaneous disappearance following removal of chronic
irritant as follows: [SE Q.2]
i. Reversible leukoplakia: Lesions of leukoplakia are
reversible after removal of chronic irritants.
{Management
I. Elimination of aetiological factors
ii. Irreversible leukoplakia: Persistent lesions, even after
l No appropriate treatment has been established for
removal of irritants.
Sanguinaria-induced leukoplakia. So, complete
Clinical features discontinuation of Sanguinaria containing products
i. Asymptomatic, discovered during routine oral exami- is mandatory and cessation of any other harmful
nation. habits like alcohol and smoking by the patients
ii. More common in older age group .35 years (40–70 which are well established risk factors.
years) of age range, more common in men. II. Conservative treatment
iii. Frequent sites are lips, vermilion border, buccal l Vitamin therapy especially vitamin A and vitamin
mucosa, mandibular gingiva, tongue, oral floor, E, B complex, 13-cis-retinoic acid and antioxidant
hard palate, maxillary gingiva, lip mucosa and soft therapy.
palate. The floor of the mouth and lateral border l Nystatin therapy (in candidal leukoplakia).
of tongue are high risk sites for malignant transfor- III. Surgical therapy
mation. l Cold knife surgical excision.
iv. Lesions may greatly vary in size, shape and distribu- l Laser surgery.
tion; the borders may be distinct or indistinct smoothly l Cryosurgery (liquid nitrogen or CO2 snow is used).
contoured or ragged. l Fulguration (electro-cautery or electro-surgery).

l Laser (light amplification by especially CO2 lasers Aetiology and pathogenesis

stimulated fusion of radiation). i. Chronic irritation
l However, in the absence of evidence-based treat-
a. Betel nut, i.e. areca nuts (alkaloids)
ment, strategies for oral leukoplakias, surgery will
b. Chillies capsaicin (active ingredient
remain the treatment of choice for leukoplakia and causing irritation)
erythroplakia. c. Tobacco Local irritants
l A general recommendation may be to re-examine d. Lime
the site every 3 months for first 1 year irrespective
of surgical excision. l Areca nut, quid chewing habit and development
l Follow up every 6 months to see whether there is
of OSMF is dose dependant and the mechanism is
any change in reaction pattern and relapse. described below:
l Self-examination is reasonable approach if there is
Areca nuts contain alkaloids like
no relapse for 5 years.
l However, an initial biopsy is mandatory. If a histo- g
pathologic diagnosis of dysplasia is rendered, the Arecoline (primary aetiologic factor)
condition should be treated in a fashion similar to
the treatment of other potentially premalignant g
processes. Modulates matrix metalloproteinases, lysyl oxidases and
collagenases
All patients should be given careful clinical follow-up, g all affect
with a biopsy of any recurrent or worsening lesion(s).}
Metabolism of collagen
Q.3. Enumerate oral precancerous lesions and condi- gleading to
tions. Describe clinical features and management of oral
submucous fibrosis. Increased fibrosis
Ans. ii. Genetic predisposition

l Genetic predisposition is an important aetiologic
l The premalignant lesions are defined as morphologically factor behind OSMF.
altered tissue in which cancer is more likely to occur l Familial occurrence of OSMF has been reported.
than in its apparently normal counterpart. For example, iii. Nutritional deficiency
l Leukoplakia
l Vitamin B complex deficiency.
l Erythroplakia
l Deficiency is precipitated by the defective nutri-
l Nicotiana palati
tion due to impaired food intake.
l Stomatitis
iv. Bacterial infections
l Dyskeratosis congenitis
For example, streptococcal toxicity.
l The premalignant condition is defined as generalized
l Klebsiella rhinoscleromatis may be causative
state of body, which is associated with significantly in- factors in OSMF.
creased risk of cancer. v. Collagen disorders
For example, oral submucous fibrosis, syphilis, lichen l OSMF is thought to be localized collagen dis-
planus, white sponge nevus and so on. ease of oral cavity.
The following are the conditions that produce trismus: l It is linked to scleroderma and rheumatoid arthritis.
i. Odontogenic infections l Scleroderma and OSMF have similar histologi-
ii. Traumatic fractures cal features.
iii. Neoplastic conditions vi. Immunological disorders
iv. Neurotoxic agents l hESR and globulin levels indicate immunodefi-
v. Psychogenic factors ciency disorder. Serum immunoglobulin levels of
vi. Pharmacological substances IgA, IgG and IgM are h significantly found in
OSMF, which suggest an antigenic stimulus in
[SE Q.3]
the absence of any infection.}
{Oral submucous fibrosis l Circulating auto antibodies are present in some cases of
l It is a chronic disease that affects the oral mucosa OSMF.
as well as the pharynx and upper two-thirds of the Clinical features
oesophagus. i. Age and sex: Equally affects both the sexes, and
l It is a high-risk precancerous condition. patients are between second and fourth decade.
ii. Site: Most frequent locations are buccal mucosa Early lesions have a good prognosis as they may
(98%) and retromolar areas. Commonly involved regress.
sites are soft palate, (49%) palatal fauces, uvula, ii. Supportive treatment
tongue and labial mucosa. l Vitamin rich diet.
iii. Prodromal symptoms: Onset of OSMF is insidi- l Iodine, B-complex preparations (e.g. injection
ous and is often 2- to 5-year duration. Most com- ranodine), injection of arrsenotyphoid and iodine
mon initial symptom is burning sensation of oral (arrsenotyphoid is a fibrin dissolving agent).
mucosa, aggravated by spicy food followed by iii. Steroids
either hypersalivation or dryness of mouth.
iv. The first sign is erythematous lesions, some- Both Topical – e.g. hydrocortisone injection along with
times in association with petechiae, pigmenta- procaine HCl intralesionally every fortnight.
tions and vesicles. Systemic – e.g. cortisone, hydrocortisone 25 mg
v. Initial lesions are followed by paler mucosa, tab in doses of 100 mg/day. Triamcinolone or 90
which comprise white marbling. mg dexamethasone.
vi. In the later course of the disease, the most
prominent clinical features appear, i.e. fibrotic l Increased vascularity at the affected site attributed
bands located beneath an atrophic epithelium. to fibrolytic, antiallergic and anti-inflammatory ac-
vii. hfibrosis leads to loss of resilience, which causes tion of corticosteroid.
interference with speech, tongue mobility and a l The fibrosis is prevented by decreasing fibroblastic
decreased ability to open the mouth. production and deposition of collagen.

viii. The atrophic epithelium may cause a smarting iv. Placental extract
sensation and inability to eat hot and spicy food. l It is an essential biogenic stimulator. Only the
ix. Diagnosis of OSMF is based on clinical features aqueous extract of placenta acts as biogenic stimu-
and patients report of a habit of betel quid chewing. lator. It accelerates cellular metabolism, stimulated
An international consensus has been reached where regenerative process, aids in absorption of exu-
at least one of the following characteristics should be dates, increases physiologic function of organs and
present to diagnose OSMF, they are as follows: significant enhancement of wound healing and it
i. Palpable fibrous bands. has notable anti-inflammatory effect. Dose: Intral-
ii. Mucosal texture feels tough and leathery. esionally 2 mL of solution is deposited in five di-
iii. Blanching of mucosa together with histo- vided regions of the lesions at intervals of 3 days or
pathologic features consistent with OSMF about 15 days. If required the course is repeated
(i.e. atrophic epithelium with loss of rete after a month.
ridges and juxta-epithelial hyalinization of v. Hyaluronidase: It acts by breaking down the hyal-
lamina propria). uronic acid, i.e. the ground substance of connective
Pathology tissues.
Early histopathological characteristics of OSMF are vi. Surgical procedures: When there is marked limitation
l Fine fibrils of collagen, oedema, hypertrophic fi- of opening, the surgery is the treatment method of
broblasts, dilated and congested blood vessels and choice.
infiltration of neutrophilic and eosinophilic granu- a. Excision of fibrous bands followed by use of
locytes. tongue flap as a graft or bilateral full thickness
gfollowed by nasolabial flap.
l Downregulation of fibroblasts, epithelial atrophy b. New technique of bilateral palatal flaps to cover
and loss of rete pegs and early signs of hyalinization exposed area in combination with the bilateral tem-
in concert with an infiltration of inflammatory cells. poralis myotomy and coronoidectomy.
g c. LASER – with CO2 laser under GA incise the buc-
l Epithelial dysplasia (7%–26%) of cases. cal mucosa and vaporize the submucosal connec-
Malignant transformation of OSMF has been esti- tive tissue to the level of buccinator muscle.
mated in the range of 7%–13% and incidence over d. Cryosurgery – local destruction of tissue by freez-
10-year period is 8%. ing it in sites.
vii. Oral physiotherapy: oral exercises are advised in early
[SE Q.3]
and moderately advanced cases.
{Management viii. Diathermy: Microwave diathermy is useful in early
i. Stopping of chewing habits, especially areca nut as and moderate lesions like mouth opening and balloon-
it is carcinogenic. If this is successfully implemented. ing of mouth.}
Q.4. Write an essay on oral candidiasis. VII. Others

l Radiation therapy
Ans.
l Sjögren syndrome
Oral candidiasis is the most prevalent opportunistic infec- l Pregnancy
tion affecting oral mucosa. l Old age
Most candida infections only affect mucosal linings, l Infancy
but the rare systemic manifestations may have fatal l Denture use
course.
Predisposing factors
Aetiology and pathogenesis
l C. albicans, C. tropicalis and C. glabrata. Local Systemic or general
l C. albicans constitute 80% of species isolated from Denture wearing Immunosuppressive diseases
human candidiasis. Smoking Impaired health status
l Candida is a common, harmless, dimorphic yeast.
Atopic constitution Immunosuppressive drugs
Predisposing factors to oral candidiasis Inhalation steroids Chemotherapy
I. Drugs and medications
Broad-spectrum antibiotics (e.g. tetracycline) Topical steroids Endocrine disorders
Multiple antibiotic regimens Hyperkeratosis Hematinic deficiencies
Corticosteroids Imbalance of oral microflora
Cytotoxic agents
Quality and quantity of salvia
Immunosuppressive agents
Anticholinergics (xerostomia producing)
II. Endocrinopathies Classification of oral candidiasis according to Sicher:
l Diabetes mellitus
l Hypoadrenalism
Acute Chronic
l Hypothyroidism i. Acute pseudo- i. Chronic hyperplastic oral candidiasis
l Hypoparathyroidism membranous ii. Chronic atrophic oral candidiasis
oral candidiasis iii. Chronic mucocutaneous candidiasis
l Polyendocrinopathy
(thrush) a. Chronic familial mucocutaneous
III. Haematologic disorders ii. Acute atrophic candidiasis
l Aplastic anaemia oral candidiasis b. Chronic localized mucocutaneous
l Agranulocytosis candidiasis
l Lymphoma c. Chronic diffuse mucocutaneous
candidiasis
l Leukaemia
d. Candidiasis endocrinopathy
IV. Immune deficiency syndrome
l HIV disease
l Thymic alymphoplasia (Nezelof syndrome) Classification of oral candidiasis according to Boucher:

l Thymic hypoplasia (DiGeorge syndrome) A. Primary oral candidiasis
l Severe combined immunodeficiency syndrome l Acute – pseudomembranous and erythematous
(Swiss type) l Chronic – pseudomembranous
l Chronic mucocutaneous candidiasis (CMC) l Erythematous
V. Leukocyte disorders l Plaque-like
l Myeloperoxidase deficiency l Nodular
l Agranulocytosis/leukopenia/neutropenia l Candida-associated lesions – denture stomatitis
VI. Malignancy l Angular cheilitis
l Leukaemia l Median rhomboid glossitis
l Lymphoma B. Secondary oral candidiasis

l Advanced cancer l Familial chronic mucocutaneous candidiasis
l Nutritional deficiencies l Diffuse chronic mucocutaneous candidiasis
l Iron deficiency l Candidiasis endocrinopathy syndrome
l Folic acid deficiency l Familial mucocutaneous candidiasis
l Vitamin B deficiency l Severe combined immune deficiency
l Vitamin C deficiency l DiGeorge syndrome
l Malnutrition l Chronic granulomatous disease
l Malabsorption l AIDS
C. Extraoral candidiasis cultured and counted and counter as in previous

l Oral candidiasis are with extraoral lesions (candidal methods.
vulvovaginitis and intertriginous candidiasis) l Advantage: Simple method.
l Better results if CFU .50/cm .

2
l Gastrointestinal candidiasis
l Candida hypersensitivity syndrome l Disadvantage: Simple method recommended for sur-
D. Systemic candidiasis veillance cultures in the absence of focal lesions,

l Mainly affects eye, kidney and skin cannot identify site of infection.
Clinical features
Treatment of oral candidiasis
Various types of clinical lesions are as follows:
l Several appropriate medications are available for treat-
l Pseudomembranous – white necrotic (loosely adherent)
ment of oropharyngeal candidiasis (topical 1 systemic
l Erythematous – red
drug agents) drug treatment should be continued for at
l Atrophic – red
least 1 week after signs and symptoms have disappeared
l Hyperplastic – white and red raised
without any tendency to recur.
l Mixed – red/white keratotic/white necrotic
I. Topical therapy
l Mucocutaneous – lip and angle
Generally indicated for milder superficial cases where
l Pseudomembranous type is most acute followed by
patients resistance is relatively good and there is im-
erythematous
mune competency.
l Atrophic and hyper plastic types are chronic
i. Nystatin
l 50% patients complain, oral burning and infections
ii. Clotrimazole
(more acute types will be more painful) and hyperplas-
iii. Chlorhexidine mouth rinse 0.1%–0.2%
tic types painless
iv. Gentian violet
l Age: 40 years with female predilection
Nystatin
Lab diagnosis l The majority of acute oral candida infections
i. Smear from infected area – scraping and smearing respond rapidly to topical nystatin.
directly on to slide l Action – This polyene drug destroys cell mem-
l Advantage: Simple and quick brane by binding to ergosterol in them.

l Disadvantage: Low sensitivity l Side effect – Unusual, it is not absorbed through
ii. Swab GIT.

iii. Imprint culture l Available forms – Oral suspension ointment/
l Sterile plastic foam pads dipped into sabouraud creams vaginal troches powder tablets.
broth, placed on lesion for 60 s, pad pressed on sab- l Pastilles (most widely used form) – 200,000 units/
ouraud agar plate and incubated, colony counter each pastille, 1–2 dissolved in mouth 4–5 times/day.
used. Clotrimazole
l Advantage: Sensitive and reliable, can differentiate l An imidazole derivative (clotrimazole) is avail-
between infected and carrier states. able for topical use.

iv. Impression culture l Action – This is an azole; it changes candida’s
l Maxillary and mandibular impressions with alginate membrane permeability by blocking the produc-
and casting in agar fortified with sabouraud broth tion of ergosterol.
and incubation. l Clotrimazole troches can also be used for treat-
l Advantage: Useful to determine relative distributions ment of oral lesions.

of yeasts on oral surfaces. l Available as 10 mg oral troche (Mycelex) dis-
l Disadvantage: Used as research tool. solved slowly in mouth, 5 times/day. Continue for
v. Salivary culture 2–4 weeks or at least week after manifestations
l 2 mL saliva is expectorated by patient into sterile have disappeared.
container. Vibrate and culture on sabouraud agar by Chlorhexidine (mouth rinse 0.1%–0.2%)
a spiral plating and counting. l It is active against candida and some bacteria and
l Advantage: Sensitive and reliable. causes increased cell membrane permeability.

l Disadvantage: More chair side time not useful in l It interferes with candidal adhesion to oral mucosa.
xerostomics. Gentian violet

vi. Oral rinse l Deep violet alcohol solution directly painted on
l Subject rinses for 60 s with PBS that is phosphate- lesions.
buffered saline at pH 7.2, 0.1 M and returns it to the l Advantage is that it is economical and quickly
original container concentrated by centrifugation, applied by clinician.

l The consumption of yogurt two to three times per l It occurs in all ages with equal predilection for both sexes.
week and improved oral hygiene can also help, l Severity of the disease increases in winter.
especially if underlying predisposing factors can- l Clinically it is characterized by small dry papules cov-
not be eliminated. ered by silvery scales. On removal of the scales, they

II. Systemic therapy leave tiny bleeding spots (Auspitz sign).
l Systemic therapy includes the use of anyone of these l The common extraoral sites include elbows, knees,
three: ketoconazole, itraconazole and fluconazole. scalp and lumbosacral skin and nails.
l Systemically administered drugs are chosen in l These patients also have arthritis. Temporomandibular
chronic deep-seated infections and superficial cases joint may be involved in such cases.
refractory to topical agents. l Intraoral lesions are rare and if involved the lesions
Ketoconazole occur on tongue and palate.

l Very effective and is still used. l There will be white scaly or raised erythematous patches
l Action: Affects permeability of fungal cell mem- with annular or irregular borders.
brane. l One of the special features of psoriasis is the capacity to
l Nizoral available as 200 mg tablets and as i.v. reproduce the skin lesion at the site of local injury. It is
preparation. called Koebner phenomenon or the isomorphic effect.
l 1–2 tabs/day with food for at least 2 weeks and
Considerations in the differential diagnosis of psoriasis
continue for 1–2 weeks after symptoms disappears.
l Reiter syndrome
l i.v. administration – Used for refractory infections
l Seborrhoeic dermatitis
in AIDS patients.
l Geographic tongue
l Caution
l Atopic eczema
l Liver toxicity (less when compared to other azoles).
l Lichen planus
l Liver profile tests done if chronic administra-
l Darier disease
tion is considered.
Fluconazole Treatment
l Fluconazole is more effective than ketoconazole, l Psoriasis can be treated using topical corticosteroids
but its frequent use can lead to the development of and keratinolytics. Methotrexate has also shown to be
resistance to the drug. effective.
l Available as diflucan 50 mg tablets. Dose: 50 mg/
Q.6. Discuss in detail clinical features, differential diag-
day as single dose in difficult cases 400 mg/day
nosis and treatment of erythroplakia.
can be used.
l It is very useful drug in AIDS patients for prophy- Ans.
laxis and treatment. It is still the mainstay of
[SE Q.7]
therapy for HIV-associated candidiasis.
l Fluconazole and amphotericin B may be used l {Erythroplakia has been defined as a ‘bright red vel-
intravenously for the treatment of the resistant vety plaque or patch which cannot be characterized
lesions of Chronic mucocutaneous candidiasis clinically or pathologically as being due to any other
(CMC) and systemic candidiasis. condition’.
l Fluconazole interacts with a number of other l The word is an adaptation of the French term ‘erythro-
medications and must be prescribed with care for plasie de Queyrat’, which describes a similar-appearing
patients who are using anticoagulants, phenytoin, lesion of the glans penis with a comparable premalig-
cyclosporine and oral hypoglycaemic agents. nant tendency.
Amphotericin B l Erythroplakia is far less common than leukoplakia in
l Its major role is as i.v. administered agent in most histopathologic series.
serious cases of systemic distribution which are l A number of studies have shown that the majority of
resistant to other antifungals. erythroplakias (particularly those located under the
l Disadvantage is significant toxicity to several tongue, on the floor of the mouth and on the soft palate
organ systems especially kidneys. and anterior tonsillar pillars) exhibit a high frequency of
Q.5. Describe briefly and give the differential diagnosis premalignant and malignant changes.
of psoriasis. l Although the aetiology of erythroplakia is uncertain,
most cases of erythroplakia are associated with heavy
Ans. smoking, with or without concomitant alcohol abuse.
l Psoriasis is a chronic, recurrent, scaly and erythematous l Shear described clinical variants of erythroplakia as:
disease of skin. i. Homogeneous erythroplakia
ii. Erythroplakia interspersed with patches of leuko- l Most asymptomatic malignant erythroplakic lesions are
plakia small; 84% are 2 cm in diameter, and 42% are 1 cm.
iii. Granular or speckled erythroplakia However, since recurrence and multifocal involvement
is common, long-term follow-up is mandatory.}
Clinical features
l Many of these lesions are irregular in outline, and some
contain islands of normal mucosa within areas of eryth- SHORT ESSAYS:

roplakia, a phenomenon that has been attributed to the
coalescence of a number of precancerous foci. Q.1. Predisposing factors and smear examination for
l Erythroplakia occurs predominantly in older men, in the Candida albicans.
sixth and seventh decades of life.
Ans.
l Erythroplakias are more commonly seen on the floor of
the mouth, the ventral tongue, the soft palate and the The following predisposing factors for oral candidiasis
tonsillar fauces, all prime areas for the development of have been identified on clinical observation:
carcinoma. i. Marked changes in oral microbial flora due to the use
l Multiple lesions may be present. These lesions are com- of antibiotics (especially broad spectrum antibiotics),
monly described as erythematous plaques with a soft vel- excessive use of antibacterial mouth rinses or xero-
vety texture. Almost all of the lesions are asymptomatic.} stomia.
ii. Chronic local irritants (dentures and orthodontic appli-
Histopathologic feature
ances).
l Severe epithelial dysplasia, carcinoma in situ or inva-
iii. Administration of corticosteroids (aerosolized inhalant
sive carcinoma.
and topical agents are more likely to cause candidiasis
Differential diagnosis than systemic administration).
l Clinically similar lesions may include erythematous iv. Poor oral hygiene.
candidiasis, areas of mechanical irritation, denture sto- v. Pregnancy.
matitis, vascular lesions and a variety of nonspecific vi. Immunologic deficiency.
inflammatory lesions. vii. Malabsorption and malnutrition.
l Differentiation of erythroplakia from benign inflamma-
Predisposing factors may be grouped as follows:
tory lesions of the oral mucosa can be enhanced by the
use of a 1% solution of toluidine blue, applied topically Local Systemic or general
with a swab or as an oral rinse. Although this technique
Denture wearing Immunosuppressive diseases
was previously found to have limited usefulness in the
evaluation of keratotic lesions, prospective studies of Smoking Impaired health status
the specificity of toluidine blue staining of areas of early Atopic constitution Immunosuppressive drugs
carcinoma contained in erythroplakic and mixed leuko-
Inhalation steroids Chemotherapy
plakic–erythroplakic lesions reported excellent results,
with false-negative (under diagnosis) and false-positive Topical steroids Endocrine disorders
(over diagnosis) rates of well below 10%. Hyperkeratosis Hematinic deficiencies
Imbalance of oral microflora
[SE Q.7]
Quality and quantity of salvia
{Treatment and prognosis
l The treatment of erythroplakia should follow the same Q.2. Aetiology and management of oral leukoplakia.
principles outlined for that of leukoplakia.
l Observation for 1–2 weeks following the elimination of Ans.
suspected irritants is acceptable, but prompt biopsy at [Ref LE Q.2]
that time is mandatory for lesions that persist.
l The toluidine blue vital staining procedure may be re- Q.3. Aetiology and management of oral submucous
done following the period of elimination of suspected fibrosis.
irritants. Lesions that stain on this second application Ans.
frequently show extensive dysplasia or early carcinoma.
Epithelial dysplasia or carcinoma in situ warrants com- [Ref LE Q.3]
plete removal of the lesion. Q.4. Lichenoid reactions.
l Actual invasive carcinoma must be treated promptly
according to guidelines for the treatment of cancer. Ans.

l Lichenoid reactions and lichen planus exhibit similar

l These lesions frequently appear lichenoid, although
histopathologic features. Lichenoid reactions were dif-
they may be nonspecific and resemble leukoplakia,
ferentiated from lichen planus on the basis of
vesiculobullous disease or even a granulomatous
i. their association with the administration of a drug,
lesion.
contact with a metal, the use of a food flavouring or
l They typically respond well to topical or systemic
systemic disease
steroids. Clobetasol (a potent topical steroid) placed
ii. their resolution when the drug or other factor was
under an occlusive tray is very effective for tempo-
eliminated or when the disease was treated
rary relief of these lesions. Long-term remission of
l Clinically, lichenoid lesions may exhibit the classic ap-
these lesions obviously depends on treatment of the
pearance of lichen planus, but atypical presentations are
underlying systemic disease.
seen, and some of the dermatologic lesions included in
this category show little clinical lichenification.
l List of some of the disorders that are currently proposed
Discoid lupus erythematosus (DLE)
as lichenoid reactions:
l It is a relatively common disease and occurs predomi-
i. Drug-induced lichenoid reactions.
nantly in females in the third or fourth decade of life.
ii. Drug-induced lichenoid eruptions include those le-
l DLE can present in both localized and disseminated
sions (i.e. oral mucosal lesions that have the clinical
forms and is also called chronic cutaneous lupus erythe-
and histopathologic characteristics of lichen planus)
matosus (CCL).
that are associated with the administration of a drug,
l DLE is confined to the skin and oral mucous mem-
and that resolve following the withdrawal of the drug.
branes and has a better prognosis than SLE. Typical
l A drug history can be one of the most important aspects
cutaneous lesions appear as red and somewhat scaly
of the assessment of a patient with an oral or oral-and-
patches that favour sun-exposed areas such as the face,
skin lichenoid reaction. However, lichenoid lesions that
chest, back and extremities.
include the lip and are symmetric in distribution and that
l These lesions characteristically expand by peripheral
also involve the skin are more likely to be drug related.
extension and are usually disc-shaped.
l However, many lesions take months to clear, in the case
l The oral lesions can occur in the absence of skin le-
of a reaction to gold salts, 1 or 2 years may be required
sions, but there is a strong association between the two.
before complete resolution.
As the lesions expand peripherally, there is central atro-
l Gold therapy, nonsteroidal anti-inflammatory drugs
phy, scar formation and occasional loss of surface pig-
(NSAIDs), diuretics, other antihypertensives and oral
mentation. Lesions often heal in one area only to occur
hypoglycaemic agents of the sulphonylurea type are all
in a different area later.
important causes of lichenoid reactions.
l The oral mucosal lesions of DLE frequently resemble
Q.5. Lupus erythematosus. reticular or erosive lichen planus.

l The primary locations for these lesions include the buccal
Ans.
mucosa, palate, tongue and vermilion border of the lips.
l Unlike lichen planus, the distribution of DLE lesions is
usually asymmetric, and the peripheral striae are much
more subtle.
{SN Q.10}
l The lesions may be atrophic, erythematous and/or ulcer-
Systemic lupus erythematosus (SLE) ated and are often painful. Hyperkeratotic lichen pla-
l Systemic lupus erythematosus (SLE) is a prototypi- nus-like plaques are probably twice as common in pa-
cal example of an immunologically mediated inflam- tients with CCL as compared to patients with SLE.
matory condition that causes multiorgan damage. l The oral lesions of DLE are markedly variable and can
l The oral lesions of systemic lupus are generally also simulate leukoplakia.
similar to those of discoid lupus and are most preva- l The diagnosis must be based not only on the clinical
lent on the buccal mucosa, followed by the gingival appearance of the lesions but also on the coexistence of
tissues, the vermilion border of the lip and the palate, skin lesions and on the results of both histologic exami-
in decreasing order of frequency. nation and direct immunofluorescence testing.
l The lesions are frequently symptomatic, especially if
Histopathologic features
the patient ingests hot or spicy foods, and often con-
l The histopathologic changes of oral lupus consist of
sist of one or more of the following components:
hyperorthokeratosis with keratotic plugs, atrophy of the
erythema, surface ulceration, keratotic plaques and
rete ridges and liquefactive degeneration of the basal
white striae or papules.
cell layer.
l Oedema of the superficial lamina propria is also quite dosage regimens are determined individually, based on
prominent. Most of the time, lupus patients lack the the patient’s medical status, severity of disease and pre-
band-like leukocytic inflammatory infiltrate seen in vious treatment responses. Consultation with the pa-
patients with lichen planus. tient’s primary care physician is important when under-
l Immediately subjacent to the surface epithelium is a lying medical problems are present.
band of PAS-positive material, and frequently there is a l Retinoids are also useful, usually in conjunction with
pronounced vasculitis in both superficial and deep con- topical corticosteroids as adjunctive therapy for OLP.
nective tissues. l Systemic and topically administered beta all-trans reti-
l Another important finding in lupus is that direct immu- noic acid, vitamin A acid, systemic etretinate and sys-
nofluorescence testing of lesional tissue shows the de- temic and topical isotretinoin are all effective, and
position of various immunoglobulins and C3 in a granu- topical application of a retinoid cream or gel will
lar band involving the basement membrane zone. eliminate reticular and plaque-like lesions in many pa-
l Importantly, direct immunofluorescent testing of unin- tients. However, following withdrawal of the medica-
volved skin in a case of SLE will show a similar deposition, the majority of lesions recur.
tion of immunoglobulins and/or complement. This is l Topical retinoids are usually favoured over systemic
called the positive lupus band test, and discoid lesions retinoids since the latter may be associated with ad-
will not show this result. verse effects such as liver dysfunction, cheilitis and
teratogenicity.
Q.6. Management of oral lichen planus (OLP). l A new systemically administered retinoid, temarotene,
is reported to be an effective therapy for OLP and to be
Ans.
free of side effects other than a slight increase in liver
Management of oral lichen planus (OLP) enzymes.
l There is no known cure for OLP; hence the manage- l Other topical and systemic therapies reported to be
ment of symptoms guides therapeutic approaches. useful, such as dapsone, doxycycline and antimalari-
l Corticosteroids have been the most predictable and suc- als, require additional research.
cessful medications for controlling signs and symp- l Topical application of cyclosporine appears to be help-
toms. Topical and/or systemic corticosteroids are pre- ful in managing recalcitrant extensive and otherwise
scribed electively for each patient. intractable oral lesions of OLP.
l Topical medications include high-potency corticoste- l When lesions have been confined to the mucosa just
roids, the most commonly used are: opposite amalgam restorations and when patients have
l 0.05% fluocinonide (Lidex), 0.05% clobetasol (Temo- been positive for patch tests to mercury or other metals,
vate) and Triamcinolone acetonide 0.1 % in orabase, complete removal of the amalgam restorations has been
oral suspension of triamcinolone, high potency steroid curative in most patients.
mouthwashes like betamethasone valerate 0.1 %, fluo- l Surgical excision is indicated for the treatment of OLP
cinolone acetonide 0.1 % and clobetasol propionate only in cases where concomitant dysplasia has been
0.05% have been used effectively. The topical forms are identified.
applied daily to meet each patient’s needs. Topical cor-
Q.7. Erythroplakia – clinical features and management.
ticosteroids reduce pain and inflammation.
l In addition, extensive erosive lesions of OLP on the Ans.
gingiva (desquamative gingivitis) may be treated effec-
[Ref LE Q.6]
tively by using occlusive splints as carriers for the topi-
cal steroid. Q.8. White spongy naevus.
l Candida overgrowth with clinical thrush may develop,
Ans.
requiring concomitant topical or systemic antifungal
therapy. It has been shown that the use of an antibacte- l White sponge nevus is a rare autosomal dominant disor-
rial rinse such as chlorhexidine before steroid applica- der with a high degree of penetrance and variable ex-
tion helps prevent fungal overgrowth. pressivity; it predominantly affects noncornified strati-
l Systemic steroids are rarely indicated for brief treat- fied squamous epithelium.
ment of severe exacerbations or for short periods of l The disease usually involves the oral mucosa and less
treatment of recalcitrant cases that fail to respond to frequently the mucous membranes of the nose, oesopha-
topical steroids. gus, genitalia and rectum.
l Systemic administration of prednisone tablets may be l The lesions of white sponge nevus may be present at
done with dosages varying between 40 and 80 mg daily birth or may first manifest or become more intense at
for less than 10 days without tapering. The time and puberty.
l Genetic analyses of families with white sponge nevus l Lesions on the tongue are usually corrugated and may
have identified a missense mutation in one allele of have a shaggy or frayed appearance, mimicking lesions
keratin 13 that leads to proline substitution for leucine caused by tongue chewing.
within the keratin gene cluster on chromosome 17. l Oral hairy leukoplakia may also present as a plaque-like
lesion and is often bilateral.

Clinical and histopathologic features
l White sponge nevus presents as bilateral symmetric Histopathology
white, soft, ‘spongy’ or velvety thick plaques of the buc- l Histopathologic examination of the epithelium reveals
cal mucosa. However, other sites in the oral cavity may severe hyperparakeratosis with an irregular surface,
be involved, including the ventral tongue, floor of the acanthosis with superficial oedema and numerous
mouth, labial mucosa, soft palate and alveolar mucosa. koilocytic cells (virally affected ‘balloon’ cells) in the
l The condition is usually asymptomatic and does not spinous layer.
exhibit tendencies towards malignant change. l The characteristic microscopic feature is the presence of
homogeneous viral nuclear inclusions with a residual

Characteristic histopathologic features
rim of normal chromatin.
l Epithelial thickening, parakeratosis, a peculiar perinu-
l The definitive diagnosis can be established by demon-
clear condensation of the cytoplasm and vacuolization
strating the presence of EBV through in situ hybridiza-
of the supra-basal layer of keratinocytes.
tion, electron microscopy or polymerase chain reaction
l Electron microscopy of exfoliated cells shows numer-
(PCR).
ous cellular granules composed of disordered aggre-
gates of tonofilaments. Differential diagnosis
l It is important to differentiate this lesion from other
Treatment
clinically similar entities such as hyperplastic candidia-
l No treatment is indicated for this benign and asymp-
sis, idiopathic leukoplakia, leukoplakia induced by
tomatic condition.
tongue chewing, tobacco-associated leukoplakia, lichen
l Patients may require palliative treatment if the condition
planus, lupus erythematosus, White sponge nevus (WSN)
is symptomatic.
and verrucous leukoplakia.
Q.9. Oral hairy leukoplakia. l Since oral hairy leukoplakia is considered to be highly
predictive of the development of AIDS, differentiation

Ans. from other lesions is critical.
l Oral hairy leukoplakia is a corrugated white lesion that Treatment and prognosis
usually occurs on the lateral or ventral surfaces of the l No treatment is indicated. The condition usually disap-
tongue in patients with severe immunodeficiency. pears when antiviral medications such as zidovudine,
l The most common disease associated with oral hairy
acyclovir or ganciclovir are used in the treatment of the
leukoplakia is HIV infection. Oral hairy leukoplakia is HIV infection and its complicating viral infections.
reported in about 25% of adults with HIV infection but l Topical application of podophyllin resin or tretinoin has
is not as common in HIV infected children. led to short-term resolution of the lesions, but relapse is
l Its prevalence reaches as high as 80% in patients with
often seen.
acquired immunodeficiency syndrome (AIDS).
l Epstein–Barr virus (EBV) is implicated as the causative
agent in oral hairy leukoplakia. A positive correlation SHORT NOTES:

with decreasing cluster designation 4 (CD4) cell counts
has been established in HIV-positive patients. Q.1. Define vesicle and papule. Give two examples of
l The presence of this lesion has been associated with the each.
subsequent development of AIDS in a large percentage Ans.
of HIV positive patients.
l Hairy leukoplakia has also occasionally been reported Vesicles
in patients with other immunosuppressive conditions. Elevated blisters containing clear fluid that are under
For example, patients undergoing organ transplantation 1 cm in diameter. For example, herpes simplex virus infec-
and those who are on prolonged steroid therapy. tion.
Papules
Typical features Solid lesions raised above the skin surface that are
l Oral hairy leukoplakia most commonly involves the smaller than 1 cm in diameter. Papules may be seen in a
lateral border of the tongue but may extend to the ven- wide variety of diseases including erythema multiforme
tral or dorsal surfaces. simplex, rubella, lupus erythematosus and sarcoidosis.
Q.2. Behcet syndrome. l Lichen planus is a common chronic, dermatologic dis-

ease of the skin and mucous membranes.
Ans.
Various clinical types of lichen planus in the oral cavity
i. Behcet syndrome is a disease of uncertain aetiology. are as follows:
ii. Possible causes of the syndrome: PPLO virus/autoimmune. i. Linear
iii. Clinical features: ii. Papular
l It is more common in young adults between 25 and iii. Confluent
40 years of age. iv. Reticular
l Men are affected 5–10 times more as compared to v. Annular or circular
women. vi. Pigmented
l It is characterized chiefly by triad: recurrent oral vii. Vesicular or bullous
and genital ulcers; ocular inflammation and skill viii. Erosive or atrophic
lesions. ix. Hypertrophic
iv. There is no specific treatment for the disease.
Q.7. Grinspan syndrome.
Q.3. Candidiasis – aetiology.
Ans.
Ans.
l Grinspan syndrome refers to the triad of lichen planus,
l Oral candidiasis is the most prevalent opportunistic diabetes mellitus and vascular hypertension.
infection affecting oral mucosa. l This association of OLP and systemic diseases may be
l Most candida infections only affect mucosal linings, coincidental as the lichen planus commonly occurs in
but the rare systemic manifestations may have fatal older adults.
course.
Q.8. Civatte bodies.
Aetiology and C. albicans Constitute 80% of species iso-
pathogenesis C. tropicalis lated from human candidiasis
Ans.
C. glabrata l Civatte bodies are histological structures seen in lichen
planus.
Candida is a common, harmless, dimorphic yeast. l On histopathological examination of lichen planus,
chronic inflammatory cell infiltration is present in juxta-

Q.4. Auspitz sign. epithelial region.
Ans. l There is presence of necrosis or liquefaction degenera-
tion of basal cell layer of epithelium.

Auspitz sign is a characteristic sign of psoriasis. l Degenerating basal keratinocytes form rounded or
l Psoriasis is characterized by the appearance of small
ovoid, amorphous eosinophilic bodies known as ‘civatte,
dry papules covered by silvery scales, removal of deep hyaline, cytoid’ bodies.
scales reveal one or more, tiny bleeding points, this is
known as Auspitz sign. Q.9. Oral manifestations of ectodermal dysplasia.
Q.5. White spongy nevus. Ans.
Ans. l Ectodermal dysplasia is also known as hereditary ecto-
dermal dysplasia.
l White sponge nevus is also called Cannon disease or
l It is a large heterogeneous group of inherited disorders
oral epithelial nevus or congenital leukokeratosis.
primarily involving ectodermal structures involving
l A congenital mucosal abnormality, in some cases may
skin, hair, nails, eccrine glands and teeth.
not appear till adolescence.
Several oral manifestations of particular interest in
l Oral lesions involve palate, cheeks, gingiva, floor of the
ectodermal dysplasia are
mouth and tongue.
l Patients invariably manifest anodontia or oligodontia
l Mucosa appears thickened, folded or corrugated and has
that is complete or partial absence of teeth.
a soft or spongy texture with a white opalescent hue.
l Abnormal morphogenesis of teeth like, truncated or
l The condition is benign and there is no treatment and is
cone shaped teeth.
not associated with any clinical complications.
l Dry and cracked protuberant lips with pseudorhagades
Q.6. Mention various types of lichen planus. formation.

l Dry mouth due to the hypoplasia of salivary glands.
Ans. l High palatal arch, cleft lip and cleft palate.

Q.10. Systemic lupus erythematosus. l Constitutional disturbance.

l Cutaneous lesions are similar to those of erythema mul-
Ans. tiforme they are commonly haemorrhagic and are often
[Ref SE Q.5] vesicular or bullous.
l Oral mucous membrane lesions may be extremely severe
Q.11. Stevens–Johnson syndrome. and so painful that mastication is impossible.
Ans. Q.12. Target lesions.

l Stevens–Johnson syndrome is simply a severe bullous Ans.
form of erythema multiforme with widespread involve-
ment of skin, oral cavity, eyes and genitalia. l The ‘target’ lesions are characteristic in patients suffer-
ing from erythema multiforme.
It commences with abrupt occurrence of following features: l The classical dermal lesions of erythema multiforme,
l Fever. which often appear on extremities are concentric ring-
l Malaise. like resulting from varying shades of erythema giving
l Photophobia. rise to terms ‘target’, ‘iris’ or ‘bull’s eye’ lesions.
l Erythematous eruptions of oral mucosa, genitalia and l The concentric erythematous lesions may be purpuric or
skin. paler in the centre and has variety of appearances hence
l Purulent conjunctivitis (eye). the name multiforme.
Topic 3
Pigmentation of the Oral Tissues
LONG ESSAYS:
1 . General and oral manifestations of bismuthism.
2. Discuss the conditions that cause pigmentations of the oral mucosa.
3. Enumerate the various factors that cause exogenous pigmentation of the oral tissues. Describe in detail the oral
manifestations of lead and mercury intoxication.
4. Discuss the differential diagnosis of oral mucosal pigmentation. [Same as LE Q.2]
5. What are the causes of pigmentation of oral mucosa? [Same as LE Q.2]
6. ‘Pigmentation in oral structure’ diagnostic clue to diagnose systemic diseases. Discuss. [Same as LE Q.2]
7. Discuss in detail the diseases causing oral pigmentation. [Same as LE Q.2]
SHORT ESSAYS:
1 . Classification of pigmentation and clinical significance of endogenous pigmentation.
2. Exogenous pigmentation of oral cavity.
3. Differential diagnosis of argyria.
4. Malignant melanoma.
5. Von Recklinghausen disease.
SHORT NOTES:
1 . Endogenous pigmentation. [Ref LE Q.2]
2. Oral manifestations of bismuthism. [Ref LE Q.1]
3. Von Recklinghausen disease. [Ref SE Q.5]
4. Addison disease.
5 . Café-au-lait spots.
6. Mention the causes of extrinsic discolouration of teeth.
7. Peutz–Jeghers syndrome.
8. Endocrinopathic pigmentation. [Same as SN Q.4]
9. Pigmented lesions of oro-facial region. [Same as SN Q.5]
SOLVED ANSWERS
LONG ESSAYS: l Usually pigment is collected in intercellular tissue but
may also be present in endothelial cells or mononuclear
Q.1. General and oral manifestations of bismuthism. phagocytes.
l Paper test: Pigmentation persists when small piece of
Ans. white paper is inserted in the gingival sulcus.
Bismuthism mainly is caused due to bismuth poisoning Treatment
through: l Stoppage of use of bismuth
a. Medicinal use of bismuth-containing drugs. l Establishing and maintaining oral hygiene
b. Bismuth-containing pastes and proprietary drugs contain- l Topical application of lignocaine hydrochloride
ing bismuth salt also result in pigmentation of bismuth. Q.2. Discuss the conditions that cause pigmentations of
Mechanism of action the oral mucosa.
Its mechanism of action in producing pigmentation is as Ans.
follows:
Bacterial degradation of organic material of food n
Bismuth compound 1 Hydrogen sulphide
{SN Q.1}
Bacterial degradation of organic material of food n Pigmentation is the deposition of colouring material.
Bismuth compound 1 Hydrogen sulphide n Pigmenta- l Oral pigmentations are mainly of two types:
tion due to bismuth sulphide granules (blue-black colour) a. Endogenous pigmentations
Clinical features b. Exogenous pigmentations
l General feature: Nausea l Endogenous pigmentations:
l Vague features: Gastrointestinal (GI) disturbances, It is the type of pigmentation in which pigments
jaundice and bloody diarrhoea. originate with in the body.
l ‘Bismuth line’ in long bones: Characteristic white bands l Exogenous pigmentations:
of increased density appear in ends of the diaphyses im- In this, pigments are deposited as such or are formed
mediately adjacent to epiphyseal lines in the long bones. as reaction of chemicals of exogenous origin.
Endogenous pigmentations of oral mucosa:
{SN Q.2}
Colour Signifies the following
Oral manifestations Pigment imparted disease process
l Metallic taste and burning sensation in oral cavity.
Haemoglobin Blue, red Varix, haemangioma, Kaposi
l Ulcerative gingiva-stomatitis with discrete blue-black and purple sarcoma, angiosarcoma and
pigmentation of interdental and marginal gingiva. hereditary haemorrhagic
l Enlarged and sore tongue. telangiectasia
l Extremely painful shallow ulcerations in buccal Haemosiderin Brown Ecchymosis, petechiae,
mucosa. thrombosed vein, haemor-
l Regional lymphadenopathy. rhagic mucocoele and hae-
mochromatosis
l ‘Blue-black’ bismuth line appears on the gingiva.
Melanin Brown, Melanotic macule, nevus,
Histopathologic features black or melanoma and basilar mela-
grey nosis with incontinence
l Bismuth sulphide granules are seen as black irregular
collection of pigment in tissue section and even in peri- Bilirubin Yellow Jaundice or liver disorders
vascular location.
Exogenous pigmentations of oral mucosa: Giving

clue to
Source Colour Disease process indicated
Oral pigmentation systemic
Silver amalgam Grey, black Tattoo, iatrogenic implanta- Pigmentation presentation disease
tion, trauma
Grey/black Solitary or focal pigmentation Amalgam
Graphite Grey, black Tattoo, trauma pigmentation lesions are macular and bluish tattoo
Lead, mercury, Grey Ingestion of paints or medi- Macular, focal grey or black Graphite
bismuth cines or poisoning traumatic implantation tattoo
from lead Heavy
Chromogenic Black, Superficial colonization Pigmentation in free marginal metal inges-
bacteria brown, green tion gingiva
grey to
black
Various pigments, their presentation in oral cavity signifies
the following systemic conditions: Q.3. Enumerate the various factors that cause exogenous
pigmentation of the oral tissues. Describe in detail the
Giving oral manifestations of lead and mercury intoxication.
clue to Ans.
Oral pigmentation systemic
Pigmentation presentation disease Various factors that cause exogenous pigmentations of
Blue, purple l Present as tumour-like ham- Haemangi-
oral mucosa are as follows:
vascular artoma, most are raised and oma
lesions nodular and some are flat, Angiosar- Disease process
macular or diffused coma Source Colour indicated
l Tongue: multinodular and Kaposi
i. Silver amalgam Grey and black Tattoo, iatrogenic im-
bluish red sarcoma
ii. Graphite Grey and black plantation and trauma
l Lip mucosa: localized, blue
iii. Lead, mercury, Grey Tattoo, trauma
and raised
bismuth Black and Ingestion of paints or
l Red, blue or purple nodular
iv. Chromogenic brown, green medicines or poisoning
tumour
bacteria Superficial colonization
l Oral tumours of red, blue or
purple on hard palate
Brown mela- l Melanomas in oral mucosa Malignant
Lead (plumbism)
notic lesions occur on anterior aspects of melanoma l Lead poisoning is known as plumbism.
hard palate Smoker’s

l Brown, black plaques with melanosis
Aetiology
an irregular outline Addison l Lead in paints, glazes, cooking vessels, batteries,
l Diffuse macular melanosis disease ointment and containers.

of buccal mucosa, lateral HIV oral l Acute lead poisoning due to moonshine an illicit
tongue, palate and floor of lesions alcoholic beverage distilled in car radiators.
mouth
l Tetraethyl lead antiknock compound from gasoline –
l Bronzing of skin and patchy
melanosis of the oral new source of lead.
mucosa l Lead from automobile exhaust dust and dust from house
Hyperpigmentation of skin, nails paint.
and mucus membrane l Acute exposure can occur in foundries, smelters battery
● Diffuse multifocal macular
brown pigmentation of buc-
plants munitions and garages.
cal mucosa, gingiva, palate Clinical features
and tongue may be involved
l Petechiae in soft palate
Nervous system
l Pb (lead) has high affinity for cells of central nervous
Brown haem- l Bright red macule or as a Viral
system and peripheral nervous system.
associated swelling if a haematoma allergic
l Acute poisoning – demyelination and axon degenera-
lesions forms. Lesions will assume pharyngitis
brown colouration but if Haemor- tion occurs.
multiple brown macular or rhagic l Patients may have lead encephalitis, peripheral neuritis
swellings are observed diathesis characterized by wrist or foot drop.
Traumatic
l Gastrointestinal symptoms like nausea, vomiting, con-
ecchymosis
stipation and colic.
l Lab findings: Patients may have hypochromic anaemia Q.5. What are the causes of pigmentation of oral mucosa?
with basophilic stippling of RBC.
Ans.
Oral findings
[Same as LE Q.2]
l Metallic taste, excessive salivation and dysphasia.
l Burtonian line – grey black line along gingival margin, Q.6. ‘Pigmentation in oral structure’ diagnostic clue to
lead line is more diffuse than bismuth line. diagnose systemic diseases. Discuss.
Treatment Ans.
l Treatment using chelating agents calcium edetate
[Same as LE Q.2]
(EDTA) and penicillamine.
Q.7. Discuss in detail the diseases causing oral pigmen-
Mercurialism
tation.
l Mercurialism is also known as Pink disease, Swift dis-
ease, dermato-polyneuritis and acrodynia. Ans.

Aetiology [Same as LE Q.2]
l Unknown mercury toxicity.
l Idiosyncratic reaction to large doses of amalgam.
l Occupational contact, drug overdose, paints like phenyl

SHORT ESSAYS:
mercuric propionate, prolonged administration of mer-
Q.1. Classification of pigmentation and clinical signifi-
curial diuretics and improper use of dental amalgam
cance of endogenous pigmentation.
alloy.
Ans.
Clinical features
l Seen in children ,2 years up to 5–6 years. Pigmentation is classified as follows:
l GIT – Intestinal colic and diarrhoea, nausea, abnormal
pain. Endogenous pigmentation Exogenous pigmentation

l Nervous symptoms – headache, insomnia, tremors of Pigments originate with in the Pigments are deposited as such
fingers, lips and extremities and mental depression. body. or formed as a reaction of
l Hair and nails – premature loss of teeth, nails and alo- For example: Haemoglobin – chemical of exogenous origin
red and blue For example: Accidental
pecia, i.e. tear of hair in patches, raw beef appearance of
Haemosiderin – brown pigmentation and iatrogenic
skin of hands, feet, nose, ears and cheeks. Melanin – black pigmentation
Pigmentation due to drugs and
Oral finding
metals localized pigmentation
l Ptyalism that is profuse salivation as mercury is
excreted in saliva.
Endogenous pigmentation of oral cavity signifies:
l Glossodynia that is enlarged and painful tongue.
Blue/purple vascular lesion indicates:
l Oral ulceration, hyperaemia and swelling of gingiva.
i. Haemangioma
l Diffuse grey pigmentation of alveolar mucosa and gums
ii. Angiosarcoma
exhibit a deeper hue.
iii. Kaposi sarcoma
l Loosening and premature shedding of teeth.
Brown melanotic lesion:
Radiographic findings
i. Melanoma
Jaw changes similar to osteomyelitis irregular area of
ii. Melanoplakia
bone destruction.
iii. Addison disease
Treatment iv. HIV oral melanosis
l Bed rest and discontinuation of mercury exposure. v. Drugs in ductal melanosis
l Administration of British anti-Lewisite (BAL) dietary
Brown haem-associated lesion:
regimen to adjust renal damage.
i. Jaundice
l Atropine and belladona – to salivary flow.
ii. Haematoma
Q.4. Discuss the differential diagnosis of oral mucosal iii. Haemochromatosis
pigmentation. iv. Ecchymosis and petechiae
Ans. Q.2. Exogenous pigmentation of oral cavity.

Exogenous pigmentation arises due to introduction of met-

als or drugs into the body via mucous membrane, intestinal
tract and skin.
Classification of exogenous pigmentation:
Accidental pigmentation (foreign Pigmentation due to Localized

substances embedded) due to Iatrogenic pigmentation drugs and metals pigmentation
Accidental during childhood Aetiology: i. Bismuthism i. Chlorhexidine stains
l Articles of road surface l During routine amalgam restorative ii. Plumbism (yellowish brown to
embedded in gingiva work removal of old fillings broken iii. Mercurialism brown colour)
l Charcoal containing tooth powder pieces embedded during extraction iv. Argyria ii. Hairy tongue (green
l Graphite tattoos. of teeth, retrograde amalgam filling v. Arsenism to brown or black)
l For example: pencil points during root canal preparation vi. Auric stomatitis iii. Tobacco stains (dark
Clinical findings: vii. Copper, chromium, brown or black
Gingiva and alveolar mucosa region, zinc and cadmium stain coal tar)
.12 years, females . male, blue-black pigmentation
flat macule or slight raised lesion
Radiographic findings:
l Presence of metal
Histological findings:
l Present as fine discrete dark growth
and irregular solid fragments dark
granules arranged along collagen
bundles, blood vessels and nerve
sheaths or interacellularly in macro-
phage multinucleated giant cell and
fibro blasts
Treatment:
l Not needed and excision if required
Q.3. Differential diagnosis of argyria. l Histologic identification of silver particles fixed to pro-
tein complexes in the dermis is diagnostic for the disease.
Ans.
Management
Argyria (silver pigmentation)
l The only special precaution to take during oral treatment
l Argyria is caused due to chronic exposure to silver
is to consider the patient’s disturbance in equilibrium.
nitrate as an occupational hazard.
l It results in pigmentation of both skin and mucous Q.4. Malignant melanoma.
membrane.
Ans.
l Whites who have silver pigmentation develop a striking,
bluish-grey (slate-coloured) skin, especially in the ex- l Malignant melanoma is a malignant neoplasm arising
posed areas. The bluish-grey discolouration also occurs from the melanocytes of the skin or mucous membrane.
in the oral mucosa. l They are biologically the most unpredictable tumours and
l Silver deposition often causes accompanying neuro- are recognized as the most aggressive as well as deadly
logic and hearing damage, which in turn affects the among the malignant tumours occurring in humans.
equilibrium. l Various types of malignant melanomas are as follows:
l It also stimulates melanocyte activity in the skin, caus- i. Superficial spreading melanoma
ing a more intense colour in exposed areas. ii. Nodular melanoma
iii. Lentigo malignant melanoma
Differential diagnosis
l The bluish-grey colour is usually easily distinguished Clinical features
from the more brownish Addisonian colour. l It occurs between the age of 20 and 90 years; however,
l Haemochromatosis also produces a browner colour. maximum of cases develop in 5th to 7th decades of life.
l Exposed areas of the skin that are not more discoloured l Both sexes are affected but there is slight male predilection.
than the covered areas differentiate cyanotic states from l Oral melanomas are most common on the hard palate,
argyria. maxillary alveolar ridge or gingiva.

Clinical presentation
l Tumours are of plexiform variety and thus are soft,
l Oral melanomas initiate as macular-pigmented focal
smooth, fluctuant, flesh coloured and nodular or
lesion.
pedenculated.
l The pigmented lesions are often dark-brown or bluish-
l Cafe-au-lait spots are the characteristic cutaneous
black or simply black in colour.
lesions present in this disease.
l The initial macular lesion grows very rapidly and often
results in a large, painful and diffuse mass. Oral manifestations

l Surface ulceration is very common and besides this, l Areas of melanin pigmentation are seen on oral mu-
haemorrhage, paraesthesia and superficial fungal infec- cosa with lips being the common site of occurrence.
tions are often present. l Neurofibromas may also occur as central jaw lesions
l As the tumour continuous to grow, small satellite in relation to the mandible or maxilla and in such
lesions can develop at the margin of the primary cases often produce a slow-growing, painless, expan-
tumour. sible and swelling of bone.
l Oral melanomas often cause rapid invasion and exten-
Radiographic features
sive destruction of bone, often resulting in loosening
l Neurofibromas of the jawbone usually produce rela-
and exfoliation of the regional teeth.
tively well-demarcated, unilocular or multilocular
l Widespread dissemination of the tumour cells occurs
radiolucent area, with expansion of the cortical plates
frequently in the lymph nodes as well as in the distant
and divergence of roots of the adjacent teeth.
sites such as lungs, liver and brain.
l Survival rates for oral melanomas are extremely Management
low and only less than 5% patients remain alive for l Solitary neurofibromas are treated by surgical exci-
5 years. sion, whereas neurofibromatosis is not treated since
surgical intervention may trigger the malignant
potential of the individual lesions.
l Some melanomas in the jaws may present radiographic
picture, which is indistinguishable from osteomyelitis.

SHORT NOTES:
Treatment
l Early diagnosis is the key to successful treatment of Q.1. Endogenous pigmentation.
malignant melanoma, as long as the lesion remains in Ans.
the radial growth phases.
l It is treated by surgical irradiation, immunotherapy and [Ref LE Q.2]
by chemotherapy or by combination of these methods. Q.2. Oral manifestations of bismuthism.
l Radical surgery with prophylactic neck dissection is
often advised. Ans.

l Survival rate is very poor and are worse with metastasis. [Ref LE Q.1]
Q.5. Von Recklinghausen disease. Q.3. Von Recklinghausen disease.
Ans. Ans.
[Ref SE Q.5]
{SN Q.3}
Q.4. Addison disease.
l Von Recklinghausen disease is an autosomal domi-
nant hereditary disorder characterized by wide spread Ans.
overgrowth of nerve sheaths with formation of mul- l Addison disease is a primary disease of the adrenal
tiple neurofibromas on the skin and mucosa, along glands, where they are unable to elaborate sufficient
with brown pigmentation of the skin. quantities of hormones. Chronic insufficiency of adre-
l Triad of this disease consists of pigmentation, tumours nal cortex results in Addison disease.
of nerves and a sessile or pedenculated tumours of
skin and mucous membrane. Aetiology
l It usually develops following autoimmune destruction
Clinical features of adrenal glands or infections (TB, HIV).
l Neurofibromas may occur at any age; however, most
Clinical features
lesions are detected in adult life.
l Early manifestations include lethargy, fatigue and mus-
l Both sexes are equally affected.
cular weakness.
l Other features include weight loss, hypotension, salt Causes for extrinsic discolouration
craving, abdominal pain, diarrhoea and vitiligo. l Oral drugs
l Increased levels of ACTH stimulate MSH and results in l Poor oral hygiene
skin and mucosal pigmentation that is bronzing of skin. l Chromogenic bacteria
l Oral pigmentation may be the first sign of Addison l Habits – tobacco and catechu
disease. l Chlorhexidine mouthwash
l In the oral mucous membrane pale brown to deep

Q.7. Peutz–Jeghers syndrome.
chocolate pigmentation, spreading over buccal mucosa
from angles of mouth and developing on gingiva, Ans.
tongue and lips, may be the first evidence of the disease.
l Peutz–Jeghers syndrome is also called hereditary intes-
Treatment tinal polyposis syndrome.
l Hormone replacement therapy with hydrocortisone and l It consists of familial generalized intestinal polyposis
fludrocortisone. and pigmented spots on the face, oral cavity and some-
times on hand and feet.
Q.5. Café-au-lait spots.
Clinical features
Ans.
l It is equally distributed in males and females.
l Cafe-au-lait pigmentations manifest as bronze or tan l There are bluish-black macules (1.5 cm) on skin. The
diffused multifocal macular pigmentations that appear skin pigmentation often fades away in life.
on the skin as well as the oral mucosa. Because of the l Frequent episodes of abdominal pain and signs of minor
pale brown colour these lesions are called cafe-au-lait obstruction, often terminate in intussusception.
spots.
Oral manifestations
l These pale brown macules vary considerably in size and
l Intraorally it appears on buccal mucosa, gingiva, tongue
have widespread distribution occurring on the face,
and hard palate in decreasing orders.
neck or the oral cavity.
l The melanin pigmentation of the lips and oral mucosa is
l It is usually associated with neurofibromatosis (Von
usually present from birth and appears as small brown
Recklinghausen syndrome), Albright syndrome (poly-
macules. There are multiple melanotic and brownish
ostotic fibrous dysplasia) and Peutz–Jeghers syndrome.
macules concentrated around the lip.
l These pigmented melanotic spots do not require any
treatment and are not associated with any risk for malig- Treatment
nant transformation. l Genetic counselling is indicated and no treatment is
required for oral lesions.

Q.6. Mention the causes of extrinsic discolouration of
l Surgical intervention is required for intussusception.
teeth.
Q.8. Endocrinopathic pigmentation.
Ans.
Ans.
l Discolouration of teeth is classified into:
a. Extrinsic discolouration [Same as SN Q.4]
b. Intrinsic discolouration
Q.9. Pigmented lesions of oro-facial region.
Extrinsic discolouration
Ans.
l Extrinsic discolouration is found on the outer surface of
teeth and is usually of local origin such as tobacco stain. [Same as SN Q.5]
Topic 4
Benign Tumours of the Oral Cavity
Including Gingival Enlargements
LONG ESSAYS:
1 . Enumerate the benign tumours of the jaws and describe in detail about ameloblastoma.
2. Write briefly histopathology of
a. Adenomatoid odontogenic tumour
b. Pleomorphic adenoma
3. Classify the cysts of the jaws and discuss in detail the odontogenic keratocyst.
4. Enumerate the odontogenic cysts of the jaws. Describe the clinical and radiographic features of three ‘dental
cysts’.
5. What are the oral causes of halitosis? How are you going to treat a case of ANUG?
6. Describe the aetiology, clinical features, radiological and histological features of ameloblastoma. [Same as LE Q.1]
7. Write in detail about the aetiopathogenesis, clinical features, investigations, management and prognosis of
ameloblastoma. [Same as LE Q.1]
SHORT ESSAYS:
1 . Primodial cyst.
2. Enumerate the benign tumours of the oral cavity; describe the clinical features, radiographic appearance and
differential diagnosis of ameloblastoma. [Ref LE Q.1]
3. Enumerate the fibro-osseous lesions that involve the jaws. Discuss the aetiology, pathogenesis and clinical fea-
tures of Paget disease. Add a note on its complications.
4. Give the differential diagnosis of conditions that cause gingival enlargement.
5. Describe briefly about:
a. Fibrous dysplasia
b. Paget disease
c. Periapical cementifying dysplasia
6. Discuss the differential diagnosis of gingival enlargement. [Same as SE Q.4]
7. Enumerate the various causes of gingival enlargement. Discuss differential diagnosis of inflammatory and
noninflammatory gingival enlargement. [Same as SE Q.4]
8. Classify gingival enlargements and discuss in detail the inflammatory gingival enlargement of systemic
background. [Same as SE Q.4]
SHORT NOTES:
1. Treatment of dilantin gingival enlargement.
2. Name four drugs causing gingival enlargement.
3. Cementoma.
4. Nasopalatine cyst.
5. Name two multilocular cysts.
6. Periapical cemental dysplasia. [Ref SE Q.5]
7. Café-au-lait spots.
8. Torus mandibularis.
9. Ameloblastoma in mandible.
10. Biochemical investigations of Paget disease.
1 1. Pregnancy tumour and gingivitis.

12. Cherubism.
13. Describe the radiographic features of fibrous dysplasia.
14. Condensing osteitis.
15. Describe radiographic appearance of dentigerous cyst.
16. Radiographic appearance of odontogenic keratocyst.
17. Pleomorphic adenoma of palate.
18. Describe the clinical features of ossifying fibroma.
19. Describe the radiographic features of Myxoma.
20. Albright syndrome.
21. Giant cell granuloma.
22. Epulis.
23. Fissural cysts.
24. Periapical granuloma.
25. Median mandibular cyst.
26. Fibromatosis gingivae.
27. Adenomatoid odontogenic tumour.
28. Von Recklinghausen disease.
29. Lipoma.
30. Pyogenic granuloma.
31. Odontomes.
32. Fibrotic gingival enlargement.
33. List out differential diagnoses for a swelling in the palate.
34. Pseudocysts.
35. Pathergy test.
36. What is Gorlin sign?
37. Residual cyst.
38. Papilloma.
39. Treatment of dilantin gingival hyperplasia. [Same as SN Q.1]
40. Name the drugs causing gingival enlargement. [Same as SN Q.2]
41. Name few nonodontogenic cysts of the jaws. [Same as SN Q.23]
42. Complex composite odontome. [Same as SN Q.31]
43. Compound odontome. [Same as SN Q.31]
44. Stafne bone cyst. [Same as SN Q.34]
SOLVED ANSWERS
LONG ESSAYS:
B. Odontogenic epithelium with odontogenic ectomes-
Q.1. Enumerate the benign tumours of the jaws and
enchyme, with or without hard tissue formation
describe in detail about ameloblastoma.
i. Ameloblastic fibroma
Ans. ii. Ameloblastic fibrodentinoma
iii. Ameloblastic fibro-odontoma
[SE Q.2]
iv. Odontoma (odontome)
{Benign odontogenic tumours v. Odontoameloblastoma
A. Odontogenic epithelium with mature, fibrous stroma vi. Calcifying cystic odontogenic tumour
without odontogenic ectomesenchyme vii. Dentinogenic ghost cell tumour
i. Ameloblastoma C. Mesenchyme and/or odontogenic ectomesenchyme
ii. Squamous odontogenic tumour with or without odontogenic epithelium
iii. Calcifying epithelial odontogenic tumour i. Odontogenic fibroma
iv. Adenomatoid odontogenic tumour ii. Odontogenic myxoma/myxofibroma
v. Keratocystic odontogenic tumour (KCOT) iii. Cementoblastoma}
Malignant odontogenic tumours l In the mandible, the molar-angle-ramus area is involved

A. Odontogenic carcinomas three times more commonly than premolar and anterior
i. Metastasizing (malignant) ameloblastoma regions combined.
ii. Ameloblastic carcinoma l Clinically ameloblastoma presents slow enlarging, pain-
iii. Primary intraosseous squamous cell carcinoma less, ovoid and fusiform bony hard swelling of the jaw.
iv. Clear cell odontogenic carcinoma l Pain, paraesthesia and mobility of regional teeth is pres-
v. Ghost cell odontogenic carcinoma ent in some cases.

B. Odontogenic sarcomas l Pathological fractures may occur in many affected bones.
i. Ameloblastic fibrosarcoma
ii. Ameloblastic fibrodentino- and fibro-odontosarcoma
l Classical radiographic appearance is multilocular cyst-
Ameloblastoma like lesion in the jaw.
It is also known by other terms like: l The multilocular can be either of honeycomb type or
l Adamantoblastoma soap-bubble type.
l Adamantinoma – coined by Malassez in 1885 l In radiograph, the lesion typically exhibits an irregular
l Ameloblastoma – coined by Churchill in 1934 and scalloped margin.
l Epithelial odontoma l The lesion can cause resorption of roots of the teeth.
l It occurs in maxilla and produces a monocystic lesion.

Definition as given by Robinson
l Sometimes even in mandible the lesion can occur as
Ameloblastoma is a tumour of odontogenic origin usu-
ally unicentric, nonfunctional intermittent in growth ana- unilocular lesion.
tomically benign and clinically persistent. Treatment and prognosis
l No single standard type of therapy can be advocated for
Definition according to WHO
Polymorphic neoplasm consisting of proliferating odon- patients with ameloblastoma. Rather, each case should
togenic epithelium usually occurring in two main forms in be judged on its own merits.
l Of prime considerations are whether the lesion is solid,
the follicular types of the growth. The tumour consists of
enamel organ-like islands of epithelium cells, while in the cystic, extraosseous or malignant, and location.
l The solid lesions require at least surgical excision, be-
plexiform type it forms continuous anastomosing islands.
cause recurrence follows curettage in 50%–90% of cases.
[SE Q.2] l Block excision or resection is generally reserved for
larger lesions.
{Pathogenesis l Cystic ameloblastomas may be treated less aggres-
l This neoplasm originates within the mandible or maxilla
sively, but with the knowledge that recurrences are often
from epithelium that is involved in the formation of
associated with simple curettage.
teeth. Potential epithelial sources include the enamel
l Peripheral ameloblastomas should be treated in a con-
organ, odontogenic rests (rests of Malassez and rests of
servative fashion. Malignant lesions should be managed
Serres), reduced enamel epithelium and the epithelial
as carcinomas.
lining of odontogenic cysts, especially dentigerous cysts.
l Patients with all forms of central ameloblastoma should
l The trigger or stimulus for neoplastic transformation of
be followed indefinitely, since recurrences may be seen
these epithelial residues is totally unknown mechanisms
as long as 10–20 years after primary therapy.}
by which ameloblastomas gain growth and invasion ad-
l Ameloblastomas of the maxilla are generally more diffi-
vantage include overexpression of antiapoptotic proteins
cult to manage than those of the mandible due to anatomic
(Bcl-2, Bcl-xL) and interface proteins (fibroblast growth
relationships and due to the high content of cancellous
factor [FGF] and matrix metalloproteinases [MMPs]).
bone in the maxilla.
l Ameloblastomas, however, have a low proliferation rate,
l Thus, intraosseous maxillary ameloblastomas are often
as shown by staining for the cell cycle – related protein,
excised with a wider normal margin than mandibular
Ki-67. Mutations of the p53 gene do not appear to play
tumours.
a role in the development or growth of ameloblastoma.
Clinical features Q.2. Write briefly histopathology of
l The ameloblastoma is a benign, aggressive tumour that a. Adenomatoid odontogenic tumour
is invasive and persistent. b. Pleomorphic adenoma
l It occurs in wide age range from 10 years to 90 years.
Ans.
l The average age of occurrence is 33–39 years.
l The males are affected more commonly than females. Adenomatoid odontogenic tumour
l Ameloblastoma occurs in all the areas of the jaws but l Adenomatoid odontogenic tumour is also known as ad-
mandible is most commonly affected. enoameloblastoma or ameloblastic adenomatoid tumour.

l The adenomatoid odontogenic tumour is uncommon, epithelial cells that have nuclei frequently polarized
well-circumscribed, and odontogenic neoplasm charac- away from the lumen. These rosette-like or microcyst
terized by the formation of multiple duct-like structures lumina frequently are lined by an eosinophilic material.
by neoplastic epithelial cells.
Pleomorphic adenoma
Macroscopic features l The pleomorphic patterns and the variable ratio of
l Central AOTs macroscopically appears as a soft, roughly ductal to myoepithelial cells are responsible for the
spherical mass with a distinct capsule. synonym pleomorphic adenoma.
l Upon gross sectioning, the tumour may exhibit solid to l A capsule of varying thickness surrounds mesenchymal
crumbly tissue or one or more cystic spaces of varying and stromal components.
sizes with yellowish brown fluid or semisolid material, l Approximately one-third of mixed tumours show an
fine, hard ‘gritty’ granular material and one to many almost equal ratio of epithelial and mesenchymal ele-
larger calcified masses. ments (believed to be derived from myoepithelial-
l Additionally, intact specimens demonstrate the crown differentiated cells).
of an embedded tooth in the solid mass or projecting l The epithelial component may appear as ducts, tubules,
into a cystic cavity. ribbons and solid sheets, and the mesenchymal compo-
Microscopic features nent may appear as myxoid, hyalinized connective tissue.
l Infrequently, fat, cartilage and/or bone may be seen.
l The AOT exhibits diverse histopathologic features:
l An intracystic epithelial proliferation is composed of

Myoepithelial cells may appear as plasmacytoid cells or
polyhedral to spindle cells. spindled cells with an immunoprofile showing coex-
l The pattern is typically lobular, although some areas
pression of cytokeratin markers, vimentin, variable pos-
may show a syncytial arrangement of cells. itivity for S-100 protein, calponin, a-smooth muscle
l Rosettes and duct-like structures of columnar epithe-
actin and muscle-specific actin.
l The plasmacytoid cells, when seen, are highly charac-
lial cells give the lesion its characteristic microscopic
features. teristic of mixed tumours and are almost never found in
l Foci of PAS-positive material are scattered through-
other salivary gland tumours.
l The ductal cell components are positive for several
out the lesion.
l The tumour is made up of a multiple proliferations of
cytokeratins.
l The pseudocapsule surrounding mixed tumours may dem-
spindle, cuboidal and columnar cells, variety of pat-
terns comprising of scattered duct-like structures, onstrate islands of tissue within it or extending through it.
l These islands represent outgrowths or pseudopods con-
eosinophilic material and calcifications in several
cases, delimited by a fibrous capsule of variable tinuous with the main tumour mass, and likely contrib-
thickness. ute to recurrences, particularly in the parotid gland.
l Although not present in all tumours, the most distin-
Q.3. Classify the cysts of the jaws and discuss in detail
guishing microscopic feature of AOT is varying num- the odontogenic keratocyst.
bers of spindle-shaped structures with lumina of vary-
ing size lined by a layer of cuboidal to columnar Ans.
Cysts associated with Cysts of soft tissue of the mouth,

Epithelial cysts Nonepithelial cysts maxillary antrum face and neck
A. Odontogenic cysts l Simple bone cyst l Benign mucosal cyst of l Dermoid and epidermoid cysts
Developmental cysts l Aneurysmal bone maxillary antrum l Branchial cleft cyst
l Dentigerous cyst cyst l Surgical ciliated cyst of l Thyroglossal duct cyst
l Eruption cyst maxilla l Anterior medial lingual cyst
l Primodial cyst l Oral cyst with gastric or intestinal
l Gingival cyst of adults epithelium
l Calcifying odontogenic cyst l Cystic hygroma
Inflammatory cysts l Cysts of salivary glands
l Radicular cyst l Parasitic cyst
l Residual cyst l Hydatid cyst
l Inflammatory cyst l Cysticerus cellulosae
l Paradental cyst
B. Nonodontogenic cysts
l Nasopalatine cyst
l Median palatine cyst
l Globulomaxillary cyst
l Nasolabial cyst
Odontogenic keratocyst l Small single cysts with regular spherical outline, should
Incidence be enucleated from an intraoral approach, provided, the
l Primordial cysts comprise approximately about 5%– access is good.
10% of odontogenic cysts of the jaws. l Larger or less accessible cysts with regular spherical
l Seen predominantly in the second, third and fourth de- border should be enucleated from an extraoral ap-
cades of life, although they can occur in any age group. proach, as an intraoral access would be inadequate. Care
l They have a slight predilection for the males than females. should be taken to ensure fragments of the extremely
thin lining are removed.
Site
l Unilocular lesions with scalloped or loculated periph-
l Most commonly seen in the mandible than the maxilla,
ery, small multilocular lesions should be treated by
about one half of the former are seen to involve the
marginal excision that is resection of the containing
angle of the mandible.
block of bone while maintaining the continuity of the
l They can occur anywhere in the jaws, including the
posterior inferior borders as in the ascending ramus,
midline, although majority of the cysts are seen poste-
angle, body of the mandible, if there is difficulty of ac-
rior to the first bicuspids.
cess, extraoral exposure is necessary.
Clinical features l If the cystic lining is too adherent and in contiguity to
l The physical signs and symptoms of a jaw cyst depend the overlying mucosa or muscle then it should be ex-
on the dimensions of the lesion. cised along with marginal excision. The defect is closed
l A small cyst is unlikely to be diagnosed on routine primarily and can be left to heal by secondary intention
examination of the mouth, and is generally detected or can be filled with hydroxyapatite crystals, autoge-
accidentally on a radiographic examination. nous bone graft, corticocancellous chips or allogenous
l Asymptomatic until the cysts have reached a large size at bone powder, chips or block.
times involving the entire ascending ramus. This is because l Large multilocular lesions with or without cortical per-
the primordial cyst initially extends in the medullary cavity foration may require resection of the involved bone
and clinically observable expansion of the bone occurs late. followed by primary or secondary reconstruction with a
l The enlarging cyst may lead to displacement of the choice of reconstruction plates of stainless steel, vital-
teeth, percussion of the teeth overlying the cyst may lium, titanium, use of titanium or stainless steel mesh
produce a dull or hollow sound. and bone grafting procedures with iliac crest graft, cos-
l A single missing tooth from the normal series should tochondral graft or allogenous bone grafts.
invite suspicion of the existence of an odontogenic kera- l Carnoy’s solution
tocyst of the primordial type. A more conservative approach to large keratocysts,

l The teeth adjoining the cyst will have vital pulps unless treatment is done with enucleation, excision of the over-
there is coincidental disease of the teeth. lying mucosa and/or muscle, if attachment existed to
l Buccal expansion of the bone is commonly seen; lingual eliminate epithelial rests and/or microcysts and careful
and palatal expansion is rare. cauterization of the bony defect with Carnoy’s solution.
l Large mandibular cysts, invariably deflect the neurovas-
Q.4. Enumerate the odontogenic cysts of the jaws. De-
cular bundle into an abnormal position.
scribe the clinical and radiographic features of three
l If acute infection sets in, with accumulation of pus
‘dental cysts’.
within the sac, neuropraxia of the nerve results with the
onset of labial paraesthesia or anaesthesia. Ans.
l When tension is relieved, with spontaneous discharge
The various odontogenic cysts of the jaws are as follows:
of pus via a sinus tract or surgical drainage, sensation
returns to normal. Developmental cysts
l Dentigerous cyst
Radiologic features
l Eruption cyst
l The keratocyst can be unilocular or multilocular.
l Primodial cyst
l Majority of the unilocular radiolucencies have a smooth
l Gingival cyst of adults
periphery, some may have scalloped margins, which
l Calcifying odontogenic cyst
suggest an unequal growth activity.
l Multilocular cysts can have various radiographic ap- Inflammatory cysts
pearances, e.g. one large cyst and some smaller daugh- l Radicular cyst
ter cysts giving the polycystic appearance. l Residual cyst

l Inflammatory cyst
Treatment
l Paradental cyst
l Treatment should always be based on clinical assess-
ment, accurate diagnosis and appropriate tests of the Dentigerous cyst

cystic aspirate. l It is also called follicular cyst or pericoronal cyst.
l It is most common type of odontogenic cyst, which l Enucleation is the treatment of choice in case of adults.
encloses the crown of the unerupted tooth by expansion
Odontogenic keratocyst
of its follicle and is attached to neck.
l Odontogenic keratocyst was first described by Philpsen
Clinical features in 1956 and recently WHO has designated OKC as a

l Second most common odontogenic cyst after periapical keratocystic odontogenic tumour.
cyst.
Clinical features
l Third molars and canine teeth most commonly affected.
l The physical signs and symptoms of a jaw cyst depend
l Age: second and third decade of life
on the dimensions of the lesion.
l Site: mandibular third molar and maxillary canine
l A small cyst is unlikely to be diagnosed on routine ex-
regions.
amination of the mouth, and is generally detected acci-
l Sex: Equally affects males and females.
dentally on a radiographic examination.
Symptoms l The patients are remarkably free of symptoms until the
l Generally, it is painless but may be painful if it gets cysts have reached a large size at times involving the en-
infected. tire ascending ramus. This is because the primordial cyst
l When dentigerous cyst expands rapidly to compress initially extends in the medullary cavity and clinically
sensory nerve it produces pain, which may be referred observable expansion of the bone occurs at later stages.
to other sites and described as headache. l The enlarging cyst may lead to displacement of the
teeth, percussion of the teeth overlying the cyst may

Signs produce a dull or hollow sound.
l It has a potential to become an aggressive lesion with
l A single missing tooth from the normal series should
expansion of bone and subsequent facial asymmetry. invite suspicion of the existence of an odontogenic kera-
l In some cases pathological fracture can occur.
tocyst of the primordial type.
l The teeth adjoining the cyst will have vital pulps unless
l Unilocular radiolucency associated with crowns of un- there is coincidental disease of the teeth.
l Buccal expansion of the bone is commonly seen, lingual
erupted impacted teeth; at times a multilocular effect
can be seen when the cyst is ovular shape due to bony and palatal expansion is rare.
l Large mandibular cysts, invariably deflect the neurovas-
trabeculations.
l Cysts have a defined sclerotic margin. cular bundle into an abnormal position.
l If acute infection prevails, with accumulation of pus
l With the pressure of an enlarging cyst, the unerupted
tooth can be pushed away from its direction of eruption, within the sac, neuropraxia of the nerve results with the
e.g. the lower molar may be pushed to the inferior bor- onset of labial paraesthesia or anaesthesia.
der, or into ascending ramus, whereas the maxillary Once the tension is relieved, with spontaneous discharge of
cuspid tooth may be pushed up into the maxillary sinus pus via a sinus tract or surgical drainage, sensation returns
or floor of nose. to normal.
l As compared to the other jaw cysts, dentigerous cysts
have a higher tendency to cause root resorption of adja- Radiological features
l The keratocyst can be unilocular or multilocular.
cent teeth.
l Majority of the unilocular radiolucencies have a smooth
l Radiologically, the dental follicle expands around the
unerupted or impacted tooth in variations, like (a) cir- periphery, some may have scalloped margins, which
cumferential, (b) lateral and (c) coronal. suggest an unequal growth activity.
l Multilocular cysts can have various radiographic ap-
Histopathology pearances, e.g. one large cyst and some smaller daugh-
l Lined by nonkeratinized stratified squamous epithelium ter cysts giving the polycystic appearance.
l Proliferation of reduced enamel epithelium
l Retepegs seen Treatment

l Enucleation, i.e. surgical excision is the treatment of
Common complications choice.
l Extensive bone destruction with growth
l Resorption of adjacent tooth roots Radicular cyst

l Displacement of teeth l It is the most common inflammatory odontogenic cyst.
Treatment Clinical features

l Marsupialization in case of children if there is possibil- l The cyst itself is symptomless and may be discovered,
ity of eruption of impacted tooth. when periapical radiographs are taken.

l It is associated with nonvital teeth. l Prevotella intermedia

l Slowly enlarging swellings are often complained of l Fusobacterium nucleatum
radicular cysts that at times attain a large size. l Bacteroides for synthesis
l Pain may be a significant chief complaint, in the pres- l Treponema denticola
ence of suppuration. iii. Oral infection (primary and secondary)

l Initially, the enlargement is bony hard, as the cyst in- l Candidiasis
creases in size, the covering bone becomes thin and l Pericoronitis
exhibits springiness due to fluctuation. l Postextraction alveolitis
l In the maxilla, buccal and palatal or only palatal expan- iv. Oral ulcerative and erosive diseases
sion due to the lateral incisor or a palatal root will be v. Xerostomia
noted. In the mandible, lingual expansion is very rare.
Treatment of ANUG
l The mucosa overlying the cystic expansion, as with the
l Involved areas are isolated with cotton rolls and dried.
other cysts, is at first of normal colour; then it may be-
l A topical anaesthetic is applied and after 2–3 min, and
come conspicuous because of the presence of dilated
the areas are gently swabbed with a cotton pellet to re-
blood vessels and finally it will take on a profound dark
move the pseud membrane and nonattached surface.
bluish tinge, in case of large cysts.
After the area is cleansed with warm water, the superfi-
l An intraoral sinus tract may be identified with discharging
cial calculus is removed.
pus or brownish fluid, when the cyst is infected. The in-
l The patient is asked to rinse the mouth every 2 h with
volved tooth/teeth will be found to be nonvital, discoloured,
a glassful of an equal mixture of warm water and 3%
fractured or with heavy restorations or a failed root canal.
hydrogen peroxide. Twice daily rinse with 0.12%
l They may be sensitive to percussion or hypermobile, or
chlorhexidine are also effective.
displaced.
l Patients with severe ANUG and lymphadenopathy are
l It may involve deciduous or the permanent dentition.
treated with antibiotics penicillin V 250 or 500 mg,
l Temporary paraesthesia or anaesthesia of the regional
6 hourly with metronidazole 400 mg, 8 hourly, for
nerve distribution may be evident as with other cysts
7 days are the drug of choice.
when infection is present.
l Scaling is performed, if sensitivity permits, after the
l Pathologic fracture may be the form of presentation in
disease process is diminished, complete gingival curet-
the mandible, as with other large cysts.
tage and root planning is done.
Radiological features l Supportive treatment consists of copious fluid consump-
l The common description of radicular cysts is a round, tion and administration of nutritional supplements.
pear or ovoid shaped radiolucency. Q.6. Describe the aetiology, clinical features, radiologi-
l Outlined by a narrow radiopaque margin that extends
cal and histological features of ameloblastoma.
from the lamina dura of the involved tooth/teeth.
l In case of very large cysts or infected cysts, this periph- Ans.
eral white line is occasionally absent. [Same as LE Q.1]
l Root resorption is rare, but may be seen.
l A lateral radicular cyst may be seen in association with Q.7. Write in detail about the aetiopathogenesis, clinical
an accessory root canal or lateral perforation during root features, investigations, management and prognosis of
canal therapy. ameloblastoma.
Treatment Ans.
Surgical removal of cyst combined with either root [Same as LE Q.1]
canal treatment or extraction of involved tooth.
Q.5. What are the oral causes of halitosis? How are you
going to treat a case of ANUG?
SHORT ESSAYS:
Q.1. Primodial cyst.
Ans.
Ans.
Oral causes of halitosis
i. Oral cavity l Primordial cyst is relatively quite uncommon.
l Poor oral hygiene/prosthesis hygiene l It originates due to cystic degeneration and liquefaction of
l Posterior dorsal surface of tongue stellate reticulum in an enamel organ before calcification.
ii. Periodontal pathogens Sometimes it occurs in the place of supernumerary teeth.
l Porphyromonas gingivalis l Primordial cysts account for 5%210% of all jaw cysts.
Clinical features Clinical features

l It has equal sex predilection occurring often in early l Occurs mainly in males over 55 years of age.
adulthood. l There is a strong genetic component. Genes involved
l Site: Mandibular third molar and ramus region, premo- include the sequestosome1 gene (SQSTM1).
lar region and maxillary incisor region. l In PDB, bone remodelling is disrupted, and an anarchic
l Size of the cyst varies considerably. alternation of bone resorption and apposition results
l It causes expansion of the bone and displacement of in mosaic-like ‘reversal lines’, often associated with
adjacent teeth. severe bone pain.
l Presents as two histological types: l In early lesions, bone destruction predominates (osteolytic
A. Nonkeratinizing type (less common) stage) and there is bowing of the long bones, especially
B. Keratinizing type (more common) the tibia, pathological fractures, broadening/flattening of
l Some investigators consider primordial cyst as odonto- the chest and spinal deformity.
genic keratocyst (OKC). l The increased bone vascularity can lead to high output
cardiac failure.
l Later, as disease activity declines, bone apposition in-
l It appears as radiolucency with a sclerotic border or
creases (osteosclerotic stage) and bones enlarge, with
reactive border, which is usually scalloped.
progressive thickening (between these phases is a mixed
l The lesion can be present as a unilocular or multilocular
phase). PDB is typically polyostotic and may affect
lesion.
skull, skull base, sphenoid, orbital and frontal bones.
l The cyst can occur below the teeth, between the teeth or
l The maxilla often enlarges, particularly in the molar
near the crest of the ridge.
region, with widening of the alveolar ridge.
Treatment l In early lesions, large irregular areas of relative radiolu-
l Surgical removal with thorough curettage of the bone. cency (osteoporosis circumscripta) are seen, but later
l Recurrence rate is high if it represents OKC; otherwise, there is an increased radiopacity, with appearance of
recurrence rate is quite low. ‘cotton wool’ pattern.
l Constriction of skull foramen may cause cranial neu-
Q.2. Enumerate the benign tumours of the oral cavity;
ropathies.
describe the clinical features, radiographic appearance
l The dense bone and hypercementosis make tooth extrac-
and differential diagnosis of ameloblastoma.
tion difficult, and there is also a liability to haemorrhage
Ans. and infection.
[Ref LE Q.1] Management
l Diagnosis is supported by imaging, biochemistry and
Q.3. Enumerate the fibro-osseous lesions that involve
histopathology.
the jaws. Discuss the aetiology, pathogenesis and
l Bone scintiscanning shows localized areas of high
clinical features of Paget disease. Add a note on its
uptake.
complications.
l Plasma alkaline phosphatase and urine hydroxyproline
Ans. levels increase with little or no changes in serum cal-
cium or phosphate levels.
Fibro-osseous lesions
l Bisphosphonates are the treatment but calcitonin may
l Cemento-osseous dysplasia (osseous dysplasia)
also help.
l Cherubism
l Fibrous dysplasia Q.4. Give the differential diagnosis of conditions that

l Hypercementosis cause gingival enlargement.
l Ossifying fibroma
Ans.
l Paget disease of bone
Classification of gingival enlargements based on

Paget disease of bone (PDB) aetiology
l It is a progressive fibro-osseous disease affecting bone i. Local inflammatory and traumatic factors
and cementum, characterized by disorganization of os- a. Poor oral hygiene, calculus deposits
teoclastogenesis (osteoclast formation), a process depen- b. Malposed teeth, improper contacts
dent on two cytokines – macrophage colony stimulating c. Irritation from ill-fitting crowns, clasps, prosthetic or
factor (M-CSF) and receptor activator of NF-kB ligand orthodontic appliances, overhanging restorations
(RANKL), which induce gene expression changes, pre- d. Mouth breathing, smoking
sumably by inducing transcription factors. e. Occlusal interferences
ii. Systemic predisposing factors l Histopathology shows woven bone directly forming
A. Endocrine (hormonal) from a fibrocellular background, fusing to adjacent
a. Puberty cortical lamellar bone.
b. Menstruation, pregnancy and oral contracep- l Typically no treatment is needed. Bisphosphonates
tive medication can help and surgery may be indicated if there is major
c. Hypothyroidism and pituitary dysfunction deformity or pressure on nerves.
d. Diabetes mellitus l McCune–Albright syndrome is FD bone lesions with
B. Nutritional skin pigmentation and endocrinopathy (precocious

a. Scurvy puberty in females and hyperthyroidism in males).
b. Nutritional deficiencies of mixed type, includ-
ing vitamin B complex Paget disease
l Paget disease of bone (PDB) is a progressive fibro-osseous
iii. Blood dyscrasias
a. Leukaemia disease affecting bone and cementum, characterized by
b. Polycythemia vera disorganization of osteoclastogenesis (osteoclast forma-
iv. Drug induced tion), a process dependent on 2 cytokines – macrophage
a. Phenytoin sodium colony-stimulating factor (M-CSF) and receptor activator
b. Nifedipine of NF-kB ligand (RANKL).
c. Cyclosporine Clinical features
d. Barbiturates l It is seen mainly in males over 55 years of age.
v. Idiopathic l In PDB, bone remodelling is disrupted, and an anarchic
vi. Familial alternation of bone resorption and apposition results
vii. Miscellaneous conditions in mosaic-like ‘reversal lines’, often associated with
viii. Systemic conditions can affect the periodontium in severe bone pain.
two mechanisms. l In early lesions, bone destruction predominates (osteolytic
a. Magnification of an existing inflammation initiated stage) and there is bowing of the long bones, especially
by dental plaque, e.g. pregnancy and puberty the tibia, pathological fractures, broadening/flattening of
b. Manifestation of the systemic disease indepen- the chest and spinal deformity.
dently of the inflammatory status of the gingiva, l The increased bone vascularity can lead to high output
e.g. neoplastic enlargement cardiac failure.
c. Conditioned enlargement l Later, as disease activity declines, bone apposition in-
d. Pregnancy gingival enlargement creases (osteosclerotic stage) and bones enlarges, with
e. Pregnancy tumour progressive thickening (between these phases is a mixed
Q.5. Describe briefly about phase). PDB is typically polyostotic and may affect
a. Fibrous dysplasia skull, skull base, sphenoid, orbital and frontal bones.
b. Paget disease l The maxilla often enlarges, particularly in the molar
c. Periapical cementifying dysplasia region, with widening of the alveolar ridge.

l In early lesions, large irregular areas of relative radiolu-
Ans.
cency (osteoporosis circumscripta) are seen, but later
Fibrous dysplasia there is increased radiopacity, with appearance of ‘cot-
l Fibrous dysplasia (FD) is a self-limiting fibro-osseous
ton wool’ pattern.
lesion caused by mutation in the gene encoding G pro- l Constriction of skull foramen may cause cranial neu-
tein (GNAS1). ropathies.
l It usually affects only one bone (monostotic, about 70%)
l The dense bone and hypercementosis make tooth ex-
but occasionally several (polyostotic). Maxillofacial FD traction difficult, and there is also a liability to haemor-
may occur anywhere in the jaws, but is essentially mono- rhage and infection.
stotic and typically affects the maxilla in young people;
although it sometimes affects adjacent bones (craniofa- Management
cial fibrous dysplasia), it rarely crosses the midline. l Diagnosis is supported by imaging, biochemistry and
l Although bone enlarges, its morphology is preserved, histopathology.

distinguishing FD from a neoplasm. l Plasma alkaline phosphatase and urine hydroxyproline
l CT can best assess the extent in the facial skeleton. levels increase with little or no changes in serum cal-
l FD lesions vary from radiolucent to radiopaque (often a cium or phosphate levels.
‘ground-glass appearance’) with ill-defined margins – a l Bisphosphonates are the treatment but calcitonin may
feature helpful to distinguish it from other lesions. also help.

l There are, however, a variety of new-generation anti-

{SN Q.6}
convulsants, immunosuppressants and antihypertensive
Periapical cemental dysplasia available today. For example, tacrolimus is a new im-
l It is also called fibrocementoma, sclerosing cementum, munosuppressant that has been shown to be an effective
periapical osteofibrosis and periapical fibrosarcoma. replacement for cyclosporine and does not cause gingi-
l It is a reactive fibro-osseous lesion derived from the val enlargement.
odontogenic cells in the periodontal ligament. l Nonsurgical treatments such as professional gingival
l It is located at the apex of the teeth. debridement and topical or systemic antimicrobials may
l Seen in middle age group at an average age of ameliorate gingival enlargement.
39 years. l Surgical management is reserved for severe cases and
l Male-to-female ratio is 1:9 and is three times more usually does not provide long-term efficacy.
common in blacks than in whites. l Conventional gingivectomy is the most commonly em-
l It is usually discovered as an incidental finding dur- ployed, although periodontal flap surgery may be indi-
ing routine radiographic surveys. cated when osseous recontouring is needed, if there are
l Mandibular anterior region is commonly affected. mucogingival considerations.
l Involved teeth are vital with no history of pain or l Laser ablation gingivectomy may offer an advantage over
sensitivity. conventional surgery since procedures are faster and

l Occasional lesions localize near the mental foramen there is improved haemostasis and more rapid healing.
and impinge on the mental nerve and produce pain, l Prevention through optimal oral hygiene is essential to
paraesthesia or even anaesthesia. minimize the severity of enlargement.

l Signs: Hypercementosis is usually associated with it.
Q.2. Name four drugs causing gingival enlargement.
It rarely enlarges.
l No treatment is required. Ans.
The drugs causing gingival enlargement are as follows:
l Phenytoin
l Valproic acid
Q.6. Discuss the differential diagnosis of gingival
l Phenobarbital
enlargement.
l Vigabatrin
Ans. l Nifedipine
l Diltiazem
[Same as SE Q.4]
Q.3. Cementoma.
Q.7. Enumerate the various causes of gingival enlarge-
ment. Discuss differential diagnosis of inflammatory Ans.
and noninflammatory gingival enlargement.
l Cementoma or benign cementoblastoma is a true neoplasm
Ans. of functional cementoblasts, which form a large mass of
cementum or cementum-like tissue on the tooth root.
[Same as SE Q.4]
Clinical features
Q.8. Classify gingival enlargements and discuss in detail
l Age: Under 25 years.
the inflammatory gingival enlargement of systemic
l Sex: Male predilection.
background.
l Site: Mandible three times more common than maxilla.
Ans. Mandibular first molar is the most commonly affected

tooth.
[Same as SE Q.4]
l The lesion is slow growing and may cause expansion
of cortical plates of the bone, but is otherwise asymp-

SHORT NOTES: tomatic.
Q.1. Treatment of dilantin gingival enlargement. Treatment
l Extraction of the tooth, as there are chances of expan-
Ans.
sion of the cortical plates.
l There are several treatment options for drug-induced
Q.4. Nasopalatine cyst.
gingival enlargement. The most predictable treatment is
either the withdrawal or change of medication. Ans.
l Nasopalatine cyst is a most common nonodontogenic l Middle-aged adults are affected.

cyst, which is developmental, nonneoplastic in nature. l It may occur singly, multiply and unilaterally, but is
l Arises from remnants of the vestigial paired palatine usually bilateral in premolar region.
ducts. l Symptoms: There is growth on the lingual surface of the
l It affects midline anterior maxilla. mandible, above the mylohyoid line, usually opposite to
l Aetiology is unknown, but possible pathogenic factors the bicuspid teeth.
are trauma, infection and mucous retention within as- l Size: Their size is variable ranging from an outgrowth
sociated salivary gland ducts. that is just palpable to one that contacts a torus on the
opposite side.
Clinical features
l Radiographically, they appear as sharply demarcated
l Male predilection within 40–60 years.
radiopaque oval-shaped shadow superimposed over the
l Small cysts are asymptomatic in early stages. In large
roots of premolars and molars and occasionally, on the
cyst, variety of symptoms can be seen including swell-
incisors and canine.
ing, discharge and pain.
l Treated by surgical excision.
l Tooth displacement is a common finding.
Q.9. Ameloblastoma in mandible.

l A nasopalatine canal cyst is purely radiolucent, with Ans.
sharply defined margins. The anterior nasal spine often
l Ameloblastoma is a benign, aggressive tumour that is
is centrally superimposed on the lucent defect, produc-
invasive and persistent.
ing a heart shape.
l Adults are most commonly affected.
Treatment l Broad age range; mean age, 30 years.
l Enucleation l Mandibular molar-ramus is the most commonly affected
site.
Q.5. Name two multilocular cysts. l Classical radiographic appearance is multilocular cyst-
Ans. Two multilocular cysts are odontogenic keratocysts like lesion in the jaw. The multilocular can be either of
and aneurismal bone cyst. honeycomb type or soap-bubble type.
Q.6. Periapical cemental dysplasia. l No single standard type of therapy can be advocated
for patients with ameloblastoma. Each case should be

Ans. judged on its own merits.
[Ref SE Q.5] l Block excision or resection is generally reserved for
larger lesions.
Q.7. Café-au-lait spots. l Cystic ameloblastomas may be treated less aggres-
Ans. sively, but with the knowledge that recurrences are often
associated with simple curettage.
l As the term implies, asymmetric areas of cutaneous l Patients with all forms of central ameloblastoma should
pigmentation, often described as café-au-lait spots have be followed indefinitely, since recurrences may be seen
the colour of coffee with cream and vary from small as long as 10–20 years after primary therapy.
ephelis-like macules to broad diffuse lesions.
l They tend to appear in late childhood and can be mul- Q.10. Biochemical investigations of Paget disease.
tiple. Ans.
l Importantly patient will manifest cutaneous signs as the
predominant feature of the disease. For example, neuro- l The biochemical investigations can provide important
fibroma, polyostotic fibrous dysplasia, Peutz–Jeghers information about the diagnosis of Paget disease.
syndrome, hypothyroidism, etc. l Serum calcium and serum phosphate levels are normal
in the presence of markedly elevated alkaline phospha-

Q.8. Torus mandibularis. tase levels.
l The intense osteoblastic activity in this metabolically
Ans.
active bone is believed to be responsible for the elevated
l Torus mandibularis is also called mandibular torus. It is alkaline phosphatase levels.
an exocytosis or outgrowth of bone found on the lingual l The amount of bone resorption may be correlated with
surface of the mandible. increases in urinary calcium and hydroxyproline levels.

l It primarily consists of the compact bone.
Q.11. Pregnancy tumour and gingivitis.
l Cause: Genetic and environmental factors are respon-
sible for its formation. Ans.

l Pregnancy tumour occurs due to hormonal changes dur- Q.15. Describe radiographic appearance of dentigerous
ing pregnancy, which lead to an altered response of cyst.
gingival tissues to local irritants towards the end of first
Ans.
trimester.
l Clinically the lesion appears as a deep red or purple l Dentigerous cyst is also called follicular cyst or peri-
mass, pedunculated or sessile. coronal cyst.
l A traumatized lesion may resemble pyogenic granu- l It usually occurs in association with the crowns of
loma. unerupted teeth.

l It is better not to treat the lesion until parturition. l The teeth involved are mandibular third molars, maxil-
l The lesion has to be excised if it is too big and is con- lary canines and the premolars. It can also occur in
stantly traumatized due to mastication. relation with the supernumerary teeth.
l Well-defined radiolucency with sclerotic or hyperostotic
Q.12. Cherubism. border in association with the crown of an unerupted
Ans. tooth.
l Usually cyst is unilocular, rarely exhibits a multilocular
l Cherubism is also known as familial dysplasia of the pattern.
jaws.
l Males are affected mostly compared to females. Q.16. Radiographic appearance of odontogenic kera-
l Characteristic chubby facial appearance of affected tocyst.
children with bilateral enlargement of the mandible.
Ans.
l ‘Eye raised to heaven’ appearance.
l Difficulty in speech, mastication, deglutition and jaw l Odontogenic keratocyst appears as multilocular radiolu-
movements. cency with undulating borders and cloudy interior.
l Alveolar process is wide, fibrous replacement of bone l The borders are hyperostotic.
may happen. l There will be displacement of the teeth.
l Radiologically expansion of buccal and lingual cortical l The maxillary lesions are usually smaller and unilocular.
plates is seen and in mandible inferior alveolar canal
may be displaced. Q.17. Pleomorphic adenoma of palate.
l Deciduous teeth shed prematurely.
Ans.
Q.13. Describe the radiographic features of fibrous l In the parotid gland, these neoplasms are slow growing
dysplasia. and usually occur in the posterior inferior aspect of the
Ans. superficial lobe.
l Intraorally, pleomorphic adenomas most often occur
The radiographic features of fibrous dysplasia depend on on the palate, followed by the upper lip and buccal
the stage of the lesion and are as follows: mucosa.
a. Lesions with osseous tissue have mottled appearance. l Pleomorphic adenomas can vary in size, depending on
b. Lesions with excessive osseous tissue appear radiopaque. the gland in which they are located.
c. The typical radiographic appearance is termed as ground l One case series reported an infrequent yet clinically
glass appearance. significant malignant transformation to carcinoma of
8.5%. In the parotid gland, the tumours are usually sev-
Q.14. Condensing osteitis.
eral centimetres in diameter but can reach much larger
Ans. sizes if left untreated.
l Condensing osteitis is also called focal sclerosing osteo- Q.18. Describe the clinical features of ossifying fibroma.
myelitis.
Ans.
l It is a localized low-grade chronic inflammation of the
bone marrow and is associated with bone formation and l Ossifying fibroma is a usually benign, slow-growing,
not bone destruction. painless bone neoplasm, typically monostotic.
l It is seen in the periapical region of a tooth with deep l Seen in the third and fourth decades in the posterior
carious lesion. mandible as a radiolucent, radiopaque, or mixed opacity

l Mandibular molar area is the frequent site of occurrence. which has a fibro-osseous microscopic appearance.
l Asymptomatic. l Ossifying fibroma is an aggressive variant with a rapid
l Radiographically: radiopacity in the periapical region of growth pattern seen mainly in boys aged less than
the involved tooth. 15 years.
l Traditionally, the initial treatment has been surgical l Epulis fissuratum seen in edentulous patients, arising
enucleation. More definitive resection has been reserved from mucosal tissue of the alveolar ridge.
for recurrent disease. l Represents extensive inflammatory hyperplasia due to
chronic local irritation, especially ill-fitting denture.

Q.19. Describe the radiographic features of myxoma.
l Lesion should be surgically excised to avoid recurrence.
Ans.
Q.23. Fissural cysts.
l Characteristically, myxoma appears radiographically as
Ans.
a unilocular or multilocular lesion.
l It is clinically and radiographically indistinguishable Nonodontogenic cysts of the jaws are as follows:
from other lesions that present with a similar radio- l Nasopalatine duct cyst
graphic appearance. l Median palatine cyst
l Globulomaxillary cyst
Q.20. Albright syndrome.
l Nasolabial cyst
Ans.
Q.24. Periapical granuloma.
l Albright syndrome is also known as McCune–Albright
Ans.
syndrome.
l Albright syndrome includes: precocious puberty 1 poly- l Periapical granuloma refers to the formation of granulo-
ostotic fibrous dysplasia 1 café-au-lait pigmentation. matous tissue at the apex of tooth with necrosed pulp.
l Severe polyostotic fibrous dysplasia involving nearly all l The diffusion of toxic products of bacteria and infected
bones of the skeleton. material due to a low-grade infection leads to the forma-
l Pigmented lesions of the skin, i.e. café-au-lait spots tion of the granulation tissue as reparative mechanism
seen. of the body.
l Endocrine disturbances occur due to hyperfunction of l It consists of the central portion of loose connective
one or more endocrine glands, they include preco- tissue and blood vessels with presence of lymphocytes,
cious puberty, goitre, hyperthyroidism and hyperpara- plasma cells, mononuclear and polymorphonuclear
thyroidism. leukocytes. Peripheral to this central portion there is a
fibrous capsule.
Q.21. Giant cell granuloma.
l It is asymptomatic.
Ans. l Well-defined radiolucency with sclerotic border.
l The giant cell granuloma is of two types: Q.25. Median mandibular cyst.
i. Central giant cell granuloma
Ans.
ii. Peripheral giant cell granuloma
l Peripheral giant cell granulomas arise interdentally or l Median mandibular cyst is a rare lesion, occurring in the
from marginal gingiva, seen on labial surface. midline of the mandible.
l Colour varies from pink to purplish blue. l It is a developmental cyst.
l Smooth to irregularly shaped, sessile or pedunculated l Asymptomatic.
multilobulated protuberances with surface indentations, l It produces obvious expansion of the cortical plate of
ulceration of the margin occasionally seen. the bone.

l Painless, vary in size and cover several teeth. l Treatment: Surgically remove the cyst by preserving the
l Central giant cell granulomas, arise within the jaws and associated teeth.
produce central cavitation, occasionally create defor-
Q.26. Fibromatosis gingivae.
mity of the jaw.
l Radiographically, soap-bubble appearance. Ans.
l Treatment: Local curettage.
l Fibromatosis gingivae, also called elephantiasis gingi-
Q.22. Epulis. vae, appear as diffuse overgrowth of gingival tissue.
l Autosomal dominant.
Ans.
l It is manifested as dense smooth, diffuse or nodular
l Giant cell epulis occurs on the gingiva. overgrowth of gingival tissue of one or both the arches
l Aetiology: Local irritation or trauma. that usually occurs at the time of eruption teeth.
l Clinically appears as a pedunculated or sessile mass; l Characteristic pebbled surface, dense gingival swelling
surface is smooth and shiny. results in spacing between the teeth and change in pro-
l It causes pressure to the adjacent teeth. file and facial appearance.
l Management: Surgical removal of excessive tissue with l The overlying epithelium is intact, and superficial blood
exposure of teeth is necessary. vessels are usually evident over the tumour.
l All types have adipocytes of various degrees of maturity.
Q.27. Adenomatoid odontogenic tumour.
l The usual simple lipoma consists of a well-circum-
Ans. scribed, lobulated mass of mature fat.

l Numerous microscopic subtypes have been described,
l Adenomatoid odontogenic tumour (AOT) is a tumour
but they are primarily of academic interest.
of odontogenic epithelium that exhibits behaviour very
different from the ameloblastoma. Q.30. Pyogenic granuloma.
l This tumour is characterized histologically by a very
Ans.
distinct capsule surrounding the tumour and structures
resembling ducts (adenomatoid) within the epithelium. Aetiology
l Initiated by trauma or irritation
l Approximately, 70% of AOTs occur in females younger
l Modified by hormones, drugs
than 20 years of age and 70% involve the anterior jaw.
This lesion rarely recurs even with conservative curettage. Location
l Predominantly gingiva, but any traumatized soft tissue
Q.28. Von Recklinghausen disease.
Histopathology
Ans.
l Hyperplastic granulation tissue
l Von Recklinghausen disease is also known as neurofi-
Treatment
bromatosis (neurofibroma and fibroma molluscum).
l Excision to periosteum or periodontal membrane
l It is a benign tumour of nerve tissue origin, derived
from the nerve sheath. Recurrence

l Neurofibroma is either solitary lesion or as part of the l Some recurrence
generalized syndrome of neurofibromatosis.

Q.31. Odontomes.
Clinical features
Ans.
Oral manifestation
l Odontome is the most common odontogenic tumour,
l Discrete, nonulcerated nodular, which tends to be of
regarded as a hamartoma rather than a neoplasm.
the same colour as the normal mucosa, but can occur
l Commonly seen in children.
on buccal mucosa, palate, alveolar ridge, vestibule and
l Asymptomatic.
tongue.
l Discovered on routing radiographic examination or
l Occasionally, neurofibroma located centrally within the
when it blocks eruption of a tooth.
jaw are seen.
l Compound type is composed of multiple miniature
l These are generally in mandibular nerve, and radio-
teeth. Most commonly found in anterior maxilla.
graphically shows a fusiform enlargement of mandibu-
l Complex type is a conglomerate mass of enamel and
lar canal.
dentine, most commonly found in the posterior jaws.
l Involvement of trigeminal nerve can cause facial pain or
l Treated by enucleation, does not recur.
paraesthesia.
l Skin lesions: Café-au-lait spots. Q.32. Fibrotic gingival enlargement.
l Malignancy: Malignant neurolemmoma.
Ans.
l Neurological: CNS tumour, mental retardation.
l Fibrotic gingival enlargement is of two types:

Treatment
i. Drug induced
l Solitary oral neurofibromas are usually treated by surgi-
ii. Idiopathic
cal excision, depending on the extent and the site.
l It is the ‘painless enlargement of gingiva at interproxi-
Q.29. Lipoma. mal aspect’.

Ans. Aetiology
Drugs:
l Lipomas are uncommon neoplasms that may occur in
l Phenytoin
any region of the oral cavity.
l Cyclosporine
l The buccal mucosa, tongue and floor of the mouth are
l Nifedipine
among the more common locations.
l Lesions typically present clinically as asymptomatic, Clinical features
yellowish submucosal masses. l Buccal and anterior segment are more affected.
l Gingiva appears pink and firm and unless infected. l Ehlers–Danlos syndrome (EDS) is a group of inher-
l Formation of psuedopockets. ited disorders characterized by excessive looseness
(laxity) of the joints, hyperelastic skin that is fragile
Treatment
and bruises easily and/or easily damaged blood
l Adequate oral hygiene maintenance and change of
vessels.
drugs or dosage and surgical excision.
Q.33. List out differential diagnoses for a swelling in the Signs
palate. l Excessive joint laxity and hypermobility.
l Soft, thin or hyperextensible skin.

Ans. l The tongue is very supple. Approximately, 50% of those
Various differential diagnoses for a swelling in the palate with the syndrome can touch the end of their nose with
are as follows: their tongue (Gorlin sign) and the palate is commonly
vaulted.
Traumatic
l Fracture of maxilla Q.37. Residual cyst.
l Hematoma
l Epulis Ans.
l Denture hyperplasia
l Residual cyst is retained periapical cyst from teeth that
Inflammatory have been removed.
l Tuberculosis l It can be found in maxilla or mandible.
l Syphilis l Histology of lining is a nondescriptive stratified squa-
l Actinomycosis mous epithelium.
l Infected cyst l Morphologically, the cyst may present as a well-defined
l Toxoplasmosis radiolucency that can vary in size from few millimetres
Necrosis to several centimetres.
l Clinically, these cyst are found on routine radiographic
l Osteoradionecrosis
l Noma examination.
l Usually, residual cyst do not expand bone.
Nonodontogenic cysts l Treatment: Surgical curettage.
l Nasopalatine
l Globulomaxillary Q.38. Papilloma.

Developmental conditions Ans.
l Torus palatines
l Hyperplasia of palatal gland l Papilloma is a common benign neoplasm of the oral

cavity, arising from the epithelial tissue.
Q.34. Pseudocysts. l Papilloma is caused by human papilloma virus.
Ans.
Clinical features
l Stafne bone cyst is a developmental defect, located l Most commonly seen in third, fourth and fifth decades
below the mandibular canal. of life and is equally affected in both sexes.
l Salivary gland or adipose tissue is seen in defect. l Sites: Tongue, lips, buccal mucosa, gingival, hard and
l No symptoms. soft palate, etc.
l Discrete corticated margin. l Papilloma appears as a slow-growing, exophytic, soft,
l Diagnostic on panoramic film. usually pedunculated, painless and nodular growth with
l No treatment required. typical cauliflower-like appearance.
Q.35. Pathergy test. l It is characterized by numerous figure like projection
on their surface, which can be either blunt or pointed.

Ans.
Because of these projections, it appears as an ovoid
l Pathergy test, done for Behcet disease. swelling with a rough, corrugated surface.
l Cutaneous hypertrophy to intracutaneous injection or l The size of the lesion is usually small and that varies
needle sticks with the finding of pustule forming 24 h from few millimetre to centimetre in diameter.
after needle puncture.
Treatment
Q.36. What is Gorlin sign? l Conservative surgical excision of the lesion including
Ans. the base. Recurrence is common.

Q.39. Treatment of dilantin gingival hyperplasia. Q.42. Complex composite odontome.

Ans. Ans.
Q.40. Name the drugs causing gingival enlargement. Q.43. Compound odontome.
Ans. Ans.
Q.41. Name few nonodontogenic cysts of the jaws. Q.44. Stafne bone cyst.
Ans. Ans.
Topic 5
Oral Cancer

LONG ESSAYS:
1. Enumerate premalignant lesions and premalignant conditions. Describe the aetiology, clinical features and
treatment of oral submucous fibrosis.
2. Describe clinical features of carcinoma of tongue.
3. Pathogenesis and management of osteoradionecrosis.
4. Describe the differential diagnosis of oral precancerous lesions and conditions. [Same as LE Q.1]
5. Enumerate premalignant conditions and premalignant lesions of oral mucosa. Describe in detail any two of
them. [Same as LE Q.1]
6. Describe the clinical features and management of oral submucous fibrosis. Discuss the aetiological factors of this
condition. [Same as LE Q.1]
SHORT ESSAYS:
1. Rodent ulcer.
2. Squamous cell carcinoma.
3. Clinical features and radiographic appearance of osteosarcoma.
4. Mention the treatment plan for submucous fibrosis. [Ref LE Q.1]
5. Malignant melanoma.
6. Kaposi sarcoma.
7. Investigations of oral cancer.
8. TNM staging of oral cancer.
9. Radiotherapy.
10. Treatment of postirradiation mucositis.
11. Basal cell carcinoma. [Same as SE Q.1]
12. Treatment of squamous cell carcinoma. [Same as SE Q.2]
13. Osteogenic sarcoma. [Same as SE Q.3]
14. Treatment plan for oral submucous fibrosis. [Same as SE Q.4]
SHORT NOTES:
1. Brachytherapy.
2. Verrucous carcinoma.
3. Aids in diagnosis of oral malignancies.
4. Oral precancerous lesions.
5. Carcinoma in situ.
6. Clinical features of erosive lichen planus.
7. Give the treatment plan for erosive lichen planus.
8. Kaposi sarcoma. [Ref SE Q.6]
9. Oral cancer – predisposing factors.
10. Management of submucous fibrosis. [Ref LE Q.1]
11. TNM staging. [Ref SE Q.8]
12. Define a premalignant lesion and a condition.
13. Oncogenes.
14. Chemopreventive agents.
15. Osteoradionecrosis.
16. Radiographic appearance of osteogenic sarcoma.
17. Epithelial dysplasia.
18. Toluidine blue test.
SOLVED ANSWERS
LONG ESSAYS:
l It is a high-risk precancerous condition.}
Q.1. Enumerate premalignant lesions and premalignant
conditions. Describe the aetiology, clinical features and Aetiology and pathogenesis
l Chronic irritation, e.g. betel nut, i.e. areca nut, chillies,
treatment of oral submucous fibrosis.
tobacco, lime, etc.
Ans. l Genetic predisposition
l Nutritional deficiency
Oral premalignant lesions are defined as morphologically
l Bacterial infections
altered tissues in which malignancy is more likely to occur than
l Collagen disorders
in its apparently normal counterparts. The alterations include
l Immunological disorders
genetic changes, epigenetic changes and surface alterations.
The sum total of these physical and morphologic altera- Clinical features
tions are of diagnostic and prognostic relevance and are l It affects both the sexes equally, and patients are
known as ‘precancerous’ changes. between second and fourth decades.
l Most common locations are buccal mucosa and retro-
Premalignant lesions
l Leukoplakia
molar areas.
l Initial symptoms commonly seen are burning sensation
l Leukoedema
l Erythroplakia
of oral mucosa aggravated by spicy food followed by
l Smoker’s palate
either hypersalivation or dryness of mouth.
l The first sign is erythematous lesion sometimes associ-
Premalignant conditions ated with petechiae, pigmentations and vesicles.
l Oral submucous fibrosis l Initial lesions are followed by paler mucosa, which
l Lichen planus comprise marbling.
l Intraepithelial carcinoma l Fibrous bands located beneath an atrophic epithelium
are the most prominent clinical feature.

[SE Q.4]
l Increased fibrosis leads to loss of resilience, which
{Oral submucous fibrosis causes interference with speech, tongue mobility and a
l It is a chronic scarring disease that affects the oral tis- decreased ability to open the mouth.
sues as well as the pharynx and upper two-thirds of the l The atrophic epithelium may cause a smarting sensation
oesophagus. and inability to eat hot and spicy food.
l Diagnosis of oral submucous fibrosis (OSMF) is based l Squamous cell carcinoma of the tongue may arise in
on clinical features and patients report of habit of betel apparently normal epithelium, in areas of leukoplakia,
quid chewing. or in an area of chronic glossitis.
l These lesions are usually larger than 2 cm at presenta-
(SE Q.4 and SN Q.10) tion, with the lateral border being the most common
{(Management subsite of origin. At this point, the patient may develop
l Restriction of the habits speech and swallowing dysfunction. Pain occurs when
It is safe to restrict betel nut chewing and to avoid spicy the tumour involves the lingual nerve, and this pain may
food. also be referred to the ear.
l Nutritional support l Carcinomas of the tongue base are clinically silent until
Vitamin B complex and iron therapy and long-term they deeply infiltrate the tongue musculature.
therapy of antioxidants gives good results. l They are usually less differentiated. Because of the dif-
l Intralesional injections of steroids ficulties with direct visualization, they may extend into
Corticosteroids are injected intralesionally with the aim the oral tongue or have lymph node metastases before
of antifibrinolytic and anti-inflammatory action. the diagnosis is established.
Intralesional injection of 1 mL suspension containing Q.3. Pathogenesis and management of osteoradionecrosis.
hydrocortisone along with 1 mL of lignocaine hydro-
chloride once a week or may be increased to twice a Ans.
week depending on the severity of the disease. l Osteoradionecrosis is necrotic tissue and bone that fails
l Medications
to heal spontaneously and does not respond to local care
Antioxidants like retinoid and b-carotene and vitamin E over a period of 6 months following radiotherapy.
prevent the formation of toxic substances and enhance l Radiotherapy causes endarteritis obliterans resulting in
the indigenous concentration of vitamin A the func- obliteration of fine vasculature, progressive fibrosis, loss
tional and structural ingredients of epithelial cells. of normal cellular elements, fibrous and fatty degenera-
l Surgery
tion of the bone marrow. These factors predispose to the
Skin grafts give better results in small lesions. Coverage development of osteoradionecrosis if exposed or injured
of the small area with full thickness flaps like nasola- and also increased vulnerability to trauma and infection.
bial, tongue and palatal flaps has provided better long- l The pathophysiologic characteristic is a nonhealing
term relief. LASER is used to reduce scar formation hypoxic wound in the bone.
further.)} l It develops most commonly after local trauma such as
dental extractions, biopsies, related cancer surgery and

Q.2. Describe clinical features of carcinoma of tongue.
periodontal procedures.
Ans. l Radiation induces tissue hypoxia in normal cells result-
ing in an imbalance where cell death and collagen lyses

l In most countries, the tongue is the most common site
exceed the homeostatic mechanism of cell replacement
of intraoral carcinoma.
and collagen synthesis, resulting in a wound that will
l Of all potential aetiologic factors, use of tobacco prod-
not heal, in which the metabolic demands exceed the
ucts is correlated as the closest cause to the carcinoma
oxygen and vascular therapy.
of the tongue.
l Squamous cell carcinoma is the most common malig- Clinical features
nancy of the tongue, typically having three gross mor- l Clinical manifestations include pain, foul taste, paraes-
phologic growth patterns: exophytic, ulcerative and thesia or anaesthesia, orocutaneous fistula’s, exposed
infiltrative. necrotic bone, pathological fracture and suppuration.
l The infiltrative and ulcerative types are most common l It is more common in mandible than in maxilla due to
on the tongue. Lateral margins and ventral surface of the decreased vascularity and density of the mandible.
tongue are more frequently affected sites. l On physical examination, missing hair follicles,
l The most common finding is an indurated, ulcerated change in surface texture of skin and colour are impor-
area of the tongue. The induration may extend deep into tant findings that assist the clinicians in finding the
the tongue musculature and root of the tongue. area of radiation injuries.
l Before causing symptoms, malignancies of the tongue l Irradiated mandible, periosteum and overlying soft tis-
may grow to significant size. Because of the relative laxity sue undergo hyperaemia, inflammation, endarteritis,
of the tissue planes separating the intrinsic tongue muscu- periarteritis, hyalinization, fibrosis and thrombosis of
lature, the cancer may spread easily and become symp- the vessels. These conditions ultimately lead to cellular
tomatic only when its size interferes with movement. death and progressive hypovascularity. The result is
aseptic necrosis of the portion of the bone directly in the Q.5. Enumerate premalignant conditions and premalig-
beam of radiation. nant lesions of oral mucosa. Describe in detail any two
l There is minimal localization of the infection, and there of them.
may be necrosis of considerable amount of bone, peri-
Ans.
osteum and overlying mucosa. Finally sequestration
occurs. [Same as LE Q.1]
Prophylactic therapy Q.6. Describe the clinical features and management of
l Prior to beginning of radiotherapy, all patients should oral submucous fibrosis. Discuss the aetiological factors
undergo a thorough dental evaluation including full of this condition.
mouth radiographs, dental and periodontal diagnosis
Ans.
and prognosis for each tooth.
l Patient education regarding the need for meticulous oral [Same as LE Q.1]
hygiene and frequent follow-up must be stressed. The
dentist should perform periodontal scaling, caries con-
trol and fabrication of fluoride trays. SHORT ESSAYS:
l Teeth that are infected/nonvital and cannot be salvaged
Q.1. Rodent ulcer.
with conservative endodontic therapy should be ex-
tracted. Ideally, extraction should be done 3 weeks prior Ans.
to radiation therapy. l Basal cell carcinoma is also known as rodent ulcer. It is
l Prophylactic antibiotic therapy (penicillin) should be given
the most common cutaneous malignancy, which typi-
in patients who are undergoing any extraction of teeth. cally affects the sun-exposed surfaces of the skin.
l To prevent radiation caries, patient should be begin daily
l It arises from the basal cells of the surface epidermis or
fluoride treatment with 1% neutral sodium fluoride gel in external root sheath of the hair follicle.
prefabricated trays for 5 min each day, for life time. l These are slow-growing tumours. On long standing they
Postradiation dental care can cause local destruction of tissues.

l Metastasis is seldom encountered. It is estimated that
l Dentures should be avoided in the irradiated arch for
1 year after therapy. less than 0.1% of tumours metastasize. The most com-
l A saliva substitute should be used to lubricate the mouth mon sites of metastasis are the lymph nodes, bones and
to replace diminished flow from irradiated mucous and lungs.
salivary glands. Clinical features
l If postirradiation pulpitis develops and involved tooth is
l Basal cell carcinoma is usually seen in individuals over
restorable, endodontic therapy should be undertaken. the fourth decade of life.
l There should be an interval of at least 3–9 months be-
l Men are affected twice as commonly as women and
fore undertaking extraction or osseous surgery, unless the fair complexioned individuals are relatively more
indicated. prone to develop basal cell carcinoma compared to dark
l Necessary extractions should be limited to 1–2 teeth per
complexioned individuals.
appointment. Removal of teeth should be performed as l Basal cell carcinoma can have various clinical appear-
atraumatically as possible. ances. Some of the relatively common varieties are as
Management follows:
l Medical therapy in the treatment of osteoradionecrosis
a. Noduloulcerative type (most common variety)
is primarily supportive involving nutritional support b. Superficial spreading type
along with superficial debridement and oral saline irri- c. Pigmented
gation for local wounds. d. Morphea-form (sclerosing)
l Antibiotics are indicated only for definitive secondary
e. The cystic type
infection as well as of use of hyperbaric oxygen therapy. Ulceronodular type
l Minimal resection or in some cases mandibulectomy
l In the initial stages, it appears as a large nontender papule
may be required for management of sequestrated bone. which slowly enlarges and exhibits a central depression,
Q.4. Describe the differential diagnosis of oral precan- which over a period of time reveals ulceration associated
cerous lesions and conditions. with some bleeding and crusting.
l The pathognomonic feature of basal cell carcinoma is a
Ans. waxy, translucent or pearly appearing ulcer with a
[Same as LE Q.1] raised pale border. Telangiectasias are common.
Pigmented form l Diagnosis is based on clinical examination of head

l It resembles melanomas and appear as bluish-black or and neck followed by a fibreoptic examination of the
brown coloured macules. laryngopharynx and then a TNM staging and inci-
sional biopsy for confirmation.
Cystic variety
l This form of basal cell carcinoma is rare and appears as Treatment
a bluish-to-grey-coloured, mucin filled cyst-like lesions. l The tumour can be treated through surgery and radiation.
l Generally, the primary tumour is excised with 1.5 cm

Sclerosing type
margins for T1N0M0 lesions and for T2N0M0 and
l This form of basal cell carcinoma is uncommon and
more advanced stages, treating the neck prophylacti-
typical lesion mimics a scar.
cally with either an incontinuity functional neck dissec-
l It appears as a white or yellow waxy sclerotic plaque.
tion or radiotherapy in a dose of 5000–6500 cGy is
l The tumour cells initiate the proliferation of fibroblasts
recommended if the incisional biopsy shows greater
within the dermis and an increased collagen deposition,
than 3-mm depth of invasion.
i.e. sclerosis.
l For nodal invasion disease of N1, functional neck dis-
Superficial type section is recommended for nodal disease of N2 or

l It is seen as an erythematous, well-circumscribed patch N3-modified radical neck dissection is preferred by
or plaque. postoperative radiotherapy from 5000 to 6500 cGy.
l The lesion may be associated with the formation of a
Q.3. Clinical features and radiographic appearance of
white coloured scales mimicking lesions of psoriasis.
osteosarcoma.
l Surgical excision for basal cell carcinoma is still the
most popular modality of treatment. Mohs micrographic Ans.

surgery offers high cure rates for basal cell carcinoma.
l Osteosarcomas are primary malignant bone tumours in
Q.2. Squamous cell carcinoma. which mesenchymal cells produce osteoid.
Ans. Predisposing factors
l The exact pathogenesis for the tumour is unknown.
l Squamous cell carcinoma is defined as ‘a malignant
l Various predisposing factors proposed are trauma, virus,
epithelial neoplasm exhibiting squamous differentiation
genetic mutations, pre-existing bone cyst, osteogenesis
as characterized by the formation of keratin and/or the
imperfecta, Paget disease, fibrous dysplasia and previous
presence of intercellular bridges’.
history of radiation.
l The epidermoid carcinoma is the most common malig-
nant neoplasm of the oral cavity. Clinical features

l Osteosarcomas of the jaw bones are usually seen in the
Aetiology
third and fourth decades of life.
l Tobacco
l Males are slightly more commonly affected than females.
l HIV infected as well as immunosuppressed individuals
l The mandible and maxilla are equally affected.
l Low consumption of vitamins A and C
l The common sites affected are the symphysis, ramus
l Prolonged exposure to UV light
and posterior parts of the body of the mandible. In the
l History of syphilis and chronic irritation/trauma
maxilla, the alveolar ridge, antrum and the palate are
l Leukoplakia
frequently affected.
l Poor oral hygiene
l The common symptoms of this lesion in jaws are swelling
Clinical features and pain, paraesthesia/anaesthesia, loose teeth and trismus.

l Presents as painless mass or ulcer. l When the tumour extends to involve the nasal cavity,
l The tumour may begin as a superficially indurated ulcer maxillary sinus and orbit, clinical signs and symptoms
with slightly raised borders and may proceed either to such as epistaxis, nasal obstruction, haemorrhage, ex-
develop a fungating, exophytic mass or to infiltrate the ophthalmos and blindness may be apparent.
deep layers of the tongue, producing fixation and indu- l The earliest radiographic changes consists of a symmetric
ration without much surface changes. widening of the periodontal ligament space around a tooth
l Typical lesion develops on the lateral border or ventral or several teeth as a result of tumour infiltration along the
surface of the tongue. ligament space. This radiographic feature is referred to as
l The lesion is red white in colour. Garrington sign. Occasionally lamina dura may be lost.
l It can appear as leukoplakia, exophytic or ulcerated, l The irregular widening of the mandibular canal, with
some lesions will be indurated firm on palpation, in- areas of narrowing and loss of fine parallel cortical mar-
dicative of tumour cells infiltrating muscle fibres of gins of the walls of the mandible. In some individuals
the tongue. spiking resorption of the teeth are seen.
l Other radiographic findings include ill-defined ‘moth- l Usually the treatment is wide resection of the surgical
eaten’ destruction of bone, honey comb-like appearance, margins followed by radiotherapy and chemotherapy.
granular appearance, sunray appearance, Codman’s tri-
Q.6. Kaposi sarcoma.
angle and onion peel appearance.
l The typical features seen on radiograph are as follows: Ans.
i. Radiolucent with absence of bone formation within
l The Kaposi sarcoma is caused by human herpes virus-8.
the tumour.
ii. Mottled with small areas of amorphous ossification. Clinical features
iii. ‘Lamellar’ ossification with bony plates radiating l Classic Kaposi sarcoma usually occurs in adult males.
from a focus like a sunburst. l Almost all individuals suffering from the classic form
will tend to have an associated malignant lymphoma.

Management
l It has rarely any intraoral findings, the palate may be
l The choice of treatment for osteosarcoma is radical
involved in some cases.
surgery along with adjuvant chemotherapy.
l Kaposi sarcoma has four distinct variants:
l As most of the osteosarcoma metastasizes by haematog-
a. Classic or Mediterranean
enous route, there is a rationale for addition of adjuvant
b. Endemic or African
chemotherapy.
c. Epidemic or AIDS associated
l Literature reveals metastasis free survival rate of 8 years
d. Post-transplant or iatrogenic immunosuppression
is 60%–70%.
associated Kaposi sarcoma
l The factors contributing to poor prognosis include neu-
l The classic variety may affect any part of the body but,
ral sensory alteration, increasing age of patients and
lower extremities are commonly affected than the trunk,
surgical margins less than 5 mm.
arms and hands. The skin of the extremities may reveal
Q.4. Mention the treatment plan for submucous fibrosis. blue to purple macules which over a period of time may
turn into painless nodules.
Ans.
l Endemic Kaposi sarcoma is also known as African
[Ref LE Q.1] Kaposi sarcoma. It can present as benign nodular, infil-

trative, florid and lymphadenopathic type.
Q.5. Malignant melanoma. l The association of AIDS with Kaposi sarcoma was first
described in the early part of 1980s. It is estimated to

Ans.
appear in up to 40% of AIDS patients.
l Due to genetic alterations resulting from solar radiation, l It accounts for up to 90% of all cancers found in the
malignant transformation of melanocytes occurs. The AIDS population.

junctional melanocytes exhibit the earliest changes. l The iatrogenically induced variety is seen a few months
l If there is junctional proliferation of melanocytes along and years following organ transplants in post-transplant
with nuclear atypia, it is referred to as atypical melano- patients due to the effects of the immunosuppressive drugs.
cytic hyperplasia. When cytologic atypia becomes more
advanced, the lesions are called as superficial spreading
melanomas. {SN Q.8}
l Subsequently they invade into the connective tissues
Robert A. Schwartz and co-workers in 1984, proposed the
and infiltrate in adjacent tissues causing nodular growths
following classification system for Kaposi sarcoma (KS):
and swellings.
l Stage I
l Malignant melanoma of the oral mucosa usually occurs
Localized nodular KS, with more than 15 cutaneous
after 40 years of age. Most of the lesions about 70%–80%
lesions or involvement restricted to one bilateral ana-
occur on the palate, upper gingiva and alveolar mucosa.
tomic site, and few, if any, gut nodules.
l Clinically, melanoma usually begins as a solitary small
l Stage II
asymptomatic brown or black macule which later un-
Includes both exophytic destructive lesions and locally
dergoes proliferation.
infiltrative cutaneous lesions as locally aggressive KS.
l It starts as an asymptomatic, slow-growing brown or
l Stage III (generalized lymphadenopathic KS)
black macule having asymmetric and irregular borders
Wide-spread lymph node involvement, with or with-
or it may appear as a rapidly growing mass associated
out skin lesions, but with no visceral involvement.
with ulceration, bleeding, pain and bone destruction.
l Stage IV (disseminated visceral KS)
l Rarely, some amelanotic variants of oral melanomas
This variety has widespread KS, usually progressing
may not show usual bluish-black discolouration.
from stage II or stage III, with involvement of mul-
l As compared to the cutaneous melanomas, oral melano-
tiple visceral organs.
mas are more fatal.
Histopathology Q.8. TNM staging of oral cancer.

The histopathological and immunohistochemical fea-
Ans.
tures of all forms of Kaposi sarcoma are similar.
TNM staging of oral cancer is as follows:
{SN Q.8}
Management {SN Q.11}
l Surgical excision:
Individual solitary lesions are surgically excised. Clinical and histopathological T classification of
l Electron beam radiotherapy: cancer of the oral cavity
It can be used effectively. Tl – Tumour 2 cm or less in greatest dimension.
l Chemotherapy: T2 – Tumour more than 2 cm but not more than 4 cm in
Occasionally intralesional or systemic chemothera- greatest dimension.
peutic agents are used. T3 – Tumour more than 4 cm in greatest dimension.
For example, vinblastine (most commonly used anti- T4 – Tumour invades adjacent structures.
neoplastic agent). Clinical and histopathological N classification of
cancer of the oral cavity
NX – Regional lymph nodes cannot be assessed.
Q.7. Investigations of oral cancer. N0 – No regional lymph metastasis.
Nl – Ipsilateral single node less than 3 cm.
Ans.
N2a – Single ipsilateral lymph node, greater than 3 cm
Various diagnostic tests can be employed to detect but less than 6 cm.
potentially malignant and malignant lesions. N2b – Multiple ipsilateral nodes up to 6 cm.
l In routine practice following diagnostic tests are used: N2c – Bilateral or contralateral lymph nodes up to 6 cm.
l Vital staining N3 – Metastasis in lymph nodes greater than 6 cm.
l Brush biopsy Clinical and histopathological M classification of
l Exfoliative cytology cancer of the oral cavity
l Tissue biopsy MX – Distant metastasis cannot be assessed.
l Various imaging techniques, for example plain radio- Ml – No distant metastasis.
graphs, CT, MRI, ultrasonography, etc. M2 – Distant metastasis.
l In the early diagnosis of oral malignancies, newer di-
agnostic tools such as VELscope and ViziLite Plus,

Raman spectroscopy and high-performance laser spec-
Q.9. Radiotherapy.
troscopy–laser-induced fluorescence (HPLC-LIF) also
play a significant role. Ans.
l The VELscope is based on the direct visualization of
l Radiation prevents the cells from multiplying by inter-
tissue fluorescence. Its hand piece emits a safe blue light
fering with their nuclear material.
into the oral cavity, causing tissue fluorescence from the
l Tumour cells in stages of active growth are more sus-
surface of the epithelium through to the basal membrane
ceptible to ionizing radiation than adult tissues. The
where premalignant changes typically start.
faster the cells are multiplying or the more undifferenti-
l By utilizing special optical filters in the VELscope hand
ated tumour cells, the more likely that radiation will be
piece, the clinician is able to immediately view the differ-
effective.
ent fluorescence signatures in the oral tissue to help dif-
ferentiate between normal and abnormal cellular activity. Principal methods employed
l Another popular screening tool for detection of oral i. X-ray therapy
cancers is ViziLite Plus. As it is passed over oral tissue (a) Superficial X-ray therapy 45–100 kV
that has been treated with the rinse solution, normal (b) Kilovoltage X-ray therapy 300 kV
healthy tissue will absorb the light and appear dark, ii. Electron therapy
abnormal tissue will appear white. iii. Surface applicator (radium mould)
l Recently in 2003, a high-performance laser spectroscopy– iv. Interstitial implantation – radium source
laser-induced fluorescence (HPLC-LIF) technique was l Most common radiation is delivered externally by
developed to detect and record simultaneously spectra the use of large X-ray generators.
and chromatograph of physiological samples. This sys- l The normal amount of tolerable radiation for a per-
tem enables the detection of multiple ‘markers’ in a son should not be exceeded and adjacent uninvolved
single physiological sample in a short time. areas are spared by the protective shielding.
l The patient’s host tissues are protected from radia- oral cavity, for boosted doses of radiation to a specific
tion by two mechanism of delivery: (i) fractionation site or for treatment following recurrence.
and (ii) multiple ports. l The isotopes used include caesium, iridium and gold.
l Directly implanted sources may be used to deliver ra-

Q.10. Treatment of postirradiation mucositis.
diation, or an after loading technique may be used in
Ans. which the radiation source is placed by using previously
inserted guide tubes.
l In patients receiving irradiation for head and neck can-
cers, radiotherapy-related mucositis is the most frequent Q.2. Verrucous carcinoma.
complication.
Ans.
l Chronic oral sensitivity frequently continues after treat-
ment, due to mucosal atrophy. l Verrucous carcinoma is also known as snuff dipper’s
l Management of severe oropharyngeal mucositis often cancer and Ackerman’s tumour.
requires the use of systemic opioids. Systemic analgesics l It has a predilection for mucous membranes of the head
should be prescribed by following the World Health Or- and neck and is most commonly found in the oral cavity
ganization (WHO) analgesic ‘ladder’, which suggests the followed by the larynx.
use of nonopioid analgesics, alone or in combination with l It has been suggested that opportunistic viruses such as
opioids and adjunctive medications, for increasing pain. HPV-6 and -16 act in them with frank carcinogenesis to
l Analgesics should be provided on a time contingent promote development of verrucous carcinomas lesions
basis, with provision for breakthrough pain. at sites of chronic irritation and inflammation.
l Systemic prednisone provided to patients with head and
Q.3. Aids in diagnosis of oral malignancies.
neck cancer in a double-blind protocol resulted in a
trend to reduced severity and duration of mucositis. Ans.
l However, the use of steroids may result in increased risk of l To detect potentially malignant and malignant lesions,
infection. Systemic b-carotene administered during a com- various diagnostic tests can be employed.
bined course of chemotherapy and radiotherapy for pa- l In routine practice, vital staining, brush biopsy, exfolia-
tients with advanced head and neck squamous carcinoma tive cytology, tissue biopsy and various imaging tech-
has been reported to reduce the severity of mucositis. niques like plain radiographs, CT, MRI, ultrasonogra-
Q.11. Basal cell carcinoma. phy, etc. can be used effectively.
l Newer diagnostic tools such as VELscope and ViziLite
Ans. Plus, Raman spectroscopy and high-performance laser
[Same as SE Q.1] spectroscopy–laser-induced fluorescence (HPLC-LIF)
also play a significant role in the early diagnosis of oral
Q.12. Treatment of squamous cell carcinoma. malignancies.
Ans. Q.4. Oral precancerous lesions.
Q.13. Osteogenic sarcoma. l A morphologically altered tissues in which cancer is
more likely to occur than in its apparently normal coun-
Ans.
terparts are known as oral precancerous lesions, e.g.
[Same as SE Q.3] leukoplakia.
l These alterations may include genetic changes, epi-
Q.14. Treatment plan for oral submucous fibrosis.
genetic changes and surface alterations in intercellular
Ans. interactions.
l The sum total of these physical and morphological al-
[Same as SE Q.4]
terations are of diagnostic and prognostic relevance and
are designated as ‘precancerous’ changes.
l The diagnosis of precancerous lesions is primarily
SHORT NOTES: based on morphology and its grading on histology (dys-
Q.1. Brachytherapy. plasia).
l It is widely practiced method to assess the risk of malig-
Ans.
nant potential of such lesions, despite the fact that this
l Brachytherapy may be the primary treatment modality estimation is subjective and carries a low prognostic
for localized tumours in the anterior two-thirds of the value.
Q.5. Carcinoma in situ. Q.9. Oral cancer – predisposing factors.

Ans. Ans.
l Carcinoma in situ is also known as intraepithelial carci- Oral cancer predisposing factors are as follows:
noma. i. Genetic susceptibility
l It is a condition that arises frequently on the skin but
ii. Immune status
occurs also on mucous membranes including those of iii. Environmental factors and nutrition
the oral cavity. iv. Habits like tobacco consumption in smokeless form or
l The term carcinoma in situ is used for lesions in
smoke form and alcohol
which epithelial changes occur throughout their entire v. Ionizing radiation
thickness, but without violation of the basement mem- vi. Oral hygiene and other dental factors
brane. vii. Cellular genetics and molecular abnormalities, etc.
Q.6. Clinical features of erosive lichen planus.
Q.10. Management of submucous fibrosis.
Ans.
Ans.
l Erosive lichen planus is a T cell–mediated autoimmune
interface in which the basal cell layer of mucosa or skin [Ref LE Q.1]
is attacked.
Q.11. TNM staging.
Clinical features
l It presents in one of the three clinical forms, i.e. reticu-
Ans.
lar, plaque or erosive form. [Ref SE Q.8]
l All forms are seen in patients older than 40 years.
l Occurs equally in men and women. Q.12. Define a premalignant lesion and a condition.
l Predilection for buccal mucosa, the tongue and the
attached gingiva is more. Ans.

l Erosive form is characterized by intense pain and
l Premalignant condition is a generalized state, associated
erythematous mucosal inflammation. with a significantly increased risk of cancer. These
l When it involves buccal mucosa or tongue, it will
alterations include genetic changes, epigenetic changes
produce fibrinous-based ulcers against a background and surface alterations in intercellular interactions, e.g.
of erythema and sometimes hyperkeratotic foci. oral submucous fibrosis.
l A premalignant lesion is defined as a morphologically
Q.7. Give the treatment plan for erosive lichen planus.
altered tissue in which cancer is more likely to occur
Ans. than in its apparently normal counterparts. These al-
terations include genetic changes, epigenetic changes
Management of erosive lichen planus
and surface alterations in intercellular interactions, e.g.
l The mild cases of erosive lichen planus often can be man-
leukoplakia.
aged with topical corticosteroids, usually 0.05% fluocinonide
gel four times daily, or combined with antifungal agent gris- Q.13. Oncogenes.
eofulvin, 250 mg of the micronized form twice daily.
l Intralesional triamcinolone may also be used for focal Ans.
symptomatic lesions.
l Oncogenes are abnormal forms of normal genes (proto-
l Most erosive lichen planus requires systemic corticoste-
oncogenes) that regulate cell growth.
roid regimen I or II and only rarely III A or III B.
l Mutation of these genes may result in direct and con-
l Griseofulvin or topical fluocinonide or topical fluoci-
tinuous stimulation of the molecular biologic pathways
nonide can be added to either regimen to reduce the
(e.g. intracellular signal transduction pathways, tran-
prednisone requirements or help maintain a remission.
scription factors, secreted growth factors) that control
l Topical retinoids, vitamin A analogue may also be used
cellular growth and division.
in reticular lichen planus.
l Oncogenes typically result from acquired somatic cell
Q.8. Kaposi sarcoma. mutations secondary to point mutations (e.g. from

chemical carcinogens), gene amplification (e.g. increase
Ans.
in the number of copies of a normal gene) or from inser-
[Ref SE Q.6] tion of viral genetic elements into host DNA.
Q.14. Chemopreventive agents. radiographic feature is referred to as Garrington sign.

Occasionally lamina dura may be lost.
Ans.
l The irregular widening of the mandibular canal, with
l Chemotherapeutic agents affect the rapidly dividing areas of narrowing and loss of fine parallel cortical
cells of the target tumour and the lining epithelium, the margins of the walls of the mandible.
oral ecology. l In some individuals, spiking resorption of the teeth are
l The vascular, inflammatory reaction may result in mu- seen.

cositis and ulceration of the oral mucosa. l Other radiographic findings include ill-defined ‘moth-
l Chemotherapeutic agents also target the hematopoietic eaten’ destruction of bone, honey comb-like appearance,
cells of the bone marrow, resulting in anaemia, throm- granular appearance, sunray appearance, Codman’s tri-
bocytopenia and leukopenia. angle and onion-peel appearance are the typical features.
Q.15. Osteoradionecrosis. Q.17. Epithelial dysplasia.
Ans. Ans.
l Osteoradionecrosis is bone death caused by radiation Epithelial dysplasia includes following features:
injury. l Increased abnormal mitosis
l As previously been thought it is not an infection of com- l Individual cell keratinization
promised bone, but an avascular necrosis of bone caused l Epithelial pearls within spinous layer
by the three H tissue effects (hypovascular, hypocellar l Alteration in nuclear cytoplasmic ratio
and hypoxic) of radiotherapy. l Loss of polarity and disorientation of cells
l Infections associated with osteoradionecrosis are sec- l Hyperchromatism of cells
ondary infections due to the exposure of bone and deep l Large, prominent nucleoli
tissue plans. l Dyskaryosis or nucleus atypism
l The three types of osteoradionecrosis are early l Poikilokaryosis or division of nuclei without division of
trauma-induced osteoradionecrosis, spontaneous os- cytoplasm
teoradionecrosis and late trauma-induced osteoradio- l Basilar hyperplasia
necrosis.
Q.18. Toluidine blue test.
Q.16. Radiographic appearance of osteogenic sarcoma.
Ans.
Ans.
l In the method of toluidine blue staining, 1% aqueous
l The earliest radiographic changes of osteogenic sar- solution of the dye that is decolourized with 1% acetic
coma is symmetric widening of the periodontal liga- acid is used.
ment space around a tooth or several teeth as a result l The dye has tendency to bind with dysplastic and malig-
of tumour infiltration along the ligament space. This nant epithelial cells with a high degree of accuracy.
Topic 6
Diseases of the Tongue and Lips

LONG ESSAYS:
1 . Discuss tongue lesions in various nutritional deficiency states and give differential diagnosis of bald tongue.
2. Describe the appearance of tongue in geographic tongue.
3. Describe the appearance of tongue in:
a. Amyloidosis
b. Hunter glossitis
4. How the clinical examination of the tongue can be carried out? Describe glossodynia and mention the treatment
plan in brief.
5. Describe briefly about benign migratory glossitis. [Same as LE Q.2]
SHORT ESSAYS:
1. Pernicious anaemia – tongue lesions. [Ref LE Q.3]
2. Angular cheilitis.
3. Glossopyrosis and glossodynia. [Ref LE Q.4]
4. Fissured tongue.
5. Migratory glossitis.
6. Angioneurotic oedema.
7. Tuberculosis ulcers on the tongue.
8. Mention the causes of macroglossia.
9. Ankyloglossia.
10. Black hairy tongue.
11. Glossitis. [Same as SE Q.1]
12. Burning mouth syndrome. [Same as SE Q.3]
13. Geographic tongue. [Same as SE Q.5]
SHORT NOTES:
1. Benign migratory glossitis.
2. Treatment of atrophic glossitis.
3. Mention the causes of ‘bald tongue’.
4. Aetiology of angular cheilitis.
5. Hairy tongue.
6. Glossopyrosis.
7. Dysgeusia.
8. Management of a patient suffering from glossodynia. [Ref LE Q.4]
9. Ankyloglossia.
10. Differential diagnosis of bald tongue. [Same as SN Q.3]
11. Bald tongue. [Same as SN Q.3]
SOLVED ANSWERS
LONG ESSAYS: Features
l Symptoms vary from a tender to burning tongue to
Q.1. Discuss tongue lesions in various nutritional defi-
ciency states and give differential diagnosis of bald tongue. extreme glossodynia.
l In the beginning, the tongue may be intensely red and
Ans. then becomes smooth as the filiform and other types of
Tongue lesions in various deficiency states papillae atrophy. In some instances, normal papillation
l It has been recognized for years that certain deficiency
returns when the patient’s basic problem is successfully
states can produce a glossitis of a completely bald or a treated.
l The deficiency states reported to produce the type of
patchy bald type.
l Diagnosticians of gone years prided themselves in their
glossitis are discussed as follows:
ability to diagnose the specific deficiency by recogniz-
ing minute differences in appearance.
l Now it is generally agreed that the glossal changes in- Nutrient Deficiency symptoms
duced by specific deficiencies are so similar that a de- Vitamin A None
finitive diagnosis based on their differentiation is at least
Thiamin (B1) Painful or burning tongue; loss of taste acuity
unlikely, if not impossible.
Nutrient Deficiency symptoms l Its dominant characteristic is a constantly changing pat-

tern of serpiginous white lines surrounding areas of
Riboflavin Inflammation, fissures and ulcers at the corner of
(B2) the lips (angular cheilitis); dry, scaly lips; red to
smooth, depapillated mucosa.
purple colour tongue; atrophy and inflammation l The changing appearance with depapillated areas has
of tongue papillae; enlarged fungiform papillae reminded of continental outlines on globe, hence popu-
giving the tongue surface a pebbly appearance lar with the term geographic tongue.
Niacin Atrophy of tongue papillae resulting in a fiery,
red, smooth, shiny surface; oedematous or en- Clinical presentation and pathogenesis
larged tongue; ulcerations of tongue on central l Benign migratory glossitis is usually noted as an inci-
surface; angular cheilitis; loss of appetite dental examination finding or by patient recognition.
Pyridoxine Inflamed and atrophic tongue with a red, Although all surfaces of the tongue may be involved, the
(B6) smooth appearance; angular cheilitis dorsum is the most common.
l Adults are affected more than children, and women
Vitamin B12 Atrophy and inflammation of tongue; bright red,
painful, oedematous tongue with glossy appear- slightly more than men.
ance; altered taste sensations and decreased l The tongue will show alternating areas of normal tex-
appetite ture and a whitish colour due to filiform papillae and
Folic acid Smooth, bright red tongue; patchy surface of surface keratinization, contrasted with smooth red areas
tongue as papillae atrophy; ulcerations along where the filiform papillae have flattened and a dekera-
edges of tongue; angular cheilitis tinization of the surface has occurred.
Zinc Impaired taste; thickening and parakeratotic l The confluent borders of these two areas are usually el-
tongue with underlying muscle atrophy evated, rolled and more intensely white. The pattern and
Protein Red, smooth, oedematous tongue; angular chei- areas of involvement will change over a period of days.
litis; fissures on lower lip; depigmentation along l At times the tongue will revert to a normal texture and
buccal border of lips appearance, and at times it will exhibit almost a bald
denudation. Usually the appearance will be somewhere
Differential diagnosis in between.
If the tongue is completely bald, the only other condi- l The lesions are innocuous and asymptomatic except on
tion that needs to be considered is xerostomia. occasions when spicy foods or acidic citrus products are
Xerostomia can usually be recognized by noting the consumed.
absence of a salivary pool in the floor of the mouth or by l A small percentage of benign migratory glossitis cases
sticking a tongue blade to the oral mucosa during the oral will be accompanied by constant burning pain, known
examination. as the glossopyrosis.
If the tongue shows partial or patchy baldness, all the l These cases are usually related to invasive candidiasis
conditions previously mentioned should be considered; and occasionally to erosive lichen planus. In fact, can-
these include Migratory glossitis (MG), psoriasis, Reiter dida colonization rather than true invasive infection may
syndrome, pityriasis rubra pilaris, changes caused by the be the stimulus for benign migratory glossitis.
use of mouthrinse, atrophic lichen planus and median l Although the disease is often referred to as ‘geographic
rhomboid glossitis (MRG). The differential diagnosis of tongue’, it does occasionally appear in the floor of the
these entities may be reviewed under the differential diag- mouth or buccal mucosa as a benign migratory stomatitis.
nosis section of MG. A thorough discussion of the differen-
Histologically
tial aspects of all the deficiency states that may produce a
l Biopsy should be taken from a prominent serpiginous
glossitis is well beyond the intended scope of this text.
lines at the periphery of a depapillated patch.
Management l A thickened layer of keratin is infiltrated with neutro-
Once the deficiency state or states have been identified, phils; these inflammatory cells often produces small
specific measures may be undertaken for their correction, if microabscesses, called Monro abscess, in keratin and
such are available. spinous layers.
l Chronic inflammatory cells can be seen in variable
Q.2. Describe the appearance of tongue in geographic
numbers within the stroma.
tongue.
l Silver and PAS staining will demonstrate candida hy-
Ans. phae or spores in the superficial layers of the epithelium.

l Geographic tongue is a psoriasiform mucositis of the Differential diagnosis
dorsum of the tongue. It is also known as benign migra- l Surface tongue lesions that are generally asymptomatic
tory glossitis. include candidiasis, lichen planus and perhaps lesions

related to both systemic lupus erythematosus and discoid l Amyloidosis may or may not be apparent on macro-
lupus erythematosus. In addition, the clinician must be scopic examination, but when the suspected organ is
aware of the possibility of premalignant dysplasia. painted with iodine and sulphuric acid, a peculiar
mahogany brown staining of amyloid deposits is
Diagnostic work-up
revealed.
l Benign migratory glossitis is a diagnosis of clinical
l If large amount of amyloid is accumulated, the affected
recognition. If clinical doubt exists or a burning tongue
organ is frequently enlarged and the tissue appears grey
sensation accompanies the lesion, a biopsy is indicated
with a waxy firm consistency.
to rule out the other entities on the differential list.
l Histologically, the deposition always begins between
l A PAS stain is recommended to rule out Candida
the cells and eventually surrounds and destroy the
organisms.
trapped native cells.
Treatment l The diagnosis of amyloidosis is established by demon-
l No specific treatment is indicated in asymptomatic stration of the characteristic emerald-green birefrin-

cases. gence of tissue specimens stained with Congo red and
l Symptomatic lesions can be treated with topical examined by polarizing microscopy.
prednisolone and a topical or systemic antifungal l There is no specific therapy for primary amyloidosis.
medication can be tried if infected secondary with

candidiasis. [SE Q.1]
l Symptomatic cases respond well to nystatin oral sus-
pension, 100,000 U/mL given as 5 mL (1 teaspoon) oral

{Hunter glossitis
l Pernicious anaemia is rare before the age of 30 years
swish and expectorate 4 times daily, alone or combined
and increases in frequency with advancing age.
with clotrimazole troches (Mycelex, Alza) and 10 mg as
l The disease is often characterized by the presence of a
a lozenge three times daily. Response to such therapy
triad of symptoms: generalized weakness, a sore, pain-
suggests the presence of Candida organisms.
ful tongue and numbness or tingling of the extremities.
l Emphasis on the innocuous nature of the condition and
l Glossitis is one of the more common symptoms of per-
the fact that it is not malignant or premalignant is rec-
nicious anaemia.
ommended.
l The patients complain of painful and burning lingual
Q.3. Describe the appearance of tongue in: sensations.

l The tongue is generally inflamed, often described as
a. Amyloidosis
b. Hunter glossitis ‘beefy red’ in colour, either in entirety or in patches
scattered over the dorsum and lateral borders.
Ans. l In some cases, small and shallow ulcers – resembling
aphthous ulcers – occur on the tongue.

Amyloidosis
l Characteristically, with the glossitis, glossodynia and
l Amyloidosis is fundamentally a disorder of protein mis-
glossopyrosis, there is gradual atrophy of the papillae of
folding.
l It is a condition associated with a number of inherited
the tongue that eventuates in a smooth or bald tongue,
which is often referred to as Hunter glossitis or Moeller
and inflammatory disorders in which extracellular de-
glossitis.
posits of fibrillar proteins are responsible for tissue
l Loss or distortion of taste is sometimes reported accom-
damage and functional compromise.
panying these changes.
l This abnormal proteinaceous substance that is deposited
l The fiery red appearance of the tongue may undergo
between cells and organs of the body in a variety of
periods of remission, but recurrent attacks are common.
clinical disorders is referred to as an amyloid.
l On occasion, the inflammation and burning sensation
l Of the more than 20 biochemically distinct forms of
extend to involve the entire oral mucosa but, more fre-
proteins, three are most common. They are
quently, the rest of the oral mucosa exhibits only the
i. Amyloid light chain (AL)
pale yellowish tinge noted on the skin.
ii. Amyloid associated (AA)
l Commonly, the oral mucous membranes in patients
iii. ab-amyloid
with this disease become intolerant to dentures.
l Any organ can be involved but the most commonly
affected organs are kidneys, heart, gastrointestinal tract, Treatment

liver and spleen. l Regardless of the aetiology of vitamin B12 deficiency,
l Amyloidosis is generally irreversible condition. high-dose oral supplementation (l000–2000 mcg daily
l Amyloid deposition in tongue results in macroglossia, for 2 weeks), followed by 1000 mcg daily for mainte-
and gingiva is also commonly affected. nance, is currently recommended.
l Historically pernicious anaemia was treated with intra- allergic disorders, salivary gland hypofunction, chronic
muscular vitamin B12 supplementation. low-grade trauma and psychiatric abnormalities.
l Management for folic acid deficiency consists of l In addition to burning sensation, patient also experience
administration of oral folic acid (5 mg/day), which is mucosal pain often described as ‘rawness’ (stomato-
given for a period of 4 months. The differentiation of dynia and glossodynia).
B12 deficiency and folic acid deficiency is crucial as l The so-called scalded mouth syndrome is an apparently
folic acid supplements may correct the anaemia but will unrelated immune response to certain medications, espe-
not stop the neurological manifestations.} cially angiotensin-converting enzyme (ACE) inhibitors.
l Burning mouth syndrome affect postmenopausal women.
Q.4. How the clinical examination of the tongue can Women experience symptoms of BMS seven times more
be carried out? Describe glossodynia and mention the frequently than men.
treatment plan in brief. l Mean age is 40 years for men.
l It has typical abrupt onset, although may be gradual.
Ans.
l Dorsum of tongue develops a burning sensation, usually
Clinical examination of tongue in the anterior third of the tongue.
l Inspect the dorsum of the tongue while it is at rest for l Mucosal changes are seldom visible, if dorsum of tongue
any swelling, ulcers, coating or variation in size, colour is significantly erythematous and smooth, an underlying
and texture. systemic or local infectious process, such as anaemia or
l Observe the margins of the tongue and note the distribu- erythematous candidiasis, should be suspected.
tion of filiform and fungiform papillae, crenations and l Other oral sites affected are hard palate and the lips.
fasciculations, depapillated areas, fissures, ulcers and l Salivary levels of various proteins, immunoglobulins
keratotic areas. and phosphates may be elevated, and there may be a
l Note the frenal attachment and any deviations as the decreased salivary pH or buffering capacity.
patient pushes out the tongue and attempts to move it to l There will be mild discomfort on awakening with in-
the right and left. creasing intensity throughout the day. Contact with hot
l Wrap a piece of gauze (4 cm 3 4 cm) around the tip of food or liquid often intensifies the symptoms.
the protruding tongue to steady it, and lightly press a l Chronically affected patients demonstrates psychological
warm mirror against the uvula to observe the base of the dysfunction, usually depression, anxiety or irritability.
tongue and vallate papillae, note any ulcers or signifi- l The discomfortness reduces as the painful condition
cant swellings. reduces or disappears.
l Holding the tongue with the gauze, gently guide the
Treatment}
tongue to the right and retract the left cheek to observe
the foliate papillae and the entire lateral border of the (SE Q.3 and SN Q.8)
tongue for ulcers, keratotic areas and red patches.
l Repeat for the opposite side, and then have the patient
l {(Underlying local or systemic causes should be identi-
fied and eliminated.
touch the tip of the tongue to the palate to display the l Counselling and reassurance may be adequate manage-
ventral surface of the tongue and floor of the mouth. ment for individuals with mild burning sensations, but
Note any varicosities, tight frenal attachments, stones in patients with symptoms that are more severe often re-
Wharton ducts, ulcers, swellings and red or white quire drug therapy.
patches. Gently palpate the muscles of the tongue for l The drug therapies that have been found to be the most
nodules and tumours, extending the finger onto the base helpful are low doses of TCAs, such as amitriptyline and
of the tongue and pressing forward if this has been doxepin, or clonazepam (a benzodiazepine derivative).
poorly visualized or if any ulcers or masses are l Mood altering drugs such as chlordiazepoxide. Addi-
suspected. tional therapies used are clonazepam alpha lipoic acid,
l Note tongue thrust on swallowing.
amitriptyline, transcutaneous electric nerve stimulation,
analgesics, antibiotics, antifungals, vitamin B complex
[SE Q.3] and placebo-controlled trial.
l Burning of the tongue that results from parafunctional
{Burning mouth syndrome (glossodynia) oral habits may be relieved with the use of a splint cov-
l Burning mouth syndrome is a common dysaesthesia
ering the teeth and/or the palate.)}
(i.e. distortion of a sense) typically described by the
patient as a burning sensation of the oral mucosa in the Q.5. Describe briefly about benign migratory glossitis.
absence of any clinically apparent alterations.
Ans.
l The cause of BMS remains unknown, but a number of
factors have been suspected, including hormonal and [Same as LE Q.2]

SHORT ESSAYS: l Numerous fissures covers the entire dorsum surface and
divides the tongue papillae into multiple separate ‘islands’.
Q.1. Pernicious anaemia – tongue lesions. l Sometimes fissures can be seen located dorsolaterally
Ans. over tongue.

l It is usually asymptomatic, but some patients may have
[Ref LE Q.3] mild burning or soreness. This condition can be seen in
Q.2. Angular cheilitis. children or adults but it increases with age.
l Fissured tongue may be a component of Melkersson–
Ans. Rosenthal syndrome.
l Angular cheilitis is one of the clinical types of oral can- l Histopathologically, there is hyperplasia of rete ridges
didiasis. and loss of keratin on the surface of filiform papillae,

l Associated factors are idiopathic, immunosuppression, which are separated by deep grooves.
loss of vertical dimension, iron deficiency and vitamin
Treatment
B12 deficiency.
l Fissured tongue is a benign condition and no specific
l Infection with Candida albicans and in some cases with
treatment is indicated.
a mixture of other microorganisms such as Staphylococ-
l Patient should be encouraged to brush the tongue with
cus aureus seems to represent a major cause.
soft bristled toothbrush, because food or debris that may
l Angular cheilitis is usually a reddish ulcerative or
be entrapped in the grooves may act as an irritation.
proliferative condition marked by one or a number of
deep fissures spreading from the corners of the mouth. Q.5. Migratory glossitis.
l The lesions are most often bilateral, usually do not bleed,
Ans.
and are restricted to the vermilion and skin surface.
l Resolution is relatively easily obtained if angular l Geographic tongue is a psoriasiform mucositis of the
cheilitis is an isolated finding. dorsum of the tongue. It is also known as benign migra-
l If it is part of a generalized oral/systemic candidal in- tory glossitis.
fection, it may be very deep seated and resistant to l It is also known as erythema migrans, glossitis areata
eradication. These lesions usually persist even though migrans, glossitis areata exfoliativa, wandering rash of
the predisposing factors have been eliminated, unless the tongue and annulus migrans.
they are treated with an antifungal ointment such as
Aetiology
nystatin in conjunction with an S. aureus agent or met-
l Although the cause is unknown, emotional stress may
ronidazole.
be one of several factors involved in the onset or exac-
l The major priority of treatment must be directed to the
erbation of this lesion.
main reservoir of infection in the body.
l Its dominant characteristic is a constantly changing
Q.3. Glossopyrosis and glossodynia. pattern of serpiginous white lines surrounding areas
of smooth, depapillated mucosa.
Ans.
l The changing appearance with depapillated areas have
[Ref LE Q.4] reminded of continental outlines on globe, hence popu-
larly known as geographic tongue.
Q.4. Fissured tongue.
Clinical features
Ans.
l The lesions are usually asymptomatic and are discovered
l Fissured tongue has also been referred to as scrotal as an incidental finding during a routine examination.
tongue or lingua plicata. l The patient may complain of a burning sensation made
l Fissured tongue is a relatively common condition char- worse by spicy foods or citrus fruits.
acterized by the presence of numerous grooves, or fis- l MG occurs most commonly in young or middle-aged
sures, on the dorsal surface of the tongue. adults but has been seen in patients ranging in age from
l Cause is uncertain, but ageing and local environmental 5 to 84 years.
factors may contribute to the development of fissured l There is a reported predilection for female patients.
tongue. l The lesions are found more frequently on fissured
l Heredity, chronic trauma and vitamin deficiency have tongues.
been proposed as some more causes for this condition. l Lesions may be single or multiple. Frequently the
l Patient exhibits multiple grooves, or furrows, on the lesions are confined to the dorsal surface and lateral
surface of the tongue, ranging from 2 to 6 mm in borders of the tongue, but they may extend to the ventral
depth. surface.
l Initially, MG appears as irregular, circinate and nonin- Treatment

durated atrophic areas that gradually widen, change Antihistamine and sympathomimetic agents such as
shape and migrate over the tongue. adrenalin provide symptomatic relief and are sometimes
l An increased incidence of MG has been reported in ju- lifesaving.
venile diabetes and in those people with several regions Recurrent episodes are sometimes controlled by consis-
of cutaneous psoriasis. tent daily administration of antihistamines (e.g. 50–75 mg
Histologically diphenhydramine hydrochloride daily).
l Biopsy should be taken from a prominent serpiginous Q.7. Tuberculosis ulcers on the tongue.
lines at the periphery of a depapillated patch.
Ans.
l A thickened layer of keratin is infiltrated with neutro-
phils, these inflammatory cells often produces small l Tuberculosis is a specific infectious granulomatous dis-
microabscesses, called Monro abscesses, in keratin and ease caused by mycobacterium tuberculosis.
spinous layers. l Lesions of secondary tuberculosis may occur at any site
l Chronic inflammatory cells can be seen in variable on the oral mucous membrane, but tongue is the most
numbers within the stroma. commonly affected followed by palate, lips, buccal mu-
l Silver and PAS staining will demonstrate candida hy- cosa, gingiva and frenula.
phae or spores in the superficial layers of the epithelium. l Lesion presents as an irregular, superficial or deep,
Treatment painful ulcers that tend to increase slowly in size.

l It is frequently found in the area of trauma and may be
l No treatment is usually necessary for benign migratory
glossitis and stomatitis. mistaken as a simple traumatic ulcer or even carcinoma.

l Oral lesions of tuberculosis (TB) will present as painful,
l Symptomatic lesions can be treated with topical pred-
nisolone and a topical or systemic antifungal medica- ragged ulcers, mostly on the posterior aspect of the oral
tion can be tried if infected secondary with candidiasis. tongue, pharyngeal tongue or palate.
Q.6. Angioneurotic oedema. Differential diagnosis

l Oral TB will closely mimic squamous cell carcinoma
Ans. and also in addition, the cancers of primary syphilis and
l Angioneurotic oedema is one form of acute anaphylac- the oral lesions of pulmonary fungal diseases such as
tic reaction representing an immediate hypersensitivity histoplasmosis, coccidioidomycosis and blastomycosis,
response allied to urticaria, allergic rhinitis and asthma. all of which have a similar appearance.
l If there is a history of trauma, it is important to remem-
l The clinical response is well demarcated, localized oe-
dema involving the deeper layers of the skin and subcu- ber that trauma remains as the leading cause of oral ul-
taneous tissues. cers and should be included in the differential diagnosis.
l When this reaction is localized to the mucosa of the Histopathology
tongue, oropharynx and larynx, considerable swelling l Tuberculosis is a disease that epitomizes the formation
of the tongue, glottis and laryngeal structures occurs of so-called epithelioid granulomas.
with rapid occlusion of the airway. l The typical histology of tuberculosis then is effacement
l In milder forms of the disorder, crenation of the tongue of the normal architecture by numerous granulomas,
margins, a sensation of recurrent swelling of the tongue, which are often confluent.
and associated rhinitis and sinusitis may be the extent of l The granulomas consist of macrophages, epithelioid
the findings. cells and multinucleated giant cells with peripheral lym-
l It may also occur on a hereditary basis, when it is as- phocytes, plasma cells and fibroblasts. The centre of the
sociated with deficiency in the function of an inhibitor granuloma may show caseous necrosis. This is not usu-
of the first component of complement. ally seen in intraoral lesions but may be an important
l Both acute and chronic forms of the disorder exist, re- component in lymph node involvement and in the lung.
current episodes that become self-limited after 6 weeks
Treatment
are called acute while attacks persisting beyond this
l Oral TB lesions are treated with the same drug regimens
period are referred to as chronic.
used to treat pulmonary TB, except that treatment lasts
l A variety of antigenic stimuli may be involved: seasonal
for a duration of 9 months rather than 6 months because
respiratory allergens, animal danders, bacterial antigens,
the lesions are considered extrapulmonary foci.
foods such as shellfish, chocolate, nuts, various drugs
and occasionally cold and physical trauma to the tongue. Prognosis
l Other evidences of predisposition to the immediate type l A responding patient will have a reduction in pain as-
of hypersensitivity reactions may or may not be present. sociated with the oral lesion and evidence of healing.
Q.8. Mention the causes of macroglossia. Autoimmune disorders

l Sarcoidosis
Ans. l Giant cell arteritis
l Macroglossia is an abnormally enlarged tongue that Miscellaneous

protrudes beyond the teeth or alveolar ridge in the rest l Angioneurotic oedema.
position.
Q.9. Ankyloglossia.
It is of two types:
i. True macroglossia Ans.
ii. Pseudo macroglossia l Ankyloglossia is also known as tongue-tie.
Various causes of true macroglossia are as follows:
Aetiology
Congenital causes
l It is the result of a short, tight and thick, lingual frenu-
l Muscular hypertrophy
lum causing tethering of the tongue tip. According to
l Vascular malformations (haemangioma and lymphan-
A.H. Messner, the incidence of ankyloglossia ranged
gioma)
from 0.02% to 4.8% in newborns.
l Congenital hypothyroidism
l Down syndrome
Classification
l Trisomy 22 Based on anatomical appearance
l Beckwith–Wiedemann syndrome Type 1: Frenulum attaches to tip of tongue in front of
l Behmel syndrome alveolar ridge in low lip sulcus.
l Tollner syndrome Type 2: Attaches 2–4 mm behind tongue tip and attaches
l Laband syndrome on alveolar ridge.
l Mucopolysaccharidoses I and II Type 3: Attaches to mid-tongue and middle of floor of the
l Transient neonatal diabetes mellitus mouth, usually tighter and less elastic. The tip of the tongue
l Ganglioside storage disease type I may appear ‘heart-shaped’.
l Lipoid proteinosis Type 4: Attaches against base of tongue, is shiny, and is
Acquired causes very inelastic.
l Endocrinal disturbances
Hazelbaker assessment tool for lingual frenulum func-
l Acquired hypothyroidism
tion (1998 version)
l Acromegaly
l This assessment tool was designed to evaluate ankylo-
l Pituitary gigantism
glossia in infants.
l Myxoedema
l The assessment tool takes into consideration the ‘appear-
Infections ance’ and ‘function’ parameters.

l Tuberculosis
Appearance parameters
l Actinomycosis
Appearance of tongue when lifted:
Traumatic injuries
Score 2: Round or square
l Self-inflicted (self-harm, injury during epileptic
Score 1: Slight cleft in tip of tongue
seizure)
Score 0: Heart-shaped
l Presurgical (intubation)/surgical trauma/postsurgical
(anaesthesia/haemorrhage) Elasticity of frenulum:
Neoplasms Score 2: Very elastic (excellent elasticity)
l Lymphangioma Score 1: Moderately elastic
l Haemangioma Score 0: Minimal or no elasticity
l Carcinoma
Length of lingual frenulum when tongue lifted:
l Sarcoma
Score 2: More than 1 cm or embedded in tongue
l Solitary plasmacytoma
Score 1: 1 cm length
l Neurofibroma
Score 0: Less than 1 cm length
l Granular cell tumour
Nutritional and metabolic disorders Attachment of lingual frenulum to tongue:

l Amyloidosis Score 2: Posterior to tip of tongue
l Scurvy Score 1: At tip
l Pellagra Score 0: Notched tip of tongue
Attachment of lingual frenulum to inferior alveolar ridge: Class III (severe) 4–8 mm
Score 2: Attached to floor of mouth well below the ridge
Class IV (complete) 0–4 mm
Score 1: Attached just below ridge
Score 0: Attached at ridge below
Clinical significance
Functional parameters l Majority of the cases of ankyloglossia resolve spontane-
Lateral movement of tongue: ously or are asymptomatic.
Score 2: Complete lateral movement l It may cause feeding problems in infants as well as articu-
Score 1: Body of tongue but not tongue tip lation problems, gingival recession, open bite and abnor-
Score 0: None mal facial development.
Ability to lift the tongue: l In some children, tongue tie may also cause speech
Score 2: Tip to mid-mouth defects, especially articulation of the sounds such as

Score 1: Only edges to mid-mouth l, r, t, d, n, th, sh and z.
Score 0: Tip stays at alveolar ridge or rises to mid-mouth l Tongue tie may also contribute to dental problems
only with jaw closure such as causing a persistent gap between the mandibu-
lar incisors.
Extension of tongue: l Intraoral radiography may be difficult in some patients
Score 2: Tip over lower lip owing to the limited space available to position the film.
Score 1: Tip over lower gum only
Score 0: Neither of the above, or anterior or mid-tongue humps Treatment
l Frenectomy is recommended.
Spread of anterior tongue:
l Frenotomy and frenuloplasty also have been effective
Score 2: Complete
treatments for ankyloglossia.
Score 1: Moderate or partial
Score 0: Little or none Q.10. Black hairy tongue.
Cupping: Ans.
Score 2: Entire edge, firm cup l Black hairy tongue is also known as lingua nigra, lingua
Score 1: Side edges only, moderate cup villosa, lingua villosa nigra and hairy tongue.
Score 0: Poor or no cup l It is a commonly observed condition of defective filiform
Peristalsis: papillae that results from a variety of precipitating factors.

Score 2: Complete, anterior to posterior originating at the tip
This condition is most commonly referred to as black hairy
Score 1: Partial, originating posterior to tip
tongue, but hairy tongue may also appear as brown, white,
Score 0: None or reverse peristalsis
green, pink or variety of hues depending on the specific
Snapback: aetiology and secondary factors.
Score 2: None
Aetiology
Score 1: Periodic
l The hypertrophy of the filiform papillae on the dorsal
Score 0: Frequent or with each suck
surface of the tongue.
Interpretation of the score: l Poor oral hygiene.
Total score of 14: Perfect score (regardless of appearance l Other contributory factors are use of tobacco and coffee
parameter score) and tea drinking.
Total score or 11: Acceptable if appearance parameter score
Clinical features
is 10
l Most commonly seen in males and patients infected
Score less than 11: Function impaired
with HIV.
Frenotomy is necessary if appearance parameter score
l As its name implies, black hairy tongue will present as
is less than 8.
a black area, along with some small red and white areas,
Classification of ankyloglossia based on distance of the on the dorsum of the tongue.
insertion of the lingual frenum to the tip of the tongue l Black hairy tongue actually represents a superficial bac-
This classification was suggested by Kotlow (2004). terial infection of the tongue by pigment-producing
microorganisms often called chromogenic bacteria. It is
Normal 16 mm therefore a type of glossitis that may exist in isolation or
as part of a pharyngitis or tonsillitis.
Class I (mild) 12–16 mm
l Rarely symptomatic, when secondarily infected with C.
Class II (moderate) 8–12 mm albicans, the patient may complain of pain or a burning
sensation on the tongue and also of pain on swallowing Q.13. Geographic tongue.
or a generalized pharyngitis.
Ans.
l Normal filiform papillae are approximately 1 mm in
length but in hairy tongue, it becomes more than 15 mm [Same as SE Q.5]
in length.
l In addition to the elongated filiform papillae and the
colonies of microorganisms formed upon an inflamed SHORT NOTES:
base, which gives rise to the hairy appearance of the Q.1. Benign migratory glossitis.
tongue, there may be a submandibular or cervical
lymphadenopathy. Ans.
l Patient complains of tickling sensation in the soft palate l Benign migratory glossitis or geographic tongue is a
and oro-pharynx during swallowing. psoriasiform mucositis of the dorsum of the tongue.
l In more severe cases, patient may actually complain of l It is also known as erythema migrans, glossitis areata
gagging sensation. migrans, glossitis areata exfoliativa, wandering rash of
l Retention of oral debris between the elongated papillae the tongue and annulus migrans.
may result in halitosis. l Aetiology is usually unknown.
l The tongue has a thick coating in the middle, with great
accentuation towards the back. Clinical features
l The lesions are usually asymptomatic.
l Rarely patient may give history of altered taste
l The patient may complain of a burning sensation made
sensation.
worse by spicy foods or citrus fruits.
Differential diagnosis l It occurs most commonly in young or middle-aged
l Candidiasis, leukoplakia, oral lichen planus and hairy adults.
leukoplakia. l Lesions may be single or multiple. Frequently the
lesions are confined to the dorsal surface and lateral

Treatment borders of the tongue.
The treatment is variable. l Initially, MG appears as irregular, circinate and nonin-
l Removing of the aetiologic factors. durated atrophic areas that gradually widen, change
l Black hairy tongue is treated with oral antibiotics for shape and migrate over the tongue.
10–14 days and physical tongue brushing. The antibi- l Histologically a thickened layer of keratin is infiltrated
otic of choice remains phenoxymethyl penicillin 500 with neutrophils, these inflammatory cells often pro-
mg four times per day. In the penicillin-allergic patient, duces small microabscesses, called Monro abscesses, in
erythromycin ethyl succinate (EES, Abbott), 400 mg keratin and spinous layers.
three times per day, is effective. l No treatment is usually necessary for benign migratory
l The tongue brushing can be accomplished with tooth- glossitis and stomatitis.
paste or with 0.12% chlorhexidine (Peridex) or with the
bare brush alone. Q.2. Treatment of atrophic glossitis.
l Brushing the tongue with brushes or the commercially
Ans.
available tongue scrapers is sufficient to remove elon-
gated filiform papillae and retard the growth. l Atropic glossitis is seen in iron deficiency anaemia.
l Surgical removal of the papillae by using electrodesic- l It is diffuse or patchy atrophy of papillae on the dorsal
cation, carbon dioxide laser or even scissor is the treat- surface of the tongue.
ment of the last resort. l This is often accompanied by tenderness or burning
l Prognosis is excellent. sensation.
l Treatment: dietary iron supplementations by means of
Q.11. Glossitis.
oral ferrous sulphate.
Ans. l Patient with malabsorption problems, parental iron may
be given periodically.
[Same as SE Q.1]
l The underlying causes of anaemia should be identified
Q.12. Burning mouth syndrome. and eliminated.
Ans. Q.3. Mention the causes of ‘bald tongue’.

l If the tongue is completely bald, the only other condi- patient as a burning sensation of the oral mucosa in the
tion that needs to be considered is xerostomia. absence of any clinically apparent alterations.
If the tongue shows partial or patchy baldness, the l Burning mouth syndrome affects postmenopausal
following conditions should be considered: women.
l Migratory glossitis l Mean age is 40 years and it has typical abrupt onset,
l Psoriasis although may be gradual.
l Reiter syndrome l Contact with hot food or liquid often intensifies the
l Pityriasis rubra pilaris symptoms.
l Changes caused by the use of mouthrinse l Chronically affected patients demonstrates psychological
l Atrophic lichen planus dysfunction, usually depression, anxiety or irritability.
l Median rhomboid glossitis
Treatment
Q.4. Aetiology of angular cheilitis. l Underlying local or systemic causes should be identi-
fied and eliminated.

Ans. l Some relief from symptoms is also usually obtained
Aetiologic factors of angular cheilitis are as follows: from the use of topical analgesics.
l Idiopathic Q.7. Dysgeusia.
l Nutritional deficiency
l Denture irritation Ans.
l Infections like C. albicans l Disordered taste (dysgeusia) constitutes the bulk of
chronic oral sensory abnormalities for which patients
Q.5. Hairy tongue.
overtly seek medical and dental care.
Ans. l Loss of olfactory stimulation by way of the first cranial
nerve (as often occurs with a cold or other nasal ob-

l Hairy tongue is also known as lingua nigra, lingua struction preventing access of volatile components of
villosa, lingua villosa nigra and hairy tongue. food to the olfactory receptors in the upper part of the
Aetiology nasal cavity) alters the ‘taste of food’ greatly because
l Irritation to filiform papillae caused by smoking, alco- oral chemoreception then becomes the main sensation
hol, hydrogen peroxide and antacids associated with eating.
l Damage to the maxillary branch of the trigeminal nerve
Clinical features may also produce diminished taste sensation in the
l Brownish to black appearance on the dorsal surface of
same way, since nonspecific stimulation of receptors of
the tongue the 5th nerve throughout the nasal mucosa, by heat and
Histologic characteristics pungent volatile components, also contributes to the
l Elongation of filiform papillae; characteristic inflamma- ‘taste of food’.
tory cells l Evaluation of dysgeusia, therefore, must always include
an examination of cranial nerves I and V, as well as VII
Treatment/prognosis and IX nerve functions.
l Brushing or scraping of the tongue
Q.8. Management of a patient suffering from gloss-
Prognosis odynia.
l Good and totally reversible
Ans.
Q.6. Glossopyrosis.
[Ref LE Q.4]
Ans.
Q.9. Ankyloglossia.
l Glossopyrosis is a burning tongue whereas glossodynia
Ans.
is a painful tongue.
l Dorsum of tongue develops a burning sensation, usually l Ankyloglossia is also known as tongue-tie.
in the anterior third of the tongue. Mucosal changes are l It occurs due to the attachment of inferior frenulum to
seldom visible. Other oral sites affected are hard palate the bottom of the tongue, which subsequently restricts
and the lips. the free movement of the tongue.
l Burning mouth syndrome is a common dysaesthesia l Ankyloglossia occurs in approximately in 1.7% of all
(i.e. distortion of a sense) typically described by the neonates.

l Tongue tie can cause feeding problems in infants. Q.10. Differential diagnosis of bald tongue.
l In some children may also cause speech defects, espe-
Ans.
cially articulation of the sounds such as l, r, t, d, n, th, sh
and z. [Same as SN Q.3]
l Tongue tie may also contribute to dental problems
Q.11. Bald tongue.
such as causing a persistent gap between the mandibu-
lar incisors. Ans.
l Frenulectomy is the recommended treatment.
[Same as SN Q.3]
Topic 7
Salivary Glands Diseases

LONG ESSAYS:
1. Enumerate the causes for xerostomia. Describe the clinical features, investigations and management of Sjögren
syndrome.
2. Describe in detail sialography and its significance in various diseases of salivary glands.
3. Clinical features, differential diagnosis and management of functional disturbance of salivary glands.
4. Name the various diseases of salivary glands. Discuss clinical features, diagnosis, differential diagnosis and
treatment of parotitis.
5. Classify salivary gland diseases. Describe the various causes, clinical features and the management of
sialadenitis.
6. Classify functional disorders of the salivary glands. Describe the aetiology, clinical features, diagnosis and
management of Sjögren syndrome. [Same as LE Q.1]
7. Describe sialography in detail and write briefly on its significance in various salivary gland disorders.
[Same as LE Q.2]
8. Describe the procedure for sialography of parotid gland. [Same as LE Q.2]
9. Describe the indications and contraindications of sialography. Describe the technique briefly. [Same as LE Q.2]
10. Enumerate the clinical and radiological features of functional disturbances of salivary glands. [Same as LE Q.3]
SHORT ESSAYS:
1. Liths in orofacial region.
2. Indications of sialography. [Ref LE Q.2]
3. Treatment of xerostomia. [Ref LE Q.3]
4. Clinical features and investigations of submandibular sialolithiasis.
5. Bacterial sialadinitis. [Ref LE Q.5]
6. Sialadenosis.
7. Sjögren syndrome.
8. Pleomorphic adenoma.
9. Parotitis. [Ref LE Q.4]
10. Sialolithiasis. [Same as SE Q.1]
11. Indications and contraindications of sialography. [Same as SE Q.2]
SHORT NOTES:
1. Mucocele.
2. Mumps.
3. Xerostomia.
4. Schirmer test.
5. Treatment of ptyalism.
6. Sialolithiasis.
7. Sialography.
8. Sialometaplasia.
9. Sjögren syndrome. [Ref LE Q.1]
10. What are the functions of saliva?
11. Sialosis.
12. Ptyalism.
13. Ranula.
14. Why sialolithiasis is more common in submandibular gland?
15. Necrotizing sialometaplasia. [Same as SN Q.8]
16. Sialadenosis. [Same as SN Q.11]
17. Sialorrhoea. [Ref LE Q.3]
SOLVED ANSWERS
LONG ESSAYS: {SN Q.9}

Q.1. Enumerate the causes for xerostomia. Describe the Sjögren syndrome
clinical features, investigations and management of l Sjögren syndrome is a chronic inflammatory dis-
Sjögren syndrome. ease that affects salivary, lacrimal and other exo-
Ans. crine glands.
Or
Xerostomia is defined as dryness of mouth, which is a l Sjögren syndrome is the expression of an autoim-
clinical manifestation of salivary gland dysfunction. mune process that results principally in dry eyes
Causes of xerostomia are as follows: (keratoconjunctivitis sicca) and dry mouth (xerosto-
mia) owing to lymphocyte-mediated destruction of
Autoimmune or Other
lacrimal and salivary gland parenchyma.
Medications systemic diseases conditions
l Analgesics l Sjögren syn- l Local radia- Types
l Opioids drome tion therapy l Primary Sjögren syndrome (sicca complex): only dry
l Anticholinergic l Primary l Type 1 or eyes and dry mouth.
drugs l Secondary 2 diabetes l Secondary Sjögren syndrome: primary Sjögren 1
l Antihistamines l Primary biliary l Radioactive
l Antidepressants cirrhosis iodine
systemic lupus erythematosus, polyarteritis nodosa,
l Selective sero- l Wegener’s treatment polymyositis, scleroderma or rheumatoid arthritis.
tonin reuptake granulomatosis l Human
inhibitors (SSRIs) l Sarcoidosis immunodefi-
l Tricyclic and l Scleroderma ciency virus Aetiology
heterocyclic an- (HIV)/ l The specific cause of this syndrome is unknown, numer-
tidepressants acquired ous immunologic alterations indicate a disease of great
l Atypical antide- immunodefi-
complexity.
pressants ciency
l This syndrome appears to be of autoimmune origin that
l Antihypertensive syndrome
agents (AIDS) may be limited to exocrine glands, or it may extend to
l Diuretics l Anxiety/ include systemic connective tissue disorders.
l Muscle relaxants depression l Viruses, particularly retroviruses and Epstein–Barr
l Sedatives/
virus, have been implicated in the aetiology of Sjögren
anxiolytics
syndrome, but none are proven causes.
Clinical features precipitating antinuclear antibodies such as anti-Sjögren

l Sjögren syndrome occurs in all ethnic and racial groups. syndrome-A (SS-A) and anti-Sjögren syndrome-B
The peak age of onset is 50 years, and 90% of cases (SS-B) in association with both primary and secondary
occur in women. Sjögren syndrome.
l Typical features are dryness of mouth and eyes as a re- l Patients who have SS-B antibodies are more likely to
sult of hypofunction of the salivary glands and lacrimal develop extra-glandular disease.
glands. l HLA-DR4 antigen is often identified in patients with
l Painful, burning sensation of the oral mucosa. secondary Sjögren syndrome; antigens found in patients
l Other secretory glands involved in dryness are of the with the primary form are often HLA-B8 and HIA-DR3
nose, larynx, pharynx, tracheobronchial tree and the types.
vagina.
Histological features
l The chief oral complaint in Sjögren syndrome is xero-
l Three types of histological patterns are seen in the
stomia, which may be the source of eating and speaking
major salivary glands:
difficulties.
a. Intense lymphocytic infiltration of the gland replac-
l These patients are also at greater risk for dental caries,
ing all the acinar structures.
periodontal disease and oral candidiasis because of dry
b. Proliferation of the ductal epithelium and myoepi-
mouth.
thelium to form ‘epimyoepithelial islands’.
l Parotid gland enlargement, which is often recurrent and
c. Atrophy of the glands following the lymphocytic
symmetric, occurs in approximately 50% of patients.
infiltration.
l A significant percentage of these patients also present
l Similar changes were seen in the accessory salivary
with complaints of arthralgia, myalgia and fatigue.
glands in the lips.
l There is an increased risk of lymphoreticular malig-
nancy developing in the primary form, the relative risk Treatment

is estimated to be approximately 44 times that in the l Sjögren syndrome and the complication of the sicca
general population. An interesting associated sign is a component are best managed symptomatically.
decrease in serum immunoglobulin levels accompany- l Artificial saliva and artificial tears are available for this
ing or preceding the malignant change. purpose.

l In the sicca complex, there is parotid gland enlargement l Preventive oral measures are extremely important relative
that is usually absent in secondary Sjögren syndrome. to xerostomia. Scrupulous oral hygiene, dietary modifica-
tion, topical fluoride therapy and remineralizing solutions
Investigations are important in maintaining oral and dental tissues.
l The salivary component of Sjögren syndrome may be l Use of sialogogues, such as pilocarpine and cevimeline,
assessed by sialochemical studies, nuclear imaging of remains of limited value, especially in long-standing
the glands (scintigraphy), contrast sialography, flow rate Sjögren syndrome.
analysis and a minor salivary gland biopsy.
Prognosis
l Sialochemistry studies have shown increased levels of
l The prognosis of Sjögren syndrome is complicated by
IgA, potassium and sodium in the saliva.
an association with malignant transformation to lym-
l The most commonly used and most reliable method of
phoma. This may occur in approximately 6%–7% of
assessing salivary alteration in this syndrome currently
cases, it is more common in those with only the sicca
is a labial salivary gland biopsy.
component of the syndrome.
l Nuclear medicine techniques using a technetium
pertechnetate isotope and subsequent scintiscanning can Q.2. Describe in detail sialography and its significance
yield functional information relative to the uptake of the in various diseases of salivary glands.
isotope by salivary gland tissue. Ans.
l Contrast sialography aids in detecting filling defects
within the gland being examined.

[SE Q.2]
l A punctate sialectasia is characteristic in individuals
with Sjögren syndrome. This finding reflects significant l {Sialography is a technique in which ducts and ductules
ductal and acinar damage. of the salivary glands are demonstrated radiographically
l Other laboratory findings commonly found in primary after a radiopaque liquid has been injected along them.
and secondary Sjögren syndrome include mild anaemia, l First performed in 1902, sialography is a radiographic
leukopenia, eosinophilia, an elevated ESR and diffuse technique wherein a radiopaque contrast agent is in-
elevation of serum immunoglobulin levels. fused into the ductal system of a salivary gland before
l In addition, numerous autoantibodies may be found, imaging with plain films, fluoroscopy, panoramic radi-
including rheumatoid factor, antinuclear antibodies and ography, conventional tomography or CT.
l Sialography remains the most detailed way to image the Q.3. Clinical features, differential diagnosis and man-
ductal system. The parotid and submandibular glands agement of functional disturbance of salivary glands.
are more readily studied with this technique.
Ans.
Indications The two types of functional disorders of salivary glands
l To demonstrate – calculi, strictures, recurrent paroti- are as follows:
tis, tumours, etc. a. Sialorrhoea
l Salivary fistula. b. Xerostomia
l Relationship of salivary glands and ducts to sur-
rounding structures.
l Autoimmune or radiation-induced sialadenitis. {SN Q.18}
Contraindications
Sialorrhoea
l Active or recent infection of the gland.
l Sialorrhoea describes increased salivary flow.
l Allergy to contrast media.}
Causes
Technique
l Painful lesions or foreign bodies in the mouth.
l A surveyor ‘scout’ film is usually made before the in-
l Drugs, e.g. anticholinesterases, insecticides
fusion of the contrast solution into the ductal system
and nerve agents; antipsychotics and cholin-
as an aid in verifying the optimal exposure factors and
ergic agonists used to treat dementia and
patient positioning parameters and for detecting radi-
myasthenia gravis).
opaque sialoliths or extra glandular pathosis.
l Toxins (e.g. mercury and thallium); and rarely
l A lacrimal or periodontal probe is used to dilate the
other causes, e.g. rabies may be implicated.
sphincter at the ductal orifice before the passage of a
l Sialorrhoea is an uncommon subjective com-
cannula (blunt needle or catheter) connected by ex-
plaint but objective evidence is even less com-
tension tubing to a syringe containing contrast agent.
mon, and the problem is sometimes perceived
l Lipid-soluble (e.g. ethiodol) or nonlipid-soluble
rather than real.
(e.g. Sinografin) contrast solution is then slowly in-
l Drooling is the overflowing of saliva from the
fused until the patient feels discomfort (usually be-
mouth not usually associated with increased
tween 0.2 and 1.5 mL, depending on the gland being
saliva production.
studied).
l Drooling is normal in healthy infants, but usu-
l These iodine-containing agents render the ductal
ally stops by about 18 months and is consid-
system radiopaque.
ered abnormal if it persists beyond the age of
l The filling phase can be monitored by fluoroscopy or
4 years.
with static films.
l Saliva soils clothing and patients may have
l The intention is to opacify the ductal system all the way
perioral skin breakdown and infections, dis-
to the acini. The image of the ductal system appears as
turbed speech and eating and can occasionally
‘tree limbs’, with no area of the gland devoid of ducts.
develop aspiration related and pulmonary com-
l With acinar filling, the ‘tree’ comes into ‘bloom’,
plications.
which is the typical appearance of the parenchymal
opacification phase.
l The gland is allowed to empty for 5 min without Diagnosis
stimulation. l Absolute quantification of saliva spill or intraoral
l If postevacuation images suggest contrast retention, pooling by volumetric measurement can help guide
a sialogogue such as lemon juice or 2% citric acid treatment. A subjective estimate can be made by
may be administered to augment evacuation by stim- counting the bibs or items of clothing soiled each day.
ulating secretion.
l Nonlipid-soluble contrast agents are preferred because {SN Q.18}
of reports of inflammatory reactions subsequent to
inadvertent extravasation of lipid-soluble agents. Management
l Management options range from conservative
[SE Q.2] therapy to medication, radiation or surgery, and

often a combination is needed.
{Advantage l Pharmacological treatment (anticholinergic drugs,
l Visualizes ductal anatomy/blockage.
e.g. atropinics such as hyoscine or ipratropium or
Disadvantage
adrenergic stimulators, e.g. clonidine) decreases
l Invasive; requires iodine-containing dye; no quantifi-
salivation.
cation.}
factors are considered, along with analysis of all pre-

l Botulinum toxin serotype A injections may have a
scription and over-the-counter medications and diet.
positive outcome.
l Direct interventional strategies include the use of
l Persistent drooling is managed by redirecting the
topical agents such as oral polymer-based sprays, so-
submandibular duct flow to the back of the mouth;
called saliva substitutes, sipping of small amounts of
or duct ligation (mainly parotid) or gland removal
water during the day.
or neurectomy
Palliation
l Gustatory salivary stimulation
Xerostomia l Drug modification when possible
l Xerostomia means dryness of mouth. l Elimination of caffeine-containing products
Causes l Chewing of sugarless candies and sugar-free gum
l Various drugs capable of causing xerostomia are as l Moist sugar-free or complex carbohydrate foods
follows: l Elimination of alcohol-containing mouth rinses
i. Analgesics l Scrupulous oral hygiene
ii. Opioids l Topical fluoride application
iii. Anticholinergic drugs l Careful dental follow-up are required to help prevent
iv. Antihistamines or control dental caries
v. Antidepressants l Oral lubricants, e.g. carboxymethylcellulose- or hy-
vi. Selective serotonin reuptake inhibitors (SSRIs) droxymethyl cellulose-based products
vii. Tricyclic and heterocyclic antidepressants l In some cases, prescription strategies include cholin-
viii. Atypical antidepressants ergic agonists like pilocarpine and cevimeline may
ix. Antihypertensive agents be helpful, as may the use of acupuncture}
l Diuretics
Q.4. Name the various diseases of salivary glands. Dis-
l Muscle relaxants
cuss clinical features, diagnosis, differential diagnosis
l Sedatives/anxiolytics
and treatment of parotitis.
l Autoimmune or systemic diseases:
l Sjögren syndrome: both primary and secondary Ans.

l Primary biliary cirrhosis Diseases of salivary glands
l Wegener’s granulomatosis Reactive lesions
l Sarcoidosis l Mucus extravasation phenomenon
l Scleroderma l Mucus retention cyst (obstructive sialadenitis)
l Other conditions: l Maxillary sinus retention cyst/pseudocyst
l Local radiation therapy l Necrotizing sialometaplasia
l Diabetes: both type 1 and 2 l Adenomatoid hyperplasia
l Radioactive iodine treatment Infectious sialadenitis
l Human immunodeficiency virus (HIV)/acquired l Mumps
immunodeficiency syndrome (AIDS) l Cytomegaloviral sialadenitis
l Anxiety/depression l Bacterial sialadenitis
Clinical features l Sarcoidosis
l Increased thirst and hence increased uptake of fluids Metabolic conditions
especially l Sjögren syndrome
l Burning and tingling sensation in the mouth l Salivary lymphoepithelial lesion
l Difficulty in swallowing l Scleroderma
l Painful salivary gland enlargement l Xerostomia
l Swelling of salivary glands l Taste disturbances
l Increased incidence of dental caries l Halitosis
l Angular cheilitis Benign neoplasms
l Oral infections l Mixed tumour (pleomorphic adenoma)
l Basal cell adenoma

[SE Q.3]
l Canalicular adenoma
{Management l Myoepithelioma
Management of the patient with xerostomia is gener-
l l Oncocytic tumours
ally directed towards palliation and requires a careful l Sebaceous adenoma
multifactorial approach, wherein local and systemic l Ductal papilloma

Malignant neoplasms Prognosis

l Mucoepidermoid carcinoma l Often remits around puberty.}
l Polymorphous low-grade adenocarcinoma

Q.5. Classify salivary gland diseases. Describe the vari-
l Adenoid cystic carcinoma
ous causes, clinical features and the management of
l Clear cell carcinoma
sialadenitis.
l Acinic cell carcinoma
l Adenocarcinoma not otherwise specified Ans.

Rare tumour
l Carcinoma ex-mixed tumour [SE Q.5]
l Metastasizing mixed tumour
l Epimyoepithelial carcinoma
{Aetiology and pathogenesis
l Salivary duct carcinoma
l Bacterial infections of salivary glands generally are
l Basal cell adenocarcinoma
due to microbial overgrowth in association with a
l Squamous cell carcinoma
reduction in salivary flow.
l Submandibular gland sialadenitis is far less com-
mon than its parotid counterpart, in part because of

[SE Q.10] the stated higher degree of bactericidal quality and
{Parotitis the greater viscosity of submandibular saliva versus
l Bacterial parotitis occurs both in a childhood form the serous and lower viscosity quality of parotid
and in an adult form; in either form, the gland fluid.
l Other possible causes include trauma to the duct
becomes swollen and painful.
l Repeated parotitis and sialectasis in a child, associ-
system and hematogenous spread of infection from
ated with a sialographic pattern of sialectasis. other areas.
l Traditionally, bacterial sialadenitis has been a com-
l Prevalence (approximate): uncommon.
l Age mainly affected: Usually begins in preschool

mon postoperative complication of surgery related to
children. inadequate hydration.}
l The most commonly isolated organisms in parotitis
l Gender mainly affected: Male.
l Aetiopathogenesis: Congenital or autoimmune duct

are penicillin-resistant Staphylococcus aureus, Strep-
defects. tococcus viridans, Streptococcus pneumoniae, Esch-
erichia coli and Haemophilus influenzae.
Clinical features and diagnostic features l Anaerobic organisms may be cultured from acute
Oral signs cases and include Porphyromonas gingivalis.
l Little pain l It is of interest to note the marked reduction in the
l Parotid swelling overall incidence of acute parotitis after antibiotic
l Intermittent, unilateral parotid swelling which lasts preparations are introduced. As resistant strains of
,3 weeks with spontaneous regression bacteria have appeared, the prevalence of acute par-
l It may occur simultaneously or alternately contralaterally otitis has increased.
Extraoral signs
l Occasional fever [SE Q.5]
l Sjögren syndrome
{Clinical features
Clinical features of acute parotitis are as follows:
Diagnosis
l The sudden onset of painful lateral facial swell-
l It is mainly based on clinical grounds but serum anti-
ing, low-grade fever, malaise and headache.
SS-A and SS-B antibodies are indicated to exclude
l Laboratory studies disclose an elevated erythro-
Sjögren syndrome.
cyte sedimentation rate (ESR) and leukocytosis,
l Imaging with ultrasonography and CT scan or sialogra-
often with a characteristic shift to the left, where
phy showing sialectasis is confirmatory.
neutrophil counts are elevated, indicating acute
Management infection.
l Medical: Episodes are managed with sialogogues, glan- l The involved gland is extremely tender, and the
dular massage and duct probing to promote ductal patient often demonstrates guarding during exami-
lavage. nation.
l No specific treatment is available. l Trismus is often noted, and purulence at the duct
l Antibiotics and corticosteroids are limited in value. orifice may be produced by gentle pressure on the
l Surgery is unnecessary. involved gland or duct.
If the infection is not eliminated early, suppura-

l Q.10. Enumerate the clinical and radiological features
tion may extend beyond the limiting capsule of of functional disturbances of salivary glands.
the parotid gland.
Ans.
l Extension into surrounding tissues along fascial
planes in the neck or extension posteriorly into [Same as LE Q.3]

the external auditory canal may follow.
Treatment and prognosis
Management of bacterial sialadenitis is as follows: SHORT ESSAYS:
l Elimination of the causative organism combined
Q.1. Liths in orofacial region.
with rehydration of the patient and drainage of
purulence, if present. Ans.
l Culture and sensitivity testing of the exudate at
l Sialoliths are calcified organic matter that forms within
the orifice of the duct is the first step in antibiotic the secretory system of the major salivary glands.
management. l The round, ovoid calcified structure present in the sali-
l After a culture is obtained, all patients should
vary duct or gland is called a ‘sialolith’.
empirically be placed on a regimen of a penicil- l It is formed by the deposition of calcium salts around a
linase-resistant antibiotic such as semisynthetic
central nidus.
penicillin.
l Along with rehydration and attempts at establish- Aetiology
ing and encouraging salivary flow, moist warm l Still unknown, yet several factors that cause pooling of
compresses, analgesics and rest are in order. saliva within the duct are known to contribute to stone
l Medications containing parasympathomimetic formation:
agents, which reduce salivary flow, should be re- l Inflammation
duced or eliminated. l Irregularities in the duct system
l In cases of chronic recurrent parotitis with consid- l Local irritants
erable destructive glandular changes, painful recur- l Anticholinergic medications
rent enlargement and xerostomia, sialadenectomy, l Fifty per cent of parotid gland sialoliths and 20% of
particularly in cases of submandibular gland in- submandibular gland sialoliths are poorly calcified. This
volvement may be considered, although duct liga- is clinically significant as these sialoliths will not be
tion and parotidectomy remain treatment options.} detected radiographically.
Location
Q.6. Classify functional disorders of the salivary glands. l They are by far most common in the submandibular
Describe the aetiology, clinical features, diagnosis and glands (80%–90%), followed by the parotid (5%–15%)
management of Sjögren syndrome. and then sublingual (2%–5%) glands.
Ans. l The higher rate of sialoliths formation in the subman-
dibular gland is due to:

[Same as LE Q.1] i. The torturous course of Wharton duct
Q.7. Describe sialography in detail and write briefly on ii. Higher calcium and phosphate levels
its significance in various salivary gland disorders. iii. The dependent position of the submandibular
glands, which leaves them prone to stasis
Ans.
Clinical features
[Same as LE Q.2] l Common in adults.
l Swelling and pain which is related to meal time.
Q.8. Describe the procedure for sialography of parotid
l Stones may be palpable.
gland.
l Occurs more frequently in submandibular duct and glands.
Ans. l The degree of symptoms is dependent on the extent of
salivary duct obstruction and the presence of secondary

[Same as LE Q.2]
infection.
Q.9. Describe the indications and contraindications of l The stone totally or partially blocks the flow of saliva,
sialography. Describe the technique briefly. causing salivary pooling within the gland ductal system.
l Salivary glands with obstructive sialoliths are frequently
Ans.
enlarged and tender. Stasis of the saliva may lead to in-
[Same as LE Q.2] fection, fibrosis and gland atrophy.
l Fistulae, a sinus tract or ulceration may occur over the l The degree of symptoms is dependent on the extent of
stone in chronic cases. salivary duct obstruction and the presence of secondary
l An examination of the soft tissue surrounding the duct infection.
may show oedema and inflammation. l Typically, eating will initiate the salivary gland swelling.
l Bidigital palpation along the pathway of the duct may l The stone totally or partially blocks the flow of sa-
confirm the presence of a stone. liva, causing salivary pooling within the gland ductal
l Supportive or nonsupportive retrograde bacterial infections system.
can occur, particularly when the obstruction is chronic. l Salivary glands with obstructive sialoliths are frequently
l Other complications from sialoliths include acute enlarged and tender. Stasis of the saliva may lead to in-
sialadenitis, ductal stricture and ductal dilatation. fection, fibrosis and gland atrophy.
l Fistulae, a sinus tract or ulceration may occur over the
Diagnosis
stone in chronic cases.
l Radiographs are helpful to visualize sialoliths; however,
l An examination of the soft tissue surrounding the duct
poorly calcified stones may not be readily identifiable.
may show oedema and inflammation.
l An occlusal radiograph is recommended for subman-
l Bidigital palpation along the pathway of the duct may
dibular glands.
confirm the presence of a stone.
l Stones in the parotid gland can be more difficult to visu-
l Complications from sialoliths include acute sialadenitis,
alize due to the superimposition of other anatomic struc-
ductal stricture and ductal dilatation.
tures. An AP view of the face is useful for visualization
l Supportive or nonsupportive retrograde bacterial infec-
of a parotid stone.
tions can occur, particularly when the obstruction is
l CT images maybe used for the detection of sialoliths
chronic.
and have a 10-fold greater sensitivity of plain-film radi-
ography for detecting calcifications. Treatment
l During the acute phase, therapy is primarily supportive.
Treatment
l During the acute phase, therapy is primarily supportive.
Standard care includes analgesics, hydration, antibiotics
l Standard care includes analgesics, hydration, antibiotics
and antipyretics, as necessary.
l In pronounced exacerbations, surgical intervention for
and antipyretics, as necessary.
l In pronounced exacerbations, surgical intervention for
drainage or removal of the stone may be required.
l Stones at or near the orifice of the duct can often be re-
drainage or removal of the stone maybe required.
l Stones at or near the orifice of the duct can often be
moved transorally by milking the gland, but deeper
removed transorally by milking the gland, but deeper stones require removal with surgery or sialoendoscopy.
l Lithotripsy and sialoendoscopy can be helpful as nonin-
stones require removal with surgery or sialoendoscopy.
l Lithotripsy and sialoendoscopy can be helpful as nonin-
vasive or minimally invasive treatments for sialoliths.
l Ultrasonography will detect stones with diameter .2 mm
vasive or minimally invasive treatments for sialoliths.
l Ultrasonography will detect stones (diameter .2 mm)
and extra corporeal lithotripsy will fragment the stone,
and extracorporeal lithotripsy will fragment the stone, although repeat lithotripsy procedures may be needed.
although repeat lithotripsy procedures may be needed. Q.5. Bacterial sialadinitis.
Q.2. Indications of sialography. Ans.
Ans.
[Ref LE Q.5]
[Ref LE Q.2]
Q.6. Sialadenosis.
Q.3. Treatment of xerostomia.
Ans.
Ans.
l Sialadenosis is characterized by neoplastic noninflam-
[Ref LE Q.3] matory enlargement of the salivary gland.
Q.4. Clinical features and investigations of submandibu- l Enlargement is usually bilateral.
lar sialolithiasis. l May present as a course of recurrent painless enlarge-
ment of gland.
Ans. l The parotid gland is more frequently affected and more
Clinical presentation commonly affects the females.

l Patients with sialoliths most commonly present with a l Swelling of the preauricular portion of the parotid gland
history of acute, painful and intermittent swelling of the is the most common symptom, but retromandibular por-
submandibular salivary gland. tion of the gland may also be affected.
l The condition is found in association with systemic Clinical presentation

diseases especially cirrhosis, diabetes, ovarian and thy- l Pleomorphic adenomas may occur at any age, but the
roid insufficiency, alcoholism and malnutrition. highest incidence is in the fourth to sixth decades of life.
l A characteristic alteration in the chemical constituents l These tumours appear as painless, firm and mobile
of saliva is a distinguishing feature of sialosis. Signifi- masses that rarely ulcerate the overlying skin or mucosa.
cant elevation of salivary potassium and concomitant l In the parotid gland, these neoplasms are slow growing
decrease in salivary sodium is observed. and usually occur in the posterior inferior aspect of the
superficial lobe.
Q.7. Sjögren syndrome. l In the submandibular glands, they present as well-
Ans. defined palpable masses.

l It is difficult to distinguish these tumours from malig-
l Sjögren syndrome is characterized by a triad of symp- nant neoplasms and indurated lymph nodes.
toms consisting of keratoconjunctivitis sicca, xerosto- l Intraorally, pleomorphic adenomas most often occur
mia and rheumatoid arthritis. on the palate, followed by the upper lip and buccal
l Primary Sjögren syndrome (sicca complex) – only dry
mucosa.
eyes and dry mouth. l Pleomorphic adenomas can vary in size, depending on
l Secondary Sjögren syndrome – primary Sjögren 1 sys-
the gland in which they are located.
temic lupus erythematosus, polyarteritis nodosa, poly- l When observed in situ, the tumours are encased in a
myositis, scleroderma or rheumatoid arthritis pseudocapsule and exhibit a lobulated appearance.
Clinical features Pathology
l Female predilection and age of occurrence is over l The gross appearance of pleomorphic adenoma is that
40 years. of a firm smooth mass within a pseudocapsule. The
l Typical features are dryness of mouth and eyes as a re- lesion demonstrates both epithelial and mesenchymal
sult of hypofunction of the salivary glands and lacrimal elements.
glands. l The epithelial cells make up a trabecular pattern that is
l Painful, burning sensation of the oral mucosa. contained within a stroma. The stroma may be chondroid,
l Other secretory glands involved in dryness are of the nose, myxoid, osteoid or fibroid. The presence of these differ-
larynx, pharynx, tracheobronchial tree and the vagina. ent elements accounts for the name pleomorphic tumour
l Sialochemistry studies have shown increased levels of or mixed tumour. Myoepithelial cells are also present in
IgA, potassium and sodium in the saliva. this tumour and add to its histopathologic complexity.
l In the sicca complex, there is parotid gland enlargement
that is usually absent in secondary Sjögren syndrome. Treatment

l Surgical removal with adequate margins is the principal
l Lymphadenopathy is twice common in the primary
form of the disease. treatment.

l Because of its microscopic projections, this tumour
Treatment requires a wide resection to avoid recurrence.

l Symptomatic treatment. l A superficial parotidectomy is sufficient for the major-
l Keratoconjunctivitis is treated with ocular lubricants ity of these lesions.

such as artificial tears containing methylcellulose. l Lesions that occur in the submandibular gland are
l Xerostomia is treated by saliva substitutes. treated by the removal of the entire gland.
l Oral hygiene and fluoride application to prevent and treat
problems associated with dry mouth like dental caries. Q.9. Parotitis.
Ans.
Q.8. Pleomorphic adenoma.
[Ref LE Q.4]
Ans.
Q.10. Sialolithiasis.
l The pleomorphic adenoma is the most common tumour
of the salivary glands; overall, it accounts for about 60% Ans.
of all salivary gland tumours. [Same as SE Q.1]
l It is often called a mixed tumour because it consists of
both epithelial and mesenchymal elements. Q.11. Indications and contraindications of sialography.
l The majority of these tumours are found in the parotid
Ans.
glands, with less than 10% in the submandibular, sub-
lingual and minor salivary glands. [Same as SE Q.2]
SHORT NOTES: l Patients with xerostomia must be advised to frequently

sip water so as to prevent dryness and also to facilitate
Q.1. Mucocele. cleansing action.
Ans. l In some patients, use of artificial saliva substitutes play
a useful role.
i. Retention of mucous material due to trauma, involving
salivary glands and their ducts is known as mucocele. Q.4. Schirmer test.
ii. Clinical features: Ans.
l Occurs most frequently on the lower lip, can also occur
on the palate, cheek, tongue and floor of the mouth. l Schirmer test is done in patients with Sjögren syndrome
l The lesion may lie superficial or deep in the tissue. to assess the amount of secretions in eyes, by keeping a
iii. Histological features: filter paper in the lower conjunctival sac and finding out
l The cavity is not lined by epithelium and is therefore the extent of wetting.
not a true cyst. l Normal patients wet 15 mm of filter paper in 5 min,
l The wall is made of compressed fibrous connective whereas patients with Sjögren syndrome wet less than
tissue and fibroblasts. 5 mm.
iv. Treatment: Q.5. Treatment of ptyalism.
l Excision.
Ans.
Q.2. Mumps.
l Ptyalism is also called as sialorrhoea.
Ans.
Management of ptyalism
l Mumps is an acute contagious viral infection usually l In children less than 4 years no treatment recom-
seen in children, characterized by unilateral or bilateral mended.
parotid swelling. l In adults following treatment is advised:
l Incubation period of 2–3 weeks. i. Oral motor training and Biofeedback.
l It is transmitted through droplet infection. ii. Removal of local factors that is dental diseases and
nasal airway obstruction.
Clinical features
iii. Anticholinergic drugs can also be used.
l Disease preceded by headaches, chills, moderate fever,
iv. Surgery is a primary recommendation in individuals
vomiting and pain below the ear.
with cognitive delay and profuse drooling and sec-
l After this firm, rubbery or elastic swelling of the sali-
ondarily in those that have failed to nonsurgical
vary glands elevating the ear which lasts for 1 week.
therapy for a minimum of 6 months.
l Produces pain on mastication.
l The swelling reaches its maximum in 3 days and then Q.6. Sialolithiasis.
gradually subsides.
Ans.
l The papilla of the opening of the parotid duct is often
puffy and reddened. l The round, ovoid calcified structure present in the sali-
vary duct or gland is called a ‘sialolith’.
Treatment
l It often occurs due to inflammation, local irritants or
l Conservative.
drugs causing decreased saliva flow resulting in stasis
l Maintaining hydration.
and obstruction.
l Prevention is by means of vaccination.
l Calcareous deposits form around a central nidus in a
Q.3. Xerostomia. concentric manner.
l Structurally, it is hydroxyapatite crystals and octacal-
Ans.
cium phosphate.
l Xerostomia refers to dry mouth, where there is de- l Submandibular gland is more prone to get sialolithiasis
creased salivary flow. due to following reasons:
l In patients with xerostomia, an important complaint i. Long and tortuous course of submandibular salivary
may be halitosis. duct
l If the saliva flow is decreased the normal cleansing ii. Secretion against gravity
action of mouth does not take place. iii. Viscous secretion
l This results in accumulation of food debris and iv. More mineral content of saliva
plaque. l Symptoms associated are:
l Halitosis. i. Pain or swelling in the gland area
ii. Long-term effects of like stasis of saliva can result in Treatment

infection, fibrosis and atrophy of the salivary gland. l Incisional biopsy to establish diagnosis.
l Larger and well-mineralized calcareous deposits are l Observation, because lesion is self-limiting and heals
visible in the radiograph as localized and well-defined spontaneously in 6–10 weeks.

radiopacity.
Q.9. Sjögren syndrome.
l The best radiograph for the visualization of sialolithia-
sis involving the submandibular salivary gland duct in Ans.
mandibular occlusal radiograph.
[Ref LE Q.1]
l Sialography demonstrates filling defect distal to the site
of obstruction. Q.10. What are the functions of saliva?
l Treatment:
i. Small calculi can be removed by manipulation or by Ans.
increasing the salivation by sucking a lemon, lead- Functions of saliva are as follows:
ing to expulsion of the stone. l Participates in digestion by providing fluid environment
ii. The larger stones need to be removed by surgical for solubilization of food and taste substance.
exposure. l Lubrication: keeps food moist.
l Protects teeth from dental caries.

Q.7. Sialography.
l Dilutes hot or irritant substance and thus prevents
Ans. injury to mucus membrane.
l Maintenance of neutral pH of oral cavity.
i. Sialography is a technique in which ducts and ductules
l Helps in wound healing.
of the salivary glands are demonstrated radiographically
l Immunoglobulins of saliva have antibacterial properties.
after a radiopaque liquid has been injected along them.
ii. Indications: Q.11. Sialosis.
l To demonstrate – calculi, strictures, recurrent paroti-
tis, tumours, etc. Ans.

l Salivary fistula
l Sialadenosis or sialosis refers to the noninflammatory,
l Relationship of salivary glands and ducts to sur-
nonneoplastic enlargement of salivary glands.
rounding structures
l It is usually a bilateral and painless enlargement.
iii. Contraindication:
l Prevalent in women.
l Active or recent infection of the gland
l Parotid glands are mostly affected.
iv. Advantage:
l Responsible factors:
l Visualizes ductal anatomy/blockage
i. Drug induced sialosis – caused by iodine containing
v. Disadvantage:
drugs, phenylbutazone, etc.
l Invasive; requires iodine-containing dye; no quantifi-
ii. Hormonal factors
cation
iii. Malnutrition
Q.8. Sialometaplasia. iv. Alcoholism
v. Dehydration
Ans.
Q.12. Ptyalism.
Necrotising sialometaplasia is a non-neoplastic inflam-
matory condition of the salivary glands. Ans.
Aetiology
l Ptyalism is also called as hyper salivation.
l In most cases, it occurs spontaneously.
l Causes of ptyalism are as follows:
l Other causes may be: trauma, radiation therapy,
i. Various forms of stomatitis.
surgery, tobacco use or vascular ischaemia.
ii. Effects of drugs that stimulate the parasympathetic
Clinical appearance
nervous system resulting increase in salivary flow.
l Usually involves the minor salivary glands, particu-
iii. Malignancy of the oral cavity.
larly the ones in the palate
l Junction of hard and soft palates Q.13. Ranula.
l Unilateral or bilateral
Ans.
l Swelling, erythema, tenderness, followed by ulcer-
ation Ranula means swollen abdomen of frog.
Clinical differential diagnosis i. This is a type of retention cyst involving submandibular
Squamous cell carcinoma, salivary gland tumour, and sublingual glands and occurring in the floor of the
chronic infection and traumatic ulcer. mouth (more often sublingual gland).
ii. Aetiology – trauma ii. Secretion against gravity

iii. Clinical findings: iii. Viscous secretion
l Slow-growing, painless swelling on one side in the iv. More mineral content of saliva
floor of the mouth.
Q.15. Necrotizing sialometaplasia.
l Tongue is pushed up.
iv. Treatment: Ans.

l Complete surgical excision along with the whole of
[Same as SN Q.8]
the sublingual salivary gland.
Q.16. Sialadenosis.
Q.14. Why sialolithiasis is more common in subman-
dibular gland? Ans.
l Submandibular gland is more prone to get sialolithiasis Q.17. Sialorrhoea.
due to following reasons:
Ans.
i. Long and tortuous course of submandibular salivary
duct [Ref LE Q.3]
Topic 8
Disorders of TMJ and MPDS
LONG ESSAYS:
1. Describe TMJ disorders in detail.
2. Describe in detail MPDS.
3. What conditions may produce trismus?
4. Describe in detail TMJ ankylosis.
5. Describe radiographic techniques to diagnose temporomandibular joint diseases and disorders.
6. Articular disc disorders of temporomandibular joint.
7. Classify temporomandibular disorders. Discuss the management of TMJ arthritis. [Same as LE Q.1]
8. Write clinical features and management of MPDS. [Same as LE Q.2]
9. Management of MPDS. [Same as LE Q.2]
10. Enumerate the causes of trismus. Discuss in detail. [Same as LE Q.3]
SHORT ESSAYS:
1 . Subluxation of TMJ.
2. Myofacial pain dysfunction syndrome (MPDS). [Ref LE Q.2]
3. Clinical features and management of degenerative arthritis of TMJ.
4. Internal derangement of temporomandibular joint.
5. Bruxism.
6. Clinical features of TMJ subluxation. [Same as SE Q.1]
7. Treatment plan for MPDS. [Same as SE Q.2]
8. Aetiology of MPDS. [Same as SE Q.2]
SHORT NOTES:
1. Four causes of trismus.
2. Subluxation of TMJ – aetiology. [Ref SE Q.1]
3. Myositis ossificans.
4. Temporomandibular joint ankylosis.
5. How will you differentiate true ankyloses from pseudoankylosis of temporomandibular joint? [Ref LE Q.4]
6. Mention the staging of internal derangement of temporomandibular joint. [Ref SE Q.4]
7. Define myofunctional pain dysfunction syndrome.
8. Enumerate the temporomandibular joint views.
9. Drugs to relieve muscular spasm.
10. Define trismus. [Same as SN Q.1]
SOLVED ANSWERS
LONG ESSAYS: Condylar hypoplasia
l
Aplasia
l
Q.1. Describe TMJ disorders in detail. Acquired disorders
Ans. l Neoplasms
l Fractures
Classification of temporomandibular disorders is as Diagnostic classification of temporomandibular
follows: disorders
I. Disorders of the Temporomandibular joint (TMJ)
Deviation in form
l Articular surface defects Diagnostic category Diagnoses
l Disc thinning and perforation Cranial bones (includ- Congenital and developmental disor-
l Adherence and adhesions ing the mandible) ders like hemifacial microsomia
l Disc displacement Temporomandibular Arthritides-like osteoarthritis ankylo-
l Disc displacement with reduction joint disorders sis can be fibrous or bony
l Disc displacement without reduction
Masticatory-muscle Myofascial pain dysfunction syndrome
Displacement of disc–condyle complex disorders Myositis
l Hypermobility
l Dislocation
Inflammatory conditions Degenerative joint disease (osteoarthritis)

l Capsulitis and synovitis l It is also known as osteoarthrosis, osteoarthritis
l Retrodiscitis and degenerative arthritis.

Degenerative diseases Aetiology
l Osteoarthrosis l It is primarily a disorder of articular cartilage
l Osteoarthritis and subchondral bone, with secondary inflam-

l Juvenile idiopathic arthritis mation of the synovial membrane.
l Polyarthritides l The process starts in loaded articular cartilage,
Ankylosis later it thins and clefts (fibrillation) and then

II. Masticatory muscle disorders breaks away during joint activity leading to
Acute conditions sclerosis of underlying bone, subcondylar cysts
l Reflex muscle splinting and osteophyte formation. It is essentially a re-
l Myositis sponse of the joint to chronic microtrauma or
l Muscle spasm pressure.
Chronic conditions l The microtrauma could be due to continuous
l Myofacial pain abrasion of the articular surfaces as in natural

l Hypertrophy wear associated with age or as a result of in-
l Fibromyalgia creased loading forces possibly related to chronic
III. Congenital, developmental and acquired disorders parafunctional activity.
of condylar process l However, the fibrous tissue covering is preserved
Congenital and developmental disorders due to remodelling and the recovery process in
l Condylar hyperplasia osteoarthrosis and osteoarthritis.
l Degenerative joint disease can be either primary infiltrate and subsequent formation of granula-
or secondary even though they may present tion tissue.
similar histopathologic pattern. l The cellular infiltrate spreads from the articular
l Primary degenerative joint disease is usually of surfaces eventually to cause an erosion of the
unknown origin, but sometimes genetic factors underlying bone.
play an important role. Clinical manifestations
l Trauma, congenital dysplasia or metabolic dis- l The rheumatoid arthritis (RA) usually involves
ease may be the cause for secondary degenera- the TMJ bilaterally.
tive disease. l The most common symptoms are mandibular
Clinical manifestations opening and joint pain. Pain may be due to the
l It is most commonly seen in people above the early acute phases of the disease. Other symp-
age of 50 years. toms include morning stiffness, joint sounds and
l Patients will have unilateral pain directly over tenderness and swelling over the joint area.
the affected condyle, limitation of mandibular l The symptoms are usually transient in nature
opening, crepitus and a feeling of stiffness after only in some cases there will be disability.
a period of inactivity. l Common findings are pain on palpation of the
l Tenderness and crepitus on intra-auricular and joints and limitation of opening. Crepitus also
pretragus palpation with deviation of the mandi- may be evident.
ble to the painful side is detected on examination. l Micrognathia and an anterior open bite are com-
l It is detected accidentally on radiographic ex- monly seen in patients with juvenile RA.
amination and may not be responsible for facial l Radiographic changes in the TMJ associated
pain symptoms or TMJ dysfunction. with RA may include a narrow joint space,
l When the defects are confined to articular soft destructive lesions of the condyle and limited
tissue, the symptoms may not be diagnosed by condylar movement.
conventional radiography. MRI helps to detect l There is little evidence of marginal proliferation
soft tissue changes better. or other reparative activity in RA in contrast

l Radiographic findings may include narrowing to the radiographic changes often observed in
of the joint space, irregular joint space, flattening degenerative joint disease.
of the articular surfaces, osteophytic formation, l High-resolution CT of TMJ in an RA patient
anterior lipping of the condyle and the presence will show erosions of the condyle and glenoid
of Ely cysts. fossae that cannot be seen by conventional radi-
l These can be seen best on tomograms or CT ography.
scans and MRI images. Treatment
Treatment l It is treated by anti-inflammatory drugs.
l Conservative treatment is a treatment of choice l The patient should be placed on a soft diet dur-
and should be considered for 6 months to 1 year ing acute exacerbation of the disease process,
before considering surgery, unless severe pain or but intermaxillary fixation is to be avoided be-
dysfunction persists after an adequate trial of cause of the risk of fibrous ankylosis.
nonsurgical therapy. l Use of a flat plane occlusal appliance may be
l Conservative therapy involves nonsteroidal anti- helpful, particularly if parafunctional habits are
inflammatory medications, heat application, soft exacerbating the symptoms.
diet, rest and occlusal splints that allow free l An exercise programme should be started after
movement of the mandible. the acute symptoms subside to help in the man-
l When TMJ pain or significant loss of function dibular movements.
persists and when distinct radiographic evidence l When patients have severe symptoms, the use of
of degenerative joint changes exists, surgery is intra-articular steroids should be considered.

indicated. Prostheses appear to decrease symptoms in fully
l An arthroplasty, which limits surgery to the or partially edentulous patients.
removal of osteophytes and erosive areas, is l Surgical treatment of the joints, including place-
commonly performed. Patients with advanced ment of prosthetic joints, is indicated in patients
degenerative changes of the TMJ are treated who have severe functional impairment or intracta-
with artificial TMJs. ble pain not successfully managed by other means.
Rheumatoid arthritis Psoriatic arthritis
l The disease process starts as a vasculitis of the l Psoriatic arthritis (PA) is an erosive polyarthritis
synovial membrane progressing to chronic in- occurring in patients with a negative rheumatoid
flammation marked by an intense round cell factor who have psoriatic skin lesions.
l The skin lesions start few years before the joint Diagnosis is made by detection of bacteria on
l
lesions. grams stain and culture of aspirated joint fluid.

l The cutaneous and joint manifestations of the l Serious sequelae include osteomyelitis of the
disease may be traced to the same immunologic temporal bone, brain abscess and ankylosis.
abnormality. l Facial asymmetry may accompany septic arthri-
l TMJ involvement is more common. tis of the TMJ, especially in children. The pri-
Clinical manifestations mary sources of these infections were the mid-
l The signs and symptoms are likely to be unilat- dle ear, teeth and the hematologic spread of
eral and they are more likely that of RA. gonorrhoea.
l Limitation of mandibular movement, deviation l Evaluation of patients with suspected septic ar-
to the side of the pain and tenderness directly thritis must include a review of signs and symp-
over the joint may be observed on examination. toms of gonorrhoea, such as purulent urethral
l Erosion of the condyle and glenoid fossae rather discharge or dysuria.
than proliferation is detected radiographically. Treatment
l Coronal CT is particularly useful in showing l Treatment of septic arthritis of the TMJ involves
TMJ changes of PA. surgical drainage, joint irrigation and 4–6 weeks
Treatment of antibiotics.
l The management of PA gives emphasis on phys- Gout and pseudogout
ical therapy and NSAIDS that control both pain l Gouty arthritis is caused by long-term elevated
and inflammation in many cases. serum urate levels, which results in the deposi-
l For patients who do not respond to conservative tion of crystals in a joint, triggering an acute
treatment of immunosuppressive drugs, particu- inflammatory response.
larly methotrexates, are used. l Acute pain in a single joint, i.e. monoarticular
l Only when there is intractable TMJ pain or arthritis, is the characteristic clinical manifesta-
disabling limitation of mandibular movement, tion of gouty arthritis.
surgery is indicated. l Gouty arthritis appears to be very rare; an attack
l Arthroplasty or condylectomy with placement of gouty arthritis is most accurately diagnosed

of costochondral grafts has been performed by examination of aspirated synovial fluid from
successfully. the involved joint by polarized light microscopy.
l Surgery may be complicated by psoriasis form- l The detection of monosodium urate crystals
ing in the surgical scar (Koebner effect). confirms the diagnosis of gout.
Septic arthritis l An acute attack of gout can be treated with col-
l Septic arthritis of the TMJ occurs in patients with chicine, NSAIDs or the intra-articular injection
previously existing joint disease such as RA. of corticosteroids.
l Septic arthritis is also seen patients receiving l The deposition of other crystals, such as calcium
immunosuppressive drugs or long-term cortico- pyrophosphate dihydrate (CPPD) or calcium

steroids. hydroxyapatite, may cause a syndrome that
l The infection of the TMJ may result from blood- resembles gout and that has been referred to as
borne bacterial infection or through infection pseudogout.
from adjacent sites such as the middle ear, max- l This disorder most frequently affects elderly
illary molars and parotid gland. individuals, with the involvement of the TMJ.
l Gonococci are the primary blood=borne agents l Colchicine or arthrocentesis is used for success-
causing septic arthritis in a previously normal TMJ. ful treatment of pseudogout of TMJ.
Clinical symptoms
l Symptoms include trismus, deviation of the
Q.2. Describe in detail MPDS.
mandible to the affected side, severe pain on Ans.
movement and an inability to occlude the teeth,
owing to the presence of inflammation in the
[SE Q.2]
joint space.
l Examination reveals redness and swelling in the l {When muscle spasm develops in one or more mastica-
region of the involved joint. tory muscles, dysfunction as well as pain occurs and the
l Septic arthritis can be differentiated from more condition usually is designated as MPDS.
common types of TMJ disorders by large tender l The muscles of mastication, the tongue muscles and
cervical lymph nodes on the side of the infection. the strap muscle of the neck function as a unit and that
dysfunction in one group of muscles is frequently as- Cardinal signs and symptoms outlined by Laskin
sociated with altered tonus and symptoms of ‘tension’ in Positive characteristics emphasized by Laskin
the other related groups. l Unilateral, dull pain in the ear or preauricular region
that is commonly worse on awakening.

Aetiology
l Tenderness of one or more muscles of mastication in
Occlusal status
palpation.
l Periodontal point of view: It is a self-protecting and
l Clicking or popping noise in the TMJ.
modifications occur in the pathway of closure to avoid
l Limitation or deviation of the mandible on opening.
and potentially damaging or painful contacts.
l Tooth muscle theory: In coordination and spasm of Negative characteristics emphasized by Laskin
some muscles of mastication is caused due to occlusal l Absence of clinical, radiographic or biochemical evi-
interferences and altered proprioceptive feedback. dence in TMJ.

l Prosthetic reasons: Decreased vertical dimension due l Lack of tenderness in TMJ area on palpation through
to overclosure caused by bilateral loss of molar teeth or external auditory meatus.

increased VD in partial and complete dentures lead to
TMJ dysfunction. Signs
l Restriction of opening and protrusion by deflection of
l Orthodontic conditions: Malocclusion and discrepancies
in occlusion or MPDS can lead to TMJ dysfunction. mandibular incisal path.
Psycho-physiologic theory Symptoms

l Masticatory pain.
The following are the reasons for spasm due to over
l Difficulty in chewing.
extension of muscles:
l Restricted mandibular excursion.
l Faulty dental restorations or FPD/RPD encroaching
l Mandibular movements are with noise on rubbing,
intra maxillary space
l Bilateral loss of posterior teeth
grinding, clicking and with popping snapping sounds.
l Soreness of muscles (myofacial trigger zones).
l Parafunctional habits clenching and grinding, bruxism}
l Parafunctional habits, e.g. bruxism.
Pathogenesis l Acute malocclusion with abnormal teeth relationship.
Energy released during muscle contraction Treatment of MPDS

g l Treatment of MPDS should include the treatment of
emotional as well as physical components of the disorder.

Formation and accumulation of lactic acid l In acute stages, conservative noninvasive treatment is
g usually successful in alleviating the pain and dysfunction.

l Treatment of MPDS should begin with strong doctor–
Changes in osmolality with decreased p H patient relationship by showing concern and empathy
g when reviewing the history of patient problems.
l Patient should be told that they are not suffering from
Muscle receptors prone to impulse excitation more serious, life-threatening disorder like malignancy.
with impairment of their critical firing levels
Conservative treatment and recommendations
g
Conservative treatment and recommendations at the
Decreased p H and lactic acid causes infusion initial visit should include the following:
and effusion of histamine, bradykinin and serotonin l Limitation of parafunctional habits: Patient should attempt
and other acines into area to limit parafunctional habits by becoming more aware of
clenching and grinding of the teeth during the day.
g
l Hot moist packs: Warm to hot, moist compresses should
Pathologic muscular derangement ‘trigger zones’ be applied over the involved muscles for 15–20 min
carry the hypersensitive from where impulses can three times a day.
bombard CNS giving rise to referred pain l Soft diet: A relatively soft diet should be advised and
limit wide opening of mouth while eating.

Joint status l Pharmacotherapy or drugs to be prescribed: Aspirin or
l Hypermobility. NSAID should be recommended for analgesic and anti-

l Sleep angulation of articular eminence. inflammatory actions.
l Degenerative changes secondary to parafunctional l Breaking up stress–pain–stress cycle with LA injections
habits. without epinephrine: Injecting the trigger points of

muscles that are in spasm with a local anaesthetic not l The release of endorphins may be involved in the
containing epinephrine is often beneficial in breaking pain relief as with acupuncture.
up the spasm and in disrupting the stress pain stress ii. Hypnosis:
cycle. l Used as an adjunct to other treatments.
l Ethylchloride spray on the skin: The skin overlying the iii. Psychological counselling and antidepressant drugs:
affected muscles can be sprayed with ethylchloride or l They are indicated in the treatment of MPDS if
fluoromethane or ultrasound can be used in an attempt anxiety or neurotic behaviour appears to be signifi-
to relieve muscle spasms. The effectiveness of local cant component of facial pain.
anaesthetic injections, ethylchloride refrigerant spray
and ultrasound in allowing patients to open wide with- [SE Q.2]
out pain may be noted immediately following treatment. {Treatment of MPDS is summarized as follows:
l Jaw exercises: Isometric exercises are often beneficial,
for example, placing the tip of the tongue in the back of

the palate and then opening and closing may help in Treatment
retraining spastic muscles. component Description
l Diazepam: Diazepam 2 mg/3 times daily and 5 mg at bed
Education The diagnosis and treatment should be
time during a 2-week trial period is commonly advocated explained to the patient
for its anxiety reducing and muscle relaxing properties. Encourage the patient to take self-care with
reassurance about the good prognosis
Occlusal splints
l They should be fabricated if pain and dysfunction per- Self-care Educate the patient towards elimination of
oral habits (e.g. tooth clenching and chew-
sist without improvement following the treatment and
ing gum)
recommendations of the initial visit.
l Splints most often used are
Physical therapy Education regarding biomechanics of jaw,
neck and head posture
i. Maxillary night guard Passive modalities and posture therapy
ii. A Hawley appliance with an anterior platform with general stretching and exercise is
l Benefits derived from occlusal splints have most com- advised
monly attributed to greater freedom in mandibular Intraoral appli- Cover all the teeth in the arch with appli-
movement and to an increase in muscle balance. ance therapy ance placed on them
Simultaneous contact against opposing teeth
Biofeedback should be achieved
l It is helpful when the primary reason for the failure in Adjust to comfortable position avoiding
initial treatment appears to be the inability to control continuous use
stress and anxiety. Pharmacotherapy NSAIDs, acetaminophen, muscle relaxants,
l Biofeedback is a valuable therapeutic aid that permits antianxiety agents, tricyclic antidepressants
patients to treat themselves while decreasing their de- and clonazepam
pendence on therapists as it provides them with infor- Behavioural/ Relaxation therapy such as hypnosis is
mation concerning bodily functions that are usually not relaxation preferred}
discernible or controllable. techniques
Nerve stimulation
l Transcutaneous electrical nerve stimulation (TENS)
treatment appears to be more effective in alleviating Q.3. What conditions may produce trismus?
chronic pain than acute pain.
Ans.
l The mode of action of TENS in reducing pain is uncer-
tain but it is attributed to neurologic, physiologic, phar- The word trismus is derived from the Greek word ‘trismus’
macologic and psychologic effects. meaning gnashing and is defined as a prolonged, tetanic
l The pharmacologic action of TENS may involve the spasm of the jaw muscles by which normal opening of the
stimulated release of endorphins, which are endogenous mouth is restricted (locked jaw).
morphine like substances.
Aetiology
l TENS also has a placebo effect in relieving pain.
i. Congenital
Other treatments l Trismus-pseudocamptodactyly syndrome
i. Acupuncture: l Craniocarpotarsal dysplasia
l Used in treatment of chronic MPDS here brief in- l Hemifacial microsomia
tense stimulation is applied designated points using l Fibrodysplasia ossificans progressiva
needles with or without electrical current. l Birth injury

ii. Traumatic (acute) l Physiotherapy

l Fractures of mandible, zygomatic or temporal bones l Heat application
l Haematomas in the joint or muscle of mastication l Warm saline gargles
l Injury due to local anaesthetic injection l Forceful mouth opening with gag
l Anterior dislocated meniscus
Q.4. Describe in detail TMJ ankylosis.
l Postsurgical (e.g. third molar removal and TMJ
surgery) Ans.
iii. Neoplastic (benign)
l Mesenchymal tumours of the TMJ and surrounding {SN Q.5}
structures (e.g. osteochondroma)
l Enlargement of the coronoid process of the mandible
l TMJ ankylosis is an intra-articular condition where
iv. Neoplastic (malignant) there is a fusion between the bony surfaces of the
l Chondrosarcoma
joint, the condyle and the glenoid fossa. The term
l Osteosarcoma
‘ankylosis’ is derived from the Greek word that means
l Tumours of the oropharynx (Trotter syndrome)
stiffening of a joint as a result of a disease process.
l Ankylosis of the mandible with immobility of the
l Metastatic disease of the mandible and infratempo-
ral fossa joint may be of an osseous, fibro-osseous or carti-

v. Neuromuscular disorders laginous variety.
l Ankylosis must be distinguished from its counterpart
l Parkinson disease
vi. Reactive (acute) pseudoankylosis.

l In pseudoankylosis, hypomobility of the joint occurs
l Septic arthritis
l Tetanus
due to coronoid hyperplasia or due to fibrous adhesions
l Osteomyelitis of the mandible and temporal bone
between the coronoid and tuberosity of the maxilla or
l Abscesses of the submasseteric, lateral pharyngeal,
zygoma as in ‘V-shaped’ fracture of the zygomatic arch
pterygomandibular, submandibular and temporal impinging on coronoid leading to fibrous or bony
spaces union are also examples of pseudoankylosis.
l In pseudoankylosis, even though jaw movement is
l Tonsillitis and peritonsillar abscess
l Parotid abscess
restricted as in bony ankylosis, the pathology is extra-
l Mumps
articular in these cases.
l Cancrum oris
vii. Reactive (chronic) Aetiopathology

l TMJ ankylosis (fibrous and bony) I. Tauma
l Degenerative joint disease l Most cases of ankylosis result from condylar injuries
l Rheumatoid arthritis sustained before 10 years of age.

l Systemic sclerosis l A unique pattern of condylar fractures is seen in
l Submucous fibrosis children. Condylar cortical bone in children is thin

l Radiation therapy with a broad condylar neck and rich subarticular
l Myofascial pain dysfunction (MPDS) interconnecting vascular plexus. An intracapsular
l Ankylosing spondylitis fracture leads to combination and haemarthrosis of
l Myositis ossificans traumatica the condylar head. This sort of intracapsular burst
viii. Psychogenic fracture is called ‘mushroom fracture’.
l Hysterical trismus l It results in the organization of a fibro-osseous mass
l Hyperventilation syndrome in a highly osteogenic environment. Moreover, im-

ix. Drug induced mobility leads to ossification and consolidation of
l Extrapyramidal reaction (facial dyskinesia) the mass, resulting in ankylosis.
l Strychnine poisoning l Ankylosis may also occur in trauma sustained during
forceps delivery.
Clinical examination Laskin (1978) had outlined various factors that may be
l Decreased interincisal distance usually normal is 3–4 cm.
implicated in the aetiology of ankylosis following
l Extrusive and protrusive movements (normal .6 cm).
trauma, they are as follows:
l Facial swelling or asymmetry.
a. Age of the patient
Treatment l Younger patients have significantly higher osteo-
l Treatment of underlying cause genic potential and rapidity of repair. Moreover,

l Anti-inflammatory drugs the articular capsule is not as well developed in
l Muscle relaxants younger patients, thus permitting easier condylar
displacement out of the fossa and thereby damage in disc followed by repair leading to ankylosis. De-
to the disc ultimately, there is a greater tendency struction of the disc leads to bony contact between the
for prolonged self-imposed immobilization of the condyle and glenoid fossa.
mandible post-traumatically in children.
b. Type of fracture Classification of ankylosis
l The condyle in children has a thinner cortex along Classification of ankylosis according to tissues involved
with a thick neck, which predisposes them to a and extent:
higher proportion of intracapsular comminuted l True ankylosis or pseudoankylosis
fractures. In contrast, adults have a thinner condy- l Extra-articular or intra-articular
lar neck which usually fractures at the neck, thus l Fibrous, bony or fibro-osseous
sparing the head of the condyle within the capsule. l Unilateral or bilateral
c. Damage to articular disc l Partial or complete
l The direct contact between a comminuted con-

Classification of ankylosis by Topazian (1966):
dyle and the glenoid fossa either from a displaced l Type I: Fibrous adhesions in or around the joint with
or torn meniscus is the key factor in the develop- restricted condylar gliding.
ment of ankylosis. l Type II: Formation of a bony bridge between the
d. Period of immobilization condyle and glenoid fossa.
l Prolonged mechanical immobilization or muscle
l Type III: Condylar neck is ankylosed to the fossa
splinting can promote osteogenesis and consolida- completely.
tion to set in an injured condyle. Total immobility
between articular surfaces after condylar injury Grading of TMJ ankylosis
leads to a bony type of fusion, whereas some Sawhney (1986) graded TMJ ankylosis into four
movement leads to a fibrous type of union. types:
l Type I: Flattening or deformity of condyle with little
II. Local infections
l The source of infection is contiguous, from adja- joint space on radiograph. There is minimal bony fu-
cent structures. sion, but extensive fibrous adhesions around joint. Some
l For example, otitis media, mastoiditis, osteomyeli- movement is possible.
l Type II: Bony fusion on the outer edge of articular
tis of temporal bone, parotid abscess, infratemporal
or submasseteric space or parapharyngeal infec- surface, but no fusion on the deeper aspect of the joint.
l Type III: A bridge of bone exists between the ramus
tions, furuncle and actinomycosis.
III. Systemic conditions and zygomatic arch. The upper articular surface and the
l In systemic conditions like tuberculosis, meningitis, articular disc on the deeper aspect are still intact. Medi-
pharyngitis, tonsillitis, rubella, varicella, scarlet fe- ally, a displaced atrophic condyle still exists and which
ver, gonococcal arthritis and ankylosing spondylitis, is functional. Type III ankylosis results from a fracture-
the route of spread of infection is haematogenous. displaced condyle, compared to the crushing types of
l The local and systemic infections may pass along as condylar injuries as in types I and II.
l Type IV: Total TMJ obliteration between ramus and
septic arthritis, which may not always cause ankylo-
sis. Staphylococcus species, Streptococcus species, skull by large bony mass. It is the most common type.
Haemophilus influenza and Neisseria gonorrhoea Clinical features
are the most likely causes of septic arthritis. The The clinical features of ankylosis depend on:
infection may take either the haematogenous, con- i. Type of ankylosis
tiguous or by direct inoculation. The synovium with a. Unilateral vs. bilateral
its high vascularity and lack of a limiting basement b. Bony vs. fibrous
membrane is vulnerable to infection. ii. Extent of joint involvement
IV. Arthritis/inflammatory conditions iii. Age of onset and duration of ankylosis: The deformity
l About 50% cases in juvenile rheumatoid arthritis will be severe if it occurs before the age of 5 years.
(Still disease) also have TMJ involvement along
with polyarthritis. Osteoarthritis may also lead to Unilateral ankylosis
ankylosis. Clinical features of unilateral ankylosis are as follows:
V. Neoplasms Facial features
l Sarcoma, osteoma and chondroma may also result in i. Obvious facial asymmetry.
ankylosed joint. The pathogenesis of ankylosis is ii. Receded chin with hypoplastic mandible on affected
generally the same in all the nontraumatic conditions: side, resulting in deviation of chin and mandible to-
degenerative, destructive and inflammatory changes wards affected side.
iii. Unilateral vertical deficiency on the affected side. l Other features include deepening of the antegonial
iv. Roundness/fullness on affected side; foreshortened notch and compensatory elongation of the coronoid
mandible, flatness and elongation on normal side as it process on the affected side.
grows towards the affected side.
Management
v. Loss of the normal bilateral symmetrical divergence
l The goals of management should include restoration of
from the mental region towards the angle.
mouth opening and joint function, facilitation of condy-
vi. The lower border of the mandible on the affected side
lar growth, correction of facial profile and to relieve
has a concavity that ends in a well-defined antegonial
upper airway obstruction.
notch.
l Surgical correction of ankylosis is best achieved by
vii. Markedly elongated coronoid process.
condylectomy, gap arthroplasty, coronoidectomy, in-
Intraoral features terpositional arthroplasty with autogenous or allo-
i. Occlusal cant with deviation of maxillary and man- plastic grafts and secondary procedures such as
dibular midlines towards affected side. orthognathic surgery and distraction osteogenesis.
ii. Angle’s class II malocclusion present on the Surgical correction should be followed by active
affected side with unilateral cross bite on the opposite physiotherapy.
side. l When ankylosis is left untreated it may result in abnormal
iii. The mouth opening is restricted; amount of opening facial growth and development, speech defects, nutri-
depends upon degree of ankylosis. tional impairment, respiratory distress syndrome, con-
ditions related to poor oral hygiene and psychological
Bilateral ankylosis
impact on the patient.
Clinical features of bilateral ankylosis are as follows:
Facial features Q.5. Describe radiographic techniques to diagnose tem-
i. Symmetrical defect. poromandibular joint diseases and disorders.
ii. Retrognathia mandible with a short ramus and a small
Ans.
body.
iii. Often microgenia, small chin. l The purpose of an imaging assessment of the TMJ is to
iv. ‘Bird-face deformity’ or ‘Andy Gump’ facies. depict clinically suspected disorders of the joint.
v. Convex profile. l The objective of TMJ imaging is to visualize both the
vi. Relatively short hyomental distance with tight supra- hard and soft tissue structures of the TMJ.
hyoid musculature. Common imaging modalities to study hard and soft
vii. Cervicomental angle may be reduced or completely tissues of TMJ are as follows:
absent.
viii. Obstructive sleep apnoea may be present due to
oropharyngeal airway narrowing in cephalocaudal, Hard tissue imaging Soft tissue imaging
anteroposterior and transverse directions. i. Orthopantomograph i. Arthrography
ii. Plain film TMJ views ii. Magnetic resonance
Intraoral features l Transcranial projection imaging
i. Mouth opening would be less than 5 mm or may be nil l Transpharyngeal projection
at times. l Transorbital projection
ii. Generally a class II malocclusion, although class I l Submentovertex view
iii. Conventional
occlusion may also be seen.
iv. Computed tomography (CT)
iii. Incompetent lips and proclined lower anteriors. v. Radionuclide imaging
iv. Open bite with protrusion of both upper and lower
anteriors resulting from the protrusive action of tongue
because of decreased tongue space. l For decades plain film radiography, mainly a transcra-
v. Severe crowding, multiple impacted teeth with oral nial projection, was the most commonly used imaging
health maintenance problems, leading to caries and technique.
periodontal problems.
Hard tissue imaging
Radiographic features Orthopantomography
l In fibrous ankylosis, joint may appear normal or the l Panoramic radiography has been advocated by many
articulating surfaces may be irregular. The joint space is authors as a good imaging modality and is routinely
markedly decreased. used to image the hard tissues of the maxillofacial re-
l In bony ankylosis, the joint space may be obliterated, gion and is a modality readily accessible to the majority
completely or partly by an osseous bridge. of oral healthcare specialists.
l In most dental settings, a panoramic radiograph can be a perpendicular relationship with the surface of the cas-
obtained and interpreted within minutes at the time of sette as determined from the condylar angulation seen
clinical examination. on a submentovertex projection.
l Orthopantomography is used as a screening projection l The lack of visualization of the soft tissues of the joint
and it is the imaging of choice when it comes to viewing is one of the major disadvantages.
the teeth and the adjacent structures. l Conventional tomography has been used extensively to
l Changes in the bony structures of the TMJ can be inter- evaluate the osseous components of the TMJ as well as
preted only on the lateral slope and central parts of the a greater number of structural changes as compared
condyle because of the oblique orientation of the beam with the oblique trans cranial projection
with respect to the long axis of the condyle. There is l Tomography represents the anatomic structures better
superimposition by the base of the skull and zygomatic than transcranial radiography; it also provides accu-
arch. rate condylar position within the fossa than transcra-
l Only obvious erosions, sclerosis and osteophytes of the nial radiography; however, it cannot predict proper
condyle can be seen. disc position.
l Special TMJ techniques provided by some TMJ tech- l Tomography has little effect on the diagnosis or treat-
niques permit placement of opened and closed views of ment plan of patients with TMJ disorders when it comes
both condyles on a single film. to diagnosis of osseous pathosis.
l Recent panoramic machines have specific TMJ pro-
Computed tomography
grammes but are of limited usefulness due to its disadvan-
l In computed tomography (CT), thin sections of the
tages. Furthermore, changes in the body of the cortical
structures of interest can be made in several planes and
bone may be difficult to visualize in the panoramic view
viewed under varying conditions that highlight either
as the buccal and lingual cortical plates may mask any
hard or soft tissues.
internal changes.
l This technique overcomes the distortion or superimposi-
Plain film radiography tion of plain film radiography and the blurring of struc-
l Plain films are made with a stationary X-ray source and tures outside the image layer of conventional tomogra-
film. phy, but suffers from volume averaging artefacts that are
l Plain films of the TMJ depict only the mineralized parts most likely on small curved cortical bone surfaces.
of the joint but do not reveal nonmineralized cartilage l CT can also provide three-dimensional reconstructed
and soft tissues. images from the original data.

l Superimposition of adjacent anatomic structures is one l CT examinations are used for the diagnosis of bony
of the major disadvantages and although imaging abnormalities including fractures, dislocations, arthritis,
the joint from multiple angles helps overcome this ankylosis and neoplasia.
limitation. l They are also useful in the evaluation of the effects
l The projections taken are oblique transcranial, the trans- of polytetrafluoroethylene (PTFE) and silicon sheet
orbital and the submentovertex views. implants.
l Each of these is projected approximately 90° to the l Cadaver and clinical studies have indicated that CT ex-
other two. The transpharyngeal view is sometimes used aminations produce excellent images for the evaluation
as an alternative to the transcranial projection. of osseous morphology.
l Disc position cannot be determined from any of these
Soft tissue imaging
techniques.
Arthrography
Conventional tomography l Arthrography involves injection of a radiopaque con-
l In tomography, the images of structures outside a prede- trast material into the joint spaces. The space occupied
termined anatomic layer containing the pertinent struc- by the disc can then be visualized lying between the
tures are blurred as the X-ray source and the film are layers of contrast material.
continuously moving.
Types of arthrography
l The major advantage of tomography is the ability to
i. Single contrast arthrography
provide multiple thin sections through the region of
ii. Double contrast arthrography
interest without superimposition.
l Various tomographic angles and motions, such as lin- i. Single contrast arthrography:
ear, circular, spiral and hypocycloidal affect the image l One of the more commonly used approaches in-
quality. volves injection of contrast material into the lower
l Distortion is minimized due to individualized head joint spaces, referred to as lower joint space or single
positioning by placing the long axis of the condyle into contrast arthrography.
l Perforations of the disc or posterior attachment are l Spot radiographs are obtained during the fluoroscopic
demonstrated by contrast material simultaneously procedure.
flowing into the upper joint space as the lower space
Advantages
is injected.
l Arthrography provides information regarding the soft
ii. Double contrast arthrography:
tissue components, specifically the shape and position
l This technique involves injecting contrast material
of the articular disc. It has been demonstrated that with
into both the spaces and viewing the more central
the addition of tomography, the diagnosis of abnormali-
portions of the joint with tomography. Because con-
ties in the position and shape of the disc is accurate.
trast material is in both the joint spaces, the outline
l Fluoroscopic observation of the injection may reveal the
of the disc is profiled, showing its configuration and
presence of adhesions, perforations and discontinuities
position.
in the capsule and provides a dynamic study of disc
l The outline of the disc can often be enhanced by using
movements, also any abnormal accumulation of joint
double-contrast arthrography. This technique involves
fluid may be evident.
injecting a small amount of air along with a small
l Synovial fluid sampling (arthrocentesis) and lavage of
amount of contrast material into both joint spaces,
the joint can accompany the procedure of arthrography.
producing a thin coat around the periphery of both
l An arthrograph can clearly distinguish the synovial
joint spaces that highlights the disc and the joint
changes of an inflammatory arthritis from an internal
spaces.
derangement resulting from meniscal dysfunction.
Procedure Limitations and complications
l The patient is placed on the fluoroscopic table in a lat- l Direct medial or lateral displacements are difficult to
eral recumbent position with the head tilted on the table interpret with arthrography cannot be used when the
top. This allows the joint to project over the skull above disc is severely deformed.
the facial bones in a manner similar to a transcranial l The rare serious complications associated with arthrog-
radiograph. raphy include joint sepsis, allergic reaction to the iodin-
l Under fluoroscopic guide, the posterosuperior aspect of ated contrast medium and haemarthrosis.
the mandibular condyle is identified with a metal l Pain during and after the procedure, extravasation of the
marker. This area is marked with an indelible pen and contrast medium, disc perforation and transient facial
local anaesthetic lidocaine is infiltrated into the superfi- paralysis are less serious complications of arthrography.
cial skin. l The radiation exposure to the patient can be significant,
l A 0.75 or 1 inch scalp vein needle and the attached tub- depending on the duration of fluoroscopy and the num-
ing are filled with contrast material and care is taken to ber of tomographic exposures made.
eliminate air bubbles. Air bubbles may simulate bodies l The most frequent complication of the technique is the
within the joint space. extravasation of contrast medium into the capsule and
l In a direction perpendicular to the skin and X-ray beam, soft tissues around the joint, causing pain. Nonionic
the 23 gauge needle is introduced in a predetermined contrast media will be the agents of choice to minimize
region of the condyle with the jaw in the closed posi- this discomfort.
tion. Advancement of the needle is done under fluoro- l Parotitis has been reported following arthrography with
scopic observation to ensure proper positioning. large needles and cannulas.
l When the condyle is encountered, the patient is in- l Some patients experience a vagal reaction, as a result of
structed to open the jaw very slightly, and the needle is increased anxiety during the procedure; this can be
guided by feel of the posterior slope of the bony con- managed by administering 0.6 mg of atropine intrave-
dylar margin. On fluoroscopic observation the needle nously.
will appear contiguous with the posterior condylar l Intravasation of contrast material infrequently occurs.
outline. Epinephrine in a dose of 0.03 mL (1:1000 per 3 mL) of
l Approximately, 0.4–0.5 mL of contrast material is in- contrast material is recommended because there is a risk
jected into the lower joint compartment under fluoro- of an acute hypotensive episode with intravasation of
scopic examination. If the contrast is successfully higher doses.
placed into the lower joint space, the opaque material l Transient facial paralysis may result from too vigorous
will be seen flowing freely anterior to the condyle in the infiltration of lidocaine. Some patients experience a mod-
anterior recess of the lower joint compartment. erate degree of pain as the needle is placed on the perios-
l The needle is then withdrawn and fluoroscopic video- teum of the condyle and as the joint is distended with
tape images are recorded during opening and closing contrast material. This discomfort is transient in majority
manoeuvres of the jaws. of the cases. If persistent joint pain occurs following the
procedure, aspirin or acetaminophen and cold compress useful for determining deviation in the form of the
application to the affected side is recommended. joint, disc displacement, dislocation or ankylosis.
Interpretations ii. Thermography
l Thermography has been used experimentally to
l The location, shape and movement of the disc can be
interpreted by observing the shape of the contrast ma- evaluate patients with facial pain and may have a
terial on either side of the disc and its flow within its role in detecting joint inflammation.
own compartment as the patient opens and closes the iii. Ultrasound
l It is not considered to be sensitive or specific for any
mouth.
l Sideways and rotational displacements of the disc can-
TMJ abnormality.
not reliably be determined from orthopantomography. Imaging protocol
l Perforation of the disc or disc attachment can be deter- Decision to be made considering the:
mined by flow of contrast medium into one space after i. Clinical situation
injection of the other; capsular tears and disc adhesions ii. Cost
can also be shown by this technique. iii. Radiation dose
Magnetic resonance imaging Plain films, panoramic radiographs, conventional and CT
l Magnetic resonance imaging (MRI) is a noninvasive tech-
can be reserved for evaluation of:
nique that uses a magnetic field and radiofrequency pulses i. Foreign body giant cell reaction to implants
instead of ionizing radiation to produce the images. ii. Suspected tumours
l MRI gives information including the location of the disc
iii. Ankylosis
in both open and closed mouth positions at multiple iv. Complex facial fractures
levels through the joint.
l Mediolateral and rotational displacements can be de- MRI
tected, as well as the straight anterior displacements. l MRI is indicated for soft tissues, including disc position
l Information on bony contours and cortical outline is and contour.

available with MRI. l MRI when contraindicated, arthrography is recom-
l Abnormalities within the bone marrow of the condyle mended.

and within the muscles and surrounding soft tissues can
Q.6. Articular disc disorders of temporomandibular
be detected.
joint.
l Other information includes the presence of soft tissue
ingrowths, fibrosis and joint effusion. Ans.

l MRI is also used to detect avascular necrosis of the con-
Articular disc disorders
dylar head and myxoid degeneration of the disc, although
Disc thinning and perforation
the significance of these findings is controversial.
l It is believed that the disc wears out over a period of
l In inflammatory arthritis, MRI has been shown to dem-
time. Hence, elderly individuals may generally present
onstrate disc destruction.
with thinning of the disc which may ultimately perforate.
Contraindications l The other causes include excessive occlusal loads from
MRI is contraindicated in certain patients, such as those parafunctional habits such as bruxism, clenching and
with: trauma.
l Pacemakers l The thinnest intermediate portion of the disc may show
l Intracranial vascular clips a circular hole with irregular or fragmented border.
l Any metallic prosthesis in the body l A perforated disc will expose the articular surface of the
Relative contraindications include patient with: joint leading to degenerative changes.

l Obesity
Clinical features
l Claustrophobia
l On auscultation of the TMJ, crepitus or grating noises
l Inability to remain motionless for the examination
may be heard.
Other imaging techniques l In the early phases of the process, pain may be a present-
i. Single-photon emission CT (SPECT) ing complaint. Once the disc is perforated occlusion may
l Single-photon emission CT (SPECT), other nuclear be altered when teeth are in maximum intercuspation.
medicine procedures like ultrasound and thermogra- l Disc changes are readily evident on MRI and arthrogra-
phy have occasionally been used to evaluate the TMJ. phy. Degenerative changes can be appreciated on tradi-
l Nuclear medicine and SPECT are particularly sensi- tional imaging modalities and CT.
tive for inflammatory disorders and arthritis are not l Most joints with disc perforations were osteoarthrotic.
Adherence and adhesions l In normal conditions, when the teeth are in occlusion,
l Adherence refers to a transient phase in which the con- the posterior band of the disc ends at the apex of the
dylar head and the articular disc (inferior joint space) or condyle. In anterior disc displacement, the posterior
the articular disc and the glenoid fossa (superior joint band of the articular disc terminates ahead of the condy-
space) may adhere together. lar apex.
l However, prolonged periods of adhesion may result in a A. Disc displacement with reduction
permanent state of adhesion (true adhesions). l It is characterized by an anterior or anteromedial
l The causes for adhesion are long periods of static load- displacement of the disc upon mouth opening. How-
ing of the joint (e.g. jaw clenching during sleep) and ever, on closing the mouth, the disc returns to a more
haemarthrosis caused, by macrotrauma or surgery. normal position relative to the condyle on opening.
l Normally, when the joint is loaded, weeping lubrication Clinical features
is exhausted and boundary lubrication takes over to l Clicking sound may be heard during mandibular
prevent adhesions. But when the jaw is subjected to opening and closing. The opening click may be
long periods of static loading, the boundary lubrication heard during any phase of the translatory cycle
is not sufficient to compensate for the exhaustion of and the closing click may be felt as the disc again
weeping lubrication, resulting in adherence of the disc becomes displaced. Mandible may be deviated to
either with the upper or lower joint compartment. the affected side.
l Muscle splinting may result in joint tenderness
Clinical features
and limitation of mouth opening.
l Patients may complain of a stiff jaw, dull aching pain
B. Disc displacement without reduction
and limited mouth opening, especially if they habitually
l In this condition, the condylar head is unable to pass
clench their teeth.
under the displaced disc.
l However, the limitation in mouth opening characteristi-
l The reasons for the condyle to be trapped include
cally corrects following a single click when the patient
thickening of posterior band, change in shape of disc
makes attempts to open the mouth.
from biconcave to biconvex and decrease in tension
l True adhesions may cause elongation of the collateral
in the posterior attachment.
disc ligaments and anterior capsular ligaments.
l Such a trapping, the disc in front of the condyle,
l During translatory movements, the condyle is ahead of
limiting the condylar translation in the affected joint
the articular disc thereby appearing that the disc is pos-
results in a ‘closed lock’.
teriorly dislocated. It is thus hypothesized that posterior
Clinical features
disc displacements may result from disc adhesions.
l It is generally a painful condition as the articular
l Clinically, restriction of the condylar movements to
capsule, disc ligaments and posterior attachment
rotation alone, is typical of adhesions between disc and
are inflamed.
superior joint space (mouth opening may be restricted
l Patient may present with pain and severe limita-
to about 25 mm).
tion in mouth opening (maximum of 25–30 mm).
l However, when the adhesion occurs between the disc
l Mandible is deflected to the ipsilateral side on
and the inferior joint compartment, rotational move-
mouth opening.
ment is inhibited and the translatory cycle is normal
l There is limitation in protrusive movements.
(patient can open the mouth to a normal inter-incisal
l Chronic cases may present with joint crepitus.
distance but experience a jerk or limitation when at-
Lateral excursions are limited.
tempting to open the mouth to its full extent).
Disc displacement Displacement of disc–condyle complex (hypermobility
l Disc displacements are also termed as internal de- and dislocation)
rangement. l Occasionally during the terminal phases of the transla-
l The commonest causes for internal derangement in- tory cycle, as the condyle moves past the articular emi-
clude trauma, clenching and biting on hard substances. nence it may suddenly move forward to facilitate a wide
l The internal derangements could include: mouth opening referred to as subluxation (hypermobil-
A. Disc displacement with reduction ity, partial dislocation).
B. Disc displacement without reduction l Hypermobility may occur due to joint laxity seen as a
l Anterior disc displacement is common and it usually oc- genetic predisposition (Ehlers–Danlos syndrome), fol-
curs when there is elongation of the disc attachment and lowing dental procedures that require prolonged mouth
deformation or thinning of the posterior border of the disc, opening (endodontic procedures, third-molar extrac-
which in turn permits the articular disc to get displaced in tion), excessive yawning and during endotracheal incu-
an anterior direction on the surface of the condyle. bation for general anaesthesia.
Clinical features usual position. It is usually associated with a fracture

l Many patients describe the sudden forward movement of base of skull or the anterior wall of bony meatus.
as a feeling of a ‘thud’ sound. iii. Lateral dislocation
l This condition is usually painless unless it becomes l Lateral dislocation has been described by Allen and
chronic. Young, in 1969, in two subgroups:

l Patients may exhibit a tapered/elongated face. a. Type I is the late subluxation and
l Hypermobility may be distinguished from anterior disc b. Type II is a complete dislocation where condyle
displacements in that the click is associated only with is forced laterally and superiorly to the tempo
wide opening and absence of closing click. fossa. It is accompanied by the fracture of body
of mandible at symphysis.
Dislocation (open lock)
iv. Superior dislocation
l Dislocation of the condyle is a common condition that
l Superior dislocation as described by Zecha in 1977,
may occur in an acute or chronic form. It is character-
the dislocation of condyle in to the middle cranial
ized by inability to close the mouth with or without
fossa and associated with fracture of glenoid fossa.
pain.
l It is said most probably due to the small rounded
l Dislocation has to be differentiated from subluxation
shape of the condyle which fails to impinge in the
which is a self-reducible condition. When the mouth is
margins strongly than the central area.
opened, the head of the condyle should not pass beyond
the apex of articular eminence. Managing temporomandibular disorder patients re-
l In case of laxity of capsular structures, a wide open quiring dental procedures
position allows the condyle to move pass the articular l Hot compresses to masseter and temporalis areas for
eminence which cannot be reduced by the patient. about 10–20 min two to three times daily for 2 days.
l Dislocation can occur in any direction with anterior l Use a minor tranquillizer or skeletal-muscle relaxant
dislocation being the commonest one. (e.g. lorazepam, 1 mg; cyclobenzaprine, 10 mg) on the
l Various predisposing factors have been associated with night and day of the procedure.
dislocation like muscle fatigue and spasm, the defect in l On the day of the procedure, before starting of the pro-
the bony surface like shallow articular eminence and cedure give an NSAID.
laxity of the capsular ligament. l During surgical procedure, to support the patient’s comfort-
l People with defect in collagen synthesis like Ehlers– able opening, use a child-sized surgical rubber mouth prop.
Danlos syndrome and Marfan syndrome are said to be l Intravenous sedation and/or inhalation analgesia, during
genetically predisposed to this condition. procedure.

l Provide frequent rest periods to avoid prolonged open-
Clinical features ing and apply moist heat to masticatory muscles during
l The condition is characterized by inability to close the rest period and gently massage them.
mouth after wide opening. Bilateral dislocation is more l Perform the procedure in the morning, when reserve is
common than unilateral dislocation. likely to be greatest.
l However, when the dislocation is unilateral, the chin is l Use of muscle relaxant and NSAID medication if neces-
deviated to the contralateral side. Palpation in the preau- sary, after procedure.
ricular region reveals an empty fossa and may reveal the l Apply cold compresses to the TMJ and muscle areas
condyle anterior to the joint. during and 24 h after the procedure.
l The inability to close the mouth is due to the spasm of
masticatory muscles. Q.7. Classify temporomandibular disorders. Discuss the

l A typical facial expression (elongated face) is due to management of TMJ arthritis.
anxiety related to the thought of not being able to close Ans.
the mouth.
[Same as LE Q.1]
Types of dislocation
Depending upon the position the condyle occupies: Q.8. Write clinical features and management of MPDS.
i. Anterior dislocation
Ans.
l Heslop, in 1956, described the anterior dislocation in
which the condyle moves anterior to the articulating [Same as LE Q.2]

eminence. It is one of the most common type of
dislocation. Q.9. Management of MPDS.
ii. Posterior dislocation
Ans.
l Helmy, in 1957, described the posterior variant in
which the head of condyle is displaced posterior to its [Same as LE Q.2]

Q.10. Enumerate the causes of trismus. Discuss in Surgical treatment

detail. l Insertion of bone graft.
l Capsulorraphy – joint is exposed and vertical incision is

Ans.
made and edges of capsule are overlapped and sutured
[Same as LE Q.3] to tighten the capsule in anteroposterior plane.
l Intermaxillary Fixation (IMF) for 7 days relieves sublux-
ation and clicking of joint.

SHORT ESSAYS: l Shortening of temporalis tendon.
Q.1. Subluxation of TMJ. Q.2. Myofacial pain dysfunction syndrome (MPDS).

Ans. Ans.
[Ref LE Q.2]
{SN Q.2}
Q.3. Clinical features and management of degenerative
l Self-reducing incomplete dislocation or habitual dis- arthritis of TMJ.
location of TMJ is known as subluxation.
Ans.
l It may be unilateral or bilateral, generally due to
stretching of the capsule and ligaments. l Other names of degenerative arthritis are: osteoarthrosis
or osteoarthritis.
Aetiology
l It is a disorder of articular cartilage and subchondral bone,
l Long continuous mouth opening, e.g. biting on a big
with secondary inflammation of the synovial membrane.
apple or burger, long yawning.
l It is a localized joint disease without systemic manifes-
l Excessive movement during oral surgical procedures.
tations.
l Chronic degenerative changes, e.g. osteoarthritis.
l Genetic factors play an important role. It is asymptomatic
l Underlying psychiatric problems.
in patients above age of 50 years, but sometimes early
l Use of phenothiazine group of drugs.
arthritic changes can be seen in younger individuals.
l Secondary degenerative joint disease results from a
Clinical feature known underlying cause, such as trauma, congenital
l It may be unilateral or bilateral. dysplasia or metabolic disease.
Symptom Clinical manifestations
l Cracking noise, temporary locking of condyle, immobili- l Patients with symptomatic DJD of the TMJ presents
zation of jaw, pain in last few millimetre of mouth opening. with unilateral pain directly on the condyle, limiting
mandibular opening, crepitus and a feeling of stiffness
Signs
after a period of inactivity.
l Condyle gets locked when mouth is opened widely, and
l Degenerative changes of the TMJ detected on radio-
upon closing it will return with jumping motion.
graphic examination could be incidental.
l On palpation click on opening and sliding of condyle
l Sometimes degenerative changes may be undiagnosed
over articular eminence.
by conventional radiography as the defects are confined
Histopathology to the articular soft tissue.
l Long-standing opening causes stretching of ligament l MRI visualizes soft-tissue changes better.
and capsule due to absence of elastic fibres the ligament l On tomograms and CT scans radiographic findings in
stretched beyond its capacity will not come back to degenerative joint disease may show narrowing of the
normal length. joint space, irregular joint space, flattening of the articu-
l Laxity of capsule and over stretched ligament causes lar surfaces, osteophytic formation, anterior lipping of
subluxation. the condyle and the presence of Ely cysts.
l The presence of joint effusion is most accurately de-
Treatment
tected in T2-weighted MRI images.
Conservative method
l Shrinkage of capsule leading to fibrosis – by use of Treatment
sclerosing agents like 5% sodium psylliate or 5% in- l This disease is managed by conservative treatment.
tracaine in oil base. Mixture of equal parts of 0.5% l Improvement is noted in many patients after 9 months,
eucupine in oil 15% aqueous solution of sodium as well as a ‘burning out’ of many cases occurs after
psylliate. 1 year is seen.
l Repeat the injections every 2–3 weeks till fibrosis of the l Conservative therapy includes nonsteroidal anti-
capsule occurs. inflammatory drugs, heat application, soft diet, rest
and occlusal splints that allow free movement of the Aetiology

mandible. Trauma, either macrotrauma or microtrauma.
l Surgery is indicated when TMJ pain or significant loss
Macrotrauma
of function persists and when distinct radiographic evi-
It can be direct or indirect.
dence of degenerative joint changes exists.
Direct trauma
Q.4. Internal derangement of temporomandibular joint.
l Trauma to mandible in open mouth position.
l Can also be iatrogenic.

Ans.
l Intubation procedures.
{SN Q.6} l Third molar extractions.
l Long dental appointments.

l Internal derangement of TMJ was first described by l Over-extension of jaw causes elongation of the liga-
Hey and Davies (1814) as a localized mechanical ments each time.
fault interfering with smooth action of a joint.
l Internal derangement is defined as a disturbance in Indirect trauma
the normal anatomical relationship between the disc l Cervical flexion-extension injury.
and condyle that interferes with smooth movement Microtrauma

of joint and cause momentary catching, clicking, l Bruxism or clenching
popping/locking, etc. l Mandible orthopaedic instability
Clinical and diagnostic features

Pathogenesis
l History of severe pain on yawning
l Internal derangement is a progressive anterior and
l History of direct trauma to the joint years earlier
medial subluxation of meniscus from its normal posi-
l Opening click and reciprocal click
tion at rest.
l Joint tenderness, especially with function
l Previous trauma may lead to stretching of lower lamina
l Deviation to affected side till clicking occurs
of bilaminar zone, allowing posterior band to sublux
l Deviation on opening
forward in relation to condylar head in centric relation.
l Crepitus
The first abnormality seen is a click on opening.
l Trismus – with 20–25 mm interincisal distance
l The open click represents the posterior band relocating
l Continuous pain on side of face and head exacerbated
posteriorly over the condyle from its subluxed position.
by moving the jaw
l Pain at this stage represents the meniscus beginning to
l Elimination of pain following local anaesthesia of the
lose its insertion into lateral pole.
affected joint
l Following further trauma (acute or chronic), the menis-
cus subluxes progressively forwards and medially, so Management

that it cannot regain its position over condylar head on Conservative management
wide opening. l Reassure the patient.
l Inflammation associated with damage to meniscal at- l Use of tricyclic antidepressant drugs in patient with history
tachments and joint surface by incorrect positioning of of bruxing, clenching and tenderness of muscles of masti-
meniscus leads to formation of exudates and eventual cation. They act to reduce jaw movements during sleep.
adhesions and fibrosis. This fibrosis maintains meniscus l Mild sedative may be prescribed to overcome anxiety
in subluxed position, and the joint becomes locked. and tension.
There will be painful restriction of opening. l Occlusal splints – anterior positioning splint.
l NSAIDs in cases of acute episodes of pain.
l Intra-articular injection of steroid for acute pain and

{SN Q.6} tenderness in the joint.
l 1 mL hydrocortisone along with 1 mL of local anaes-
Staging of internal derangement – Wilkes
thetic is injected into the joint.
Stage I Early reducing disc of displacement
Stage II Late reducing disc displacement Surgical management
Stage III Nonreducing disc displacement – acute/subacute When all the conservative measures fail and in some
cases of irreducible, medially displaced meniscus, surgery
Stage IV Nonreducing disc displacement – chronic
is the last resort.
Stage V Nonreducing disc displacement with osteoarthroses Various surgical procedures indicated are as follows:
l Arthrocentesis and lavage
l Arthroscopy spasm of the jaw muscles by which normal opening of the

l Disc repositioning mouth is restricted (locked jaw).
l Disc removal and autologous graft disc replacement Aetiology of trismus
l Autologous flap reconstruction Congenital
l Alloplastic disc replacement l Birth injury
l Condylotomy l Hemifacial macrosomia, etc.
l Condylectomy
Traumatic (acute)
Q.5. Bruxism. l Fractures of mandible, zygomatic or temporal bones
Ans. l Hematomas in the joint or muscle of mastication
l Injury from local anaesthetic injection

l Night grinding of the teeth unintentionally is known as l Postsurgical (e.g. third molar removal and TMJ surgery)
bruxism.
l The aetiology is not understood, but several factors are Neoplastic (benign)
thought to be responsible for this such as emotional l Mesenchymal tumours of the TMJ and surrounding
stress, etc. structures (e.g. osteochondroma)

l Occlusal appliances such as splint should be worn dur-
Neoplastic (malignant)
ing night, but does not decrease the activity of bruxism. l Chondrosarcoma, osteosarcoma, tumours of the oro-
Treatment pharynx (Trotter syndrome), etc.

l Symptoms decrease when buspirone was added. Reactive (acute)
l Buspirone has a postsynaptic dopaminergic effect and
l Septic arthritis
may act to partially restore suppressed dopamine levels l Tetanus
associated with the use of SSRIs. l Abscesses of the submasseteric, lateral pharyngeal,
l Severe bruxers injected in the masseter muscles with
pterygomandibular, submandibular and temporal
botulinum toxin in an open-label prospective trial and spaces
reported significant improvement in symptoms and l Tonsillitis and peritonsillar abscess
minimal adverse effects. l Parotid abscess
l The treatment effect lasted approximately 5 months and
l Mumps
had to be repeated.
l Botulinum toxin exerts a paralytic effect on the muscle Reactive (chronic)
by inhibiting the release of acetylcholine at the neuro- l TMJ ankylosis (fibrous and bony)
muscular junction. l Degenerative joint disease
l Rheumatoid arthritis
Q.6. Clinical features of TMJ subluxation. l Myofascial pain dysfunction (MPD), etc.
Ans. Psychogenic
[Same as SE Q.1] l Hysterical trismus
Q.7. Treatment plan for MPDS. Drug induced

l Strychnine poisoning
Ans.
Q.2. Subluxation of TMJ – aetiology.
[Same as SE Q.2]
Ans.
Q.8. Aetiology of MPDS.
[Ref SE Q.1]
Ans.
Q.3. Myositis ossificans.
[Same as SE Q.2]
Ans.
Myositis ossificans is a rare disturbance characterized
SHORT NOTES: l
by the formation of bone in the interstitial tissue of

Q.1. Four causes of trismus. muscle.
l It has also been observed in the superficial tissues away
Ans.
from muscle, even in the skin.
The word ‘trismus’ is derived from the Greek trismus l When muscles of the face are involved, the masseter
meaning gnashing and is defined as a prolonged, tetanic muscle is most frequently affected.
l It results in a restriction of mandibular movements, Q.8. Enumerate the temporomandibular joint views.
which should alert the clinician to the possibility of
Ans.
myositis ossificans.
Various TMJ views are as follows:
Q.4. Temporomandibular joint ankylosis. i. Transcranial view
l Provides a sagittal view of the lateral aspects of the
Ans.
condyle and temporal component of the joint.
l Ankylosis of TMJ can be true ankylosis or false ankylosis. ii. Transorbital view
l The most common cause of TMJ ankylosis is trauma to l The mediolateral dimension of the articular emi-
the chin although infections also may be involved. nence, condylar head and condylar neck is visible,
l Children are more prone to ankylosis because of greater which makes this view particularly useful for visu-
osteogenic potential and an incompletely formed disc. alizing condylar neck fractures.
l Ankylosis results from prolonged immobilization iii. Transpharyngeal view
following condylar fracture. l Sagittal view of the medial pole of the condyle and
l Limited mandibular movement, deviation of the man- medial aspect of the condyle are seen.
dible to the affected side on opening, and facial asym- iv. Submentovertex view
metry may be observed in TMJ ankylosis. l Shows the base of the skull, condyles bilaterally.
l Osseous deposition may be seen on radiographs. v. Reverse Townes’ view
l Treatment: It can be treated by surgical procedures like l Useful to view condylar neck and medially dis-
condylectomy, gap arthroplasty or interpositional gap placed condyle.
arthroplasty. vi. PA mandible
l Gap arthroplasty using interpositional materials be- l Bilateral condylar fractures.
tween the cut segments is the technique most commonly vii. Lateral skull view
performed. l Unilateral condyle
Q.5. How will you differentiate true ankyloses from viii. Lateral obligue (ramus)
l Unilateral coronoid and condyle and also the ramus
pseudoankylosis of temporomandibular joint?
of mandible are seen.
Ans.
Q.9. Drugs to relieve muscular spasm.
[Ref LE Q.4]
Ans.
Q.6. Mention the staging of internal derangement of
temporomandibular joint. Various drugs used to relieve muscular spasm are as
follows:
Ans. l NSAIDs, acetaminophen, muscle relaxants, antianxiety
[Ref SE Q.4] agents and clonazepam.

l Tricyclic antidepressants have been used up to a toler-
Q.7. Define myofunctional pain dysfunction syndrome. ated level for its central acting muscle relaxant analge-
Ans. sic affect.
l Aspirin or NSAID should be recommended for analge-
l The muscles of mastication, the tongue muscles and the sic and anti-inflammatory actions.
strap muscle of the neck function as a unit and that dys-
function in one group of muscles is frequently associ- Q.10. Define trismus.
ated with altered tonus and symptoms of ‘tension’ in the Ans.
other related groups.
l When muscle spasm develops in one or more mastica-
[Same as SN Q.1]
tory muscles, dysfunction as well as pain occurs and the
condition usually is designated as MPDS.
Topic 9
Ionizing Radiation and Regressive Alterations
of the Oral Cavity
LONG ESSAYS:
1. Describe radiation complications of the jaws.
SHORT ESSAYS:
1. Classify regressive alterations of teeth.
SHORT NOTES:
1 . Pink disease.
2. Mention causes of resorption of roots.
3. Abfraction.
5. Attrition.
SOLVED ANSWERS
LONG ESSAYS: l Reassurance that this condition and accompanying

pain will subside is welcomed by patients.
Q.1. Describe radiation complications of the jaws. II. Radiation-induced xerostomia
l Radiation-induced xerostomia is caused by the di-
Ans.
rect damaging effects of radiation on both major
Complications of radiation and their management and minor salivary glands located in the path of
I. Radiation mucositis radiation.
l Radiation mucositis is the response of oral mucosa l Glandular tissue in general is very sensitive to radia-
to acute radiation injury. tion. Following radiation therapy, the mouth becomes
l It presents as a diffuse erythema with pain or muco- dry as a result of the loss of salivary gland acini.
sal ulcerations and a fibrinous exudate. l The skin becomes dry as well because of loss of
l It is a self-limiting condition, may develop in the sweat and sebaceous glands.
last 3 weeks of radiotherapy and may extend for l A histopathologic study of irradiated glands will
about 1 month after radiotherapy. show the three-H tissue replacement of the acini but
l During this acute painful phase, topical viscous 2% preservation of the ducts. Ductal epithelium is
xylocaine gel as well as systemic analgesics may be somewhat radiation resistant.
needed to control pain. Antibiotics are not required l As most radiation ports leave some areas of mucosa
unless there is an associated lymphadenitis or sys- untouched, there is an opportunity to stimulate
temic toxicity. the remaining glands to overproduce. Although it
l Patients will benefit from chlorhexidine gluconate improves mouth moisture in only about 70% of
rinses, if tolerated, to reduce bacterial colonization irradiated patients.
of the ulcers. l Pilocarpine (Salagen, MGI Pharma), 5 mg by
l Nutritional support may be needed in some cases. mouth three times daily, often improves eating,
l In severe cases, it is reasonable to provide intrave- speaking, and swallowing functions.
nous fluid therapy and nasogastric tube feeding for l It should be taken regularly to gain and maintain
a short time. an improvement, and it must be given with caution
to individuals with heart diseases associated with l Improving mouth moisture and increasing the liq-
bradycardia, heart block, or other medications that uid content of the diet helps indirectly.
may slow heart rate or conduction. l Oesophageal dilations do not improve this condi-
l Additionally, sports water bottles are used by many tion unless the oesophagus itself was included in
individuals, and Evian atomized water spray has the radiation ports.
been found to be beneficial to many. V. Radiation effects on jaw growth and developing teeth
III. Radiation caries l Radiation therapy during the growth and develop-
l Those teeth in the direct path of 6000 cGy or ment years will create a dose-related hypoplasia of
greater radiation are most at risk of developing the mandible as well as partial or complete agenesis
radiation caries. of teeth within the portals of radiotherapy.
l It results from xerostomia, which permits cario- l These effects are primarily manifested as an antero-
genic bacteria to proliferate unopposed by the usual posterior deficiency of the mandible that is retrogna-
lysosomes and IgA immunoglobulins in saliva and thia and a general reduction in the size of the ramus
causes the loss of the saliva’s natural buffering and body of the mandible, creating a severe chin
capacity. Although this mechanism contributes to deficiency appearance.
radiation caries, it is not its only or most significant l The teeth within the radiated bone will generally be
cause. smaller and will usually exhibit arrested root devel-

l Radiation caries is hard and black and occurs at the opment. Since the crowns will be affected to a
gingival margin, cusp tips and incisal surfaces. lesser degree, many teeth will appear radiographi-
l Radiation caries is either present only in the irradi- cally to have a normal crown size with no roots,
ated field or is more severe in the irradiated field, mimicking an exfoliating primary tooth. Some teeth
whereas the entire mouth is affected by xerostomia. will fail to form altogether, that is, agenesis.
l Radiation caries is mainly due to pulpal necrosis l The teeth may be replaced with removable partial
and odontoblast death, which causes deterioration dentures or with implant-supported fixed dental ap-
of both the dentine and the dentinoenamel junction. pliances, provided that all remaining growth has been
l The enamel is subsequently lost from the dentine completed and the patient has undergone the 20/10
because of dentinal dehydration and dentinoenamel hyperbaric oxygen (HBO) protocol (20 sessions at
junction deterioration similar to dentinogenesis 2.4 ATA for 90 min on 100% oxygen prior to surgery
imperfecta. The exposed dentine becomes black or and 10 sessions after surgery).
brown and hard and deteriorates further. l In cases of significant anteroposterior deficiency
l Pulp testing teeth with radiation caries mayor may and provided that the patient has completed the
not produce a response. Yet when the pulp is exam- 20/10 HBO protocol osteotomies advancing the jaw
ined, it is avascular. The tooth with radiation caries using bone grafting can be accomplished.
may have a responsive pulp but is actually nonvital As an alternative, distraction osteogenesis can also
due to avascular necrosis of the vascular pulpal tis- be successfully provided usually in a young patient
sues, including the odontoblasts. who has undergone the 20/10 HBO protocol.
l Even the best oral hygiene, dental care and fluoride VI. Radiation-induced trismus
carriers will not prevent all radiation caries. Once l Radiation-induced trismus is a condition that fre-
developed, radiation caries should be treated quently accompanies osteoradionecrosis in the pos-
promptly using restorative techniques appropriate terior body and ramus region of the mandible and is
for the degree of lost and involved tooth substance. usually improved with the successful treatment of
IV. Radiation dysphagia the osteoradionecrosis.
l It is one of the most troubling and least treatable l The trismus is not a consequence of the effects
later complications of radiotherapy. of radiation on the temporomandibular joint but

l Many patients will report difficulty in ‘swallowing’ instead is due either to radiation fibrosis within the
food, ‘getting stuck’ in the hypopharynx and will masseter and medial pterygoid muscles or due to
aspirate on swallowing after radiotherapy. restrictive fibrosis in the mucosa of the anterior
l This condition is caused by radiation fibrosis within tonsillar pillar and retromolar areas.
the pharyngeal constrictors, which makes these se- l If the trismus is due to tight and unresilient mucosal
ries of three muscle pairs stiff and unable to con- restrictions in the tonsillar and/or retromolar areas,
tract in the coordinated fashion that is necessary to a significant increase in opening may be achieved
propel food into the oesophagus. by excising this tissue and replacing it with a viable
l There is only a little that can be done directly to cor- skin paddle from either a myocutaneous or a free
rect this. Occasionally, swallowing therapy helps. microvascular flap.
l If the trismus is the result of radiation fibrosis in the Resorption of teeth

pterygomasseteric sling, the prognosis is much a. External resorption
worse. Such fibrosis cannot be effectively excised l It occurs due to periapical granuloma or by pressure
without risking the blood supply to the ramus and of cysts most common by apical periodontal cyst and
thus precipitating an osteoradionecrosis. tumours by heavy orthodontic forces.
l Modest gains can be achieved with bilateral coro- b. Internal resorption
noidectomies or partial excisions of the fibrosis in l It is also known as odontoclastoma or pink tooth of
the masseter or medial pterygoid muscles. mummery. It is due to inflammatory hyperplasia of

l These also must be followed with intensive jaw- the pulp.
opening exercises using a device such as the thera-
bite, by tongue blade exercises or by the chewing of Changes in dentine
soft, sugarless gum. a. Dental sclerosis/transparent dentine/reparative
dentine
l Calcification of dentinal tubules due to trauma, car-
SHORT ESSAYS: ies, etc.
b. Secondary dentine/irregular dentine
Q.1. Classify regressive alterations of teeth.
l It is also known as adventitious dentine, deposited
Ans. after the completion of primary dentine and is associ-
Regressive alterations affecting teeth ated with normal ageing process, also known as irri-
tation dentine as it is also stimulated by trauma,
l Tooth wear
caries, attrition, etc.
a. Attrition
l Tertiary dentine localized exclusively adjacent to the
b. Abrasion
irritated zone, tubules are less in number, very irregular.
c. Erosion (corrosion)
c. Dead tracts
d. Abfraction
l Are not calcified and are permeable to penetration of
l Resorption of teeth
dyes.
a. External
b. Internal Changes in pulp
l Changes in dentine a. Reticular atrophy of pulp
a. Reparative dentine l There is an atrophy of pulp tissue and decrease in the
b. Secondary dentine size of pulp chamber due to increase age.
c. Dead tracts b. Pulp calcifications
l Changes in pulp
There are various types of denticles as follows:
a. Reticular atrophy of pulp
i. True denticles resemble dentine due to their tubular
b. Pulp calcifications
structure; resemble secondary dentine as tubules are
l Changes in cementum
less and irregular and more common in pulp chambers.
a. Cementicles
ii. False denticles are localized masses of the calcified tis-
b. Hypercementosis
sue and do not contain dentinal tubules. They are made
These are all described as follows: of concentric layers of dentine. Are more common in
Tooth wear pulp chamber and are larger than true denticles.
a. Attrition iii. Free denticles are not attached to dentinal wall, but ly-
l Physiologic wearing away of the tooth material as- ing entirely in pulp tissues.
sociated with the ageing process iv. Attached denticles are continuous with dentinal wall; it
b. Abrasion is more common than free denticles.
l Pathological wearing of tooth substance usually v. Diffuse calcifications are most common in root canals;
occurs at exposed root surface of the tooth seen as a as calcific degenerates.
wedge-shaped ditch near CEJ. Changes in cementum
c. Erosion a . Cementicles
l Chemical loss of tooth material without involving These are foci of calcified tissue that lie free in peri-
bacterial action; smooth, highly polished and scooped odontal ligament. They develop by calcification of nests
out depression on enamel adjacent to CEJ. of epithelial cell rests in Periodontal Ligament (PDL).
d. Abfraction b. Hypercementosis/cementum hyperplasia
l Refers to loss of tooth structure from repeated tooth Deposition of secondary cementum (cellular), on the
flexure caused by occlusal stresses. root surface. Increased incidence in nonfunctional teeth.
SHORT NOTES: Q.3. Abfraction.

Q.1. Pink disease. Ans.
Ans. l Abfraction refers to the loss of tooth structure from
repeated tooth flexure caused by occlusal stresses.
l Pink disease is also known as acrodynia or Swift disease.
l It is due to mercurial toxicity. Q.4. Osteoradionecrosis.
l It is most common in young infants of less than 2 years
Ans.
of age.
l Skin resembles raw-beef, skin peeling, severe pruritis l Osteoradionecrosis implies infection of bone rendering
and children tear their hair out in patches. necrosis by ionizing radiation.
l Treatment: BAL, i.e. British anti-lewisite. l Occurs due to radiation in massive doses, partial necro-
sis of bone and trauma which causes infection.

Q.2. Mention causes of resorption of roots. l Cure of malignancy of tongue, floor of oral cavity, salivary
Ans. glands, sinuses and neoplasm causes necrosis of maxillary

and mandibular bones, and ulceration of soft tissues.
a. External resorption may occur due to: l Osteoradionecrosis is best managed with topical antibi-
l Periapical inflammation
otic (tetracycline) or antiseptic (chlorhexidine) rinses.
l Tumours and cysts
l Hyperbaric oxygen (HBO) therapy increases the oxy-
l Reimplantation
genation of tissue, increases angiogenesis and promotes
l Excessive mechanical or occlusal forces (e.g. orth-
osteoblast and fibroblast function.
odontic treatment) especially in hypothyroidism
l Impacted teeth Q.5. Attrition.
l Idiopathic (maxillary premolars – maximum; man-
dibular incisors and molars – least) Ans.

l Trauma
l Physiological wearing away of the tooth material is
l Hormonal imbalances
known as attrition.
b. Internal resorption l Usually associated with ageing.
l Pink tooth of mummery/odontoclastoma/internal
l Polished facets on occlusal surfaces.
granuloma l Arch length decreases due to proximal attrition.
l Idiopathic
l Advanced attrition seen in amelogenesis imperfecta and
l Due to inflammatory hyperplasia of pulp
dentinogenesis imperfecta.
Topic 10
Odontologic Diseases

LONG ESSAYS:
1. Write briefly about the clinical features of
a. Amelogenesis imperfecta
b. Dentinogenesis imperfecta.
2. Describe in detail developmental anomalies of shape of teeth.
SHORT ESSAYS:
1 . Internal resorption.
2. Dens invaginatus.
3. Anodontia.
SHORT NOTES:
1. Enamel hypoplasia.
2. Talon cusp.
3. Dilaceration.
4. Dens in dente.
5. Turner tooth.
6. Clinical features of regional odontodysplasia.
7. Dentinogenesis imperfecta.
8. Pink tooth of mummery.
9. Hutchinson triad.
10. Fordyce granules.
11. Anodontia.
12. Concrescence.
13. Supernumerary teeth.
14. Taurodontism.
15. Describe briefly the causes for early loss of teeth.
16. Median rhomboid glossitis.
17. Geographic tongue.
18. Benign migratory glossitis.
19. Macroglossia.
20. Dentine dysplasia.
21. Black hairy tongue.
22. Natal teeth.
23. Peutz–Jeghers syndrome.
24. Globulomaxillary cyst.
25. Gingival cysts of infants.
26. What is fusion.
27. Oligodontia.
28. Gardner syndrome.
29. Mesiodens.
30. Turner hypoplasia. [Same as SN Q.5]
SOLVED ANSWERS
Clinical features
LONG ESSAYS:
l Hypoplastic type: Enamel thickness is not complete.
Q.1. Write briefly about the clinical features of l Hypocalcification type: Enamel is soft and can be re-
a. Amelogenesis imperfecta moved by prophylactic instrument.
b. Dentinogenesis imperfecta. l Hypomaturative type: Enamel can be pierced with
explorer point and chipped off.

Ans.
l Teeth are brownish in colour. Vertical lines or grooves
Amelogenesis imperfecta may be present on surface.
l It is a group of hereditary defects of enamel associ- l Enamel is chalky and it can be chipped off with expo-
ated with other generalized defects, dentine is usually sure of underlying dentine.
normal. l Contact points are abraded.
l It may be of three types:
Treatment
a. Hypoplastic type: It is the defect of enamel organic
l There is no treatment except for improvement of cos-
matrix formation.
metic appearance by veneering or capping of teeth.
b. Hypocalcification type: It is the defect of mineraliza-
tion of enamel. Dentinogenesis imperfecta
c. Hypomaturation type: It is the defect of enamel crys- l Dentinogenesis imperfecta is an autosomal dominant
tal maturation. condition.
l It is defect of collagen formation hence only dentine is Treatment for both type I and type II dentinogenesis
affected rather than enamel. imperfecta
l Treatment of these patients is directed towards prevent-
Dentinogenesis imperfecta revised classification ing the loss of enamel and subsequent loss of dentine
l Dentinogenesis imperfecta I through attrition.
Dentinogenesis imperfecta without osteogenesis imper- l Crown capping may be done on teeth to avoid attrition.
fecta (opalescent dentine), this corresponds to dentino- Cast metal crowns on posterior teeth and jacket crowns
genesis imperfecta type II of Shields classification. on anterior teeth have been used with considerable
l Dentinogenesis imperfecta II (brandywine type dentino- success.
genesis imperfecta)
This corresponds to dentinogenesis imperfecta type III Q.2. Describe in detail developmental anomalies of
of Shields classification. shape of teeth.
There is no substitute for the category designated as Ans.
dentinogenesis imperfecta type I of the previous classi-
fication (Shields). Developmental disturbances affecting shape of teeth
i. Gemination, fusion and concrescence
Dentinogenesis imperfecta I ii. Accessory cusps
Clinical features l Cusp of Carabelli
l Enamel may be thinner than normal, with amber-like l Talon cusp
translucency and teeth have variety of colours blue-grey l Dens invaginatous
or amber brown and are opalescent. l Dens evaginatous
Radiographic features iii. Ectopic enamel

l Enamel pearls
l In both primary/permanent teeth, radiographs show
l Cervical enamel extensions
bulbous crowns with a cervical constriction.
l Short slender roots and obliterated pulp canals and iv. Taurodontism
chambers in type I dentinogenesis imperfecta. v. Dilaceration
vi. Supernumerary roots
l Enamel is normal, while in dentine irregular tubules are I. a. Gemination
l Gemination is a developmental anomaly that re-
seen with large areas of uncalcified matrix.
l Pulp chamber is obliterated by continuous deposition fers to division of single tooth germ into incom-
of dentine with entrapped ‘odontoblasts’. plete or complete formation of two teeth.
l Crowns may be partially or totally separated from
l Dentinoenamel junction is without scalloping, so oc-
clusal surface is lost due to attrition. each other.

l Roots are fused and single root canal is present
Dentinogenesis imperfecta II (Brandywine type dentin- within the root.
ogenesis imperfecta) l The structure is usually one with two completely
l This disorder was found in Brandywine triracial isolate or incompletely separated crowns that have a sin-
in southern Maryland. This corresponds to dentinogen- gle root and a root canal.
esis imperfecta type III of Shields classification. l The condition is seen in both deciduous and
Clinical features permanent dentition, with a higher frequency in

l The crowns of the deciduous and permanent teeth wear the anterior and maxillary region.
rapidly after eruption and multiple pulp exposures are I. b. Fusion
l Fusion is defined as single enlarged tooth or joined
seen in primary teeth.
l Colour of teeth has unusual translucent/opalescent hue. tooth in which the tooth count reveals a missing
l Enamel lost earlier due to fracture; defective tooth when the anomalous tooth is counted as one.
l One of the most important criteria for fusion is the
Dentino Enamel Junction (DEJ) and dentine is worn off.
fused tooth must exhibit confluent dentine.
Radiographic features l Both permanent and deciduous dentition are af-
l Deciduous dentition shows ‘shell teeth’ appearance due fected in case of fusion, although it is more com-
to enlarged pulp chambers and root canals. mon in deciduous teeth.
l The permanent teeth have pulpal spaces that are either l Fusion can be complete or incomplete and its ex-
smaller than normal or completely obliterated. tent will depend on stage of odontogenesis at
Histological features which fusion takes place.
l The incisor teeth are more frequently affected in
l Histopathology of teeth in shields type III has not been
adequately documented. both the dentitions.

I. c . Concrescence Dens evaginatous (occlusal tuberculated premolar,

l Concrescence is defined as union of two adjacent Leong’s premolar, evaginated odontome)
teeth by cementum only without confluence of the l Dens evaginatus is a developmental condition ap-
underlying dentine. pearing as an accessory cusp or globule of enamel

l It is the type of fusion, which is limited only to the on occlusal surface between buccal and lingual
roots of teeth and it occurs after the root formation cusps of premolars unilaterally or bilaterally.
of involved teeth is completed. l This is opposite of invagination. That means there
l Aetiology: Concrescence may be developmental or occurs extrusion of the dental papilla outwards
postinflammatory or due to traumatic injury. into the enamel organ.
l Common between maxillary second molar and l Clinical findings:
unerupted third molar. l This condition is more common in people of
II. Accessory cusps Chinese race.

a. Cusp of Carabelli l More common in maxillary first premolars
b. Talon cusp but also occurs rarely on molars, cuspids and

c. Dens invaginatous (dens in dente) incisors.
d. Dens evaginatous l Presents a tubercle of enamel with a core of
Cusp of Carabelli dentine with a narrow pulp chamber.

l Present on mesiopalatal cusp of maxillary first l When the tooth erupts, this bit of enamel is
molars. higher than the cusps, and covers the underly-

l An analogous accessory cusp is seen occasionally ing mass of dentine.
on the mesiobuccal cusp of a mandibular perma- l If present in deciduous teeth, it causes diffi-
nent or deciduous molar known as protostylid. culty in feeding.

Talon cusp l When the thin surface enamel of the tubercle
l Talon cusp is an anomalous projection resembling breaks down, infection of the tooth takes place
eagle’s talon projects lingually from cingulum resulting in death of the pulp and abscess for-
area of permanent incisors. mation.
l A developmental groove is present at the site, l Treatment consists of extraction of the tooth.
where this projection meets with the lingual sur- III. Ectopic enamel
face of tooth. l Enamel pearls
l This groove is prone to caries, so it should be l Cervical enamel extensions
removed. If pulp exposure is present then end- l Ectopic enamel or enamel pearls or enameloma
odontic therapy is done. or enamel drop usually occurs in furcation area

l Found in association with ‘Rubinstein–Taybi syn- below the crest of gingiva.
drome’. l Cervical enamel extension also occurs along the
Dens in dente or dens invaginatous surface of dental roots.

l Dens in dente is a developmental variation, which l Maxillary and mandibular molars are most com-
arises as a result of enamel epithelial invagination monly affected.
of the crown surface before calcification. l Predisposes to development of buccal bifurcation
l Several causes of this condition are: focal growth cysts.

proliferation and focal growth retardation that IV. Taurodontism (bull-like teeth)
take place in certain areas of tooth bud, increased l Taurodontism is a dental anomaly in which the
localized external pressure. body of the tooth is enlarged at the expense of roots.
l After calcification it appears as accentuation of Aetiology
lingual pit. l Specialized or retrograde character.
l Teeth most frequently involved are maxillary lat- l Primitive pattern.
eral and maxillary central incisors. l Atavistic feature.
l Radiographic features l Mendelian recessive trait.
Appearance of tooth within tooth due to deep l Mutation.
pear-shaped invagination from lingual pits, ap- l Associated with Klinefelter syndrome.
proximating to pulp. l It is due to failure of Hertwig epithelial root
l Treatment sheath to invaginate at proper horizontal level.

This anomaly makes teeth prone to caries so Clinical findings
endodontic therapy should be done. Restoratory l It may affect both deciduous and permanent
procedures are unsuccessful because of this deep dentition, but more common in permanent
invagination, which generally approximates pulp. dentition.
l Molars are commonly affected. l Once perforation has occurred, extraction of tooth is
l Tooth morphology is normal. the treatment.
Q.2. Dens invaginatus.
l Enlarged and rectangular pulp chamber is present.
l No constriction of pulp at cervical area. Ans.

l Roots are very short.
l Dens invaginatus is otherwise known as dens in dente or
l Furcation is present just above root apex.
gestant odontoma.
Treatment
l It is a developmental variation that arises as a result
l No treatment is required.
of enamel epithelial invagination of the crown surface
V. Dilaceration
before calcification.
l Dilaceration refers to angulation or curve in root or
l It is an enamel lined surface invagination of crown or
crown of tooth.
root.
l Angulation is caused due to trauma to the tooth dur-
ing formative stage of tooth. Causes

l Curve is present at apical, middle or at cervical por- l It is because of focal growth proliferation and focal
tion depending on the portion which is forming at growth retardation that takes place in certain areas of
the time of trauma. tooth bud due to increased localized external pressure.
l Occlusal trauma in deciduous tooth may also cause l Coronal form is formed by the infolding of enamel or-
dilaceration of permanent tooth. gan in to dental papilla, while radicular form is pro-
l More common in the maxillary anterior region. duced due to invagination of Hertwig root sheath.
l Significance: Tooth with bent root is difficult to
Clinical features
extract.
l Teeth most frequently involved are maxillary lateral and
VI. Supernumerary roots
maxillary central incisors.
l One or more extra roots may be present in tooth.
l After calcification of teeth, it appears as accentuation of
l Usually single rooted teeth such as mandibular cus-
lingual pit.
pids and bicuspids are involved.
l Oehlers classified coronal dens invaginatus into three
l Third molars of both jaws also present one or more
types based on depth of invagination:
extra roots.
Type I: Invagination ends in a blind sac, limited to den-
tal crown.
SHORT ESSAYS: Type II: Invagination extends in to CEJ, also ending in
a blind sac.
Q.1. Internal resorption.
Type III: Invagination extends to the interior of the
Ans. root, providing an opening to periodontium, some-
times presenting another foramen in apical region of
l Internal resorption is also known as chronic perforating
the root.
hyperplasia of pulp, odontoclastoma or pink tooth of
mummery. Radiographic features
l It is an unusual form of resorption that begins centrally l Appearance of tooth within tooth due to deep pear-
within the pulp, apparently initiated by a peculiar in- shaped invagination from lingual pits, approximating to
flammatory hyperplasia of the pulp. pulp.
Aetiology l In severe forms, crown is malformed and an open apex
l Idiopathic is present.
Clinical features
Treatment
l No early clinical signs and symptoms.
l This anomaly makes teeth prone to caries so endodontic
l Tooth may show pink spot (pink tooth) when more of
therapy should be done.
dentine is resorbed from one area of the crown, leav-
l Restorative procedures are unsuccessful because of this
ing a covering of translucent enamel.
deep invagination, which generally approximates pulp.
l It appears as a pink area due to vascular pulp visible
through the translucent enamel. Q.3. Anodontia.

Radiographic appearance
Ans.
l Pink spot appears as round or ovoid area of radiolu-
cency in the central portion of the tooth. l Anodontia is defined as the condition in which there is
Treatment congenital absence of teeth in oral cavity.
l If condition is discovered before perforation of l Anodontia is rare and most cases occur in the presence
crown, root canal therapy may be carried out. of ectodermal dysplasia.

Aetiology l Enamel of the affected teeth fails to develop to its nor-

The causes of anodontia are as follows: mal thickness.
i. Hereditary factor l Yellowish brown colour of the teeth.
ii. Environmental factor l Enamel may be pitted, rough, smooth and glossy.
iii. Familial factor l Open contacts and anterior open bite may occur.
iv. Syndrome associated

Q.2. Talon cusp.
v. Radiation injury to the developing tooth germ
Ans.
Types
l Anodontia can also be divided into following types: l Talon cusp is an anomalous structure resembling an
a. True anodontia: It occurs due to failure of develop- eagle’s talon, projects lingually from the cingulum areas
ment or formation of tooth in jaw bone. of a maxillary or mandibular permanent incisor.
b. Pseudo anodontia: It refers to the condition in which l It consists of deep developmental groove where the cusp
teeth are present within the jaw bone but are not blends with the sloping lingual tooth surface.
clinically visible in the mouth, as they have not l It is composed of normal enamel and dentine and con-
erupted, e.g. impacted teeth. tains a horn of pulp tissue.

c. Induced or false anodontia: It is the condition in l It may be associated with Rubinstein–Taybi syndrome.
which teeth are missing in the oral cavity because of

Q.3. Dilaceration.
their previous extractions.
Ans.
True anodontia
True anodontia is of two types: l Dilaceration refers to an angulation, or a sharp bend or
a. Complete anodontia: There is congenital absence of all curve, in the root or crown of a formed tooth.
the teeth. l This condition is caused due to trauma during the period
b. Partial anodontia: Congenital absence of one or few in which the tooth is forming.
teeth. l Dilacerated teeth frequently present difficult problems
at the time of extraction.

Complete anodontia
l It is the condition in which there is neither any decidu- Q.4. Dens in dente.
ous tooth nor any permanent tooth present in the oral Ans.
cavity.
l A complete anodontia is a common feature of heredi- l Dens in dente is also known as dens invaginatus/dilated
tary ectodermal dysplasia; however, in many cases cus- composite odontome or gestant odontome.
pids are present in this disease. l It is a developmental variation that arises as a result of
l Complete anodontia occurs among children those who an invagination in the surface of the tooth crown before
have received high doses of radiation to the jaws as calcification has occurred.
infants for therapeutic reasons. l Causes: increased localized external pressure, facial
growth retardation.
Partial anodontia l Permanent maxillary lateral incisors are commonly in-
l It is a common phenomenon and is characterized by
volved followed by maxillary central incisors.
congenital absence of one or few teeth. l Condition is usually bilateral.
l In partial anodontia any tooth can be congenitally
missing. Q.5. Turner tooth.

For example, the third molars are most frequently ob- Ans.
served congenitally missing teeth.
The mandibular first molars and the mandibular lateral l Turner first described this localized type of hypoplasia.
incisors are least likely to be missing. l He noted defects in the enamel of two premolars and
traced the defects to apical infection of the nearest pri-
mary molar.
SHORT NOTES: l Enamel hypoplasia resulting from local infection is
Q.1. Enamel hypoplasia. called Turner tooth.

Q.6. Clinical features of regional odontodysplasia.
Ans.
Ans.
l Enamel hypoplasia occurs as a result of some defect in
ameloblasts due to nutritional deficiencies, exanthema- l One or several teeth in a localized area are affected.
tous diseases, congenital syphilis, ingestion of fluoride, l Anterior teeth are affected mostly.
local infection or idiopathic. l Maxillary arch is more commonly involved.
Clinical features l They appear as small yellow spots, either discretely

l Delayed or no eruption of teeth may be seen. separated or large plaques, often projecting slightly
l Defective mineralization causes irregular shape of teeth. above the surface of tissue.
l They are found most frequently in a bilaterally sym-
Radiographic feature
metrical pattern on the mucosa of cheeks opposite to
l Ghost-like appearance of tooth with large pulp, thin
molar teeth, inner surface of the lips, retromolar region
enamel and dentine.
and occasionally tongue, gingiva, frenum and palate.
Q.11. Anodontia.
l Enamel is hypoplastic and hypomineralized.
l Dentine has thickened predentin layer. Ans.

Q.7. Dentinogenesis imperfecta. l Anodontia is defined as the condition in which there is
Ans. congenital absence of teeth in oral cavity.
l Absence of teeth in the oral cavity causes growth re-
l Dentinogenesis imperfecta is a developmental distur- striction of alveolar process. This is more common in
bance in the structure of the teeth. the permanent dentition.
l This is an autosomal condition affecting both deciduous l Anodontia may be total (complete) or partial (incom-
and permanent teeth. plete) and true or pseudo.
l Affected teeth are grey to yellowish brown and have
broad crowns with a constriction area of the cervical True anodontia

l Congenital absence of teeth is termed as true anodontia.
area resulting in a tulip-shape.
l Total absence of teeth is found in case of hereditary
l Types:
l Dentinogenesis imperfecta type I (opalescent dentine)

ectodermal dysplasia.
l Partial absence of teeth is termed as true partial anodon-
l Dentinogenesis imperfecta type II (brandy wine type).
tia and affects third molars, lateral incisors and premo-
Treatment for both type I and type II dentinogenesis im- lars usually.
perfecta
l Crown capping may be done on teeth to avoid attrition.
False or pseudoanodontia
Cast metal crowns on posterior teeth and jacket crowns It results from noneruption of multiple teeth.
on anterior teeth have been used with considerable Q.12. Concrescence.
success.
Ans.
Q.8. Pink tooth of mummery.
l Concrescence is a developmental anomaly where the
Ans. fusion of teeth occurs along the cementum only.
l It occurs after the root formation is completed.
l Internal resorption (pink tooth of mummery) odonto-
l This may be due to trauma, crowding of teeth with
clastoma/internal granuloma/chronic perforating hyper-
plasia of pulp) resorption of interdental bone.
l Idiopathic Q.13. Supernumerary teeth.
l Due to inflammatory hyperplasia of pulp
Ans.
Q.9. Hutchinson triad.
l Supernumerary teeth are a developmental disturbance in
Ans. the number of teeth.
l A supernumerary tooth is an additional entity to the
l Hutchinson triad is a pathognomonic feature of con-
genital syphilis. normal series and is seen in all quadrants of the jaw
l Morphological types of supernumerary teeth:
l The Hutchinson triad includes hypoplasia of the inci-
l Conical
sors and molar teeth, eighth nerve deafness and intesti-
l Tuberculate
nal keratitis.
l Supplemental
Q.10. Fordyce granules. l Odontome
l Supplemental supernumerary teeth are teeth that resem-

Ans.
ble the typical anatomy of posterior and anterior teeth.
l Fordyce granules are a developmental anomaly charac- l Rudimentary supernumerary teeth these are conical in
terized by heterotopic collection of sebaceous glands at shape. Usually they are found in syndromes like cleido-
various sites in the oral cavity. cranial dysplasia, and orofacial digital syndrome.
l Multiple supernumerary teeth can occur in association l Geographic tongue is often detected during routine den-
with the conditions like Gardener syndrome and cleido- tal examination of paediatric patients who are unaware
cranial dysplasia. of the condition.
l Red, smooth areas devoid of filiform papillae appear on
Q.14. Taurodontism.
the dorsum of the tongue. The margins of the lesions are
Ans. well developed and slightly raised.
l The involved areas enlarge and migrate by extension of
l Taurodontism is a dental anomaly in which the body of
the tooth is enlarged at the expense of the roots. the desquamation of the papillae at one margin of the
l The term taurodontism refers to ‘bull-like teeth’.
lesion and regeneration at the other.
l Every few days a change can be noted in the pattern of
l Cause: Failure of Hertwig epithelial sheath to invaginate
at the proper horizontal level. the lesions.

l The condition is self-limited, hence no treatment is nec-
l Most commonly involves permanent dentition followed
by deciduous dentition, molars are be commonly essary.

involved. Q.19. Macroglossia.
l Condition may be unilateral or bilateral.
l Involved teeth are rectangular in shape.

Ans.
Q.15. Describe briefly the causes for early loss of teeth. i. Macroglossia is a developmental disturbance of tongue.
ii. It is also called as tongue hypertrophy or enlarged
Ans. tongue.
l Along with hypophosphatasia, prepubertal periodontitis iii. Types are
appears to be the most common cause of premature ex- a. True macroglossia
foliation of the primary teeth, especially in girls. b. Psuedomacroglossia
l The early exfoliation of primary teeth resulting from
iv. Clinical features
l Severe retrognathia, unusually small maxilla or man-
periodontitis has been observed occasionally in young
children. dibular size.
l It may be associated with Down syndrome and Beck-
Q.16. Median rhomboid glossitis. with–Wiedemann syndrome.
Ans. v. Treatment
Surgical intervention
l Median rhomboid glossitis is a developmental distur-
bance of tongue. Q.20. Dentine dysplasia.
Clinical features Ans.

l It presents as oval-shaped reddish patch or plaque in the l Dentine dysplasia is also known as ‘rootless teeth’ and
posterior midline of the dorsum of the tongue, just anterior is a developmental disturbance in the structure of
to the V-shaped grouping of the circumvallate papillae. teeth.
l It appears in the childhood and is of 3:1 male predilection. l It is a rare disturbance of dentine formation character-
l Lesion with atrophic candidiasis appears erythematous. ized by normal enamel but atypical dentine formation
l Infected lesions show midline soft palate erythema in with abnormal pulpal morphology.
the area of routine contact with tongue involvement l Shields and colleagues categorized it into two types:
referred as a ‘kissing lesion’. i. Radicular dentine dysplasia (type I)
l They may be caused due to localized chronic fungal ii. Coronal dentine dysplasia
infection specially candida. l Both primary and secondary dentitions are affected in
Q.17. Geographic tongue. dentine dysplasia type I, which is inherited as an auto-

somal dominant trait.
And l Radiographically, the roots are short and may be more
Q.18. Benign migratory glossitis. pointed than normal.

l Usually, the root canals and pulp chambers are absent
Ans.
except for a chevron-shaped remnant in the crown.
l Benign migratory glossitis is also known as geographic l The colour and general morphology of the crowns of the
tongue/wandering rash of tongue/glossitis areata exfo- teeth are usually normal, although they may be slightly
liativa/erythema migrans. opalescent and blue or brown.
l It is a wandering type of lesion and probably the most l Periapical radiolucencies may be present at the apices
common tongue anomaly. of affected teeth.

l Dentine dysplasia type II is inherited as an autosomal l Histopathologically, there is increased melanin produc-
dominant trait in which the primary dentition appears tion without melanocytic hyperplasia.
opalescent and on radiographs has obliterated pulp
chambers, similar to the appearance in dentinogenesis Q.24. Globulomaxillary cyst.
imperfecta. Ans.
l In dentine dysplasia type II, the permanent dentition has
normal colour and radiographically exhibits a thistle l Globulomaxillary cyst is described as a fissural cyst
tube pulp configuration with pulp stones. found within the bone between the maxillary lateral in-
cisor and canine teeth.
Q.21. Black hairy tongue. l Clinical features: Asymptomatic, only if cysts become
Ans. infected, patient may complain of local discomfort or

pain in the area.
l Hairy tongue is also known as lingua nigra, lingua vil-
l Radiologically, it is a well-defined inverted pear-shaped
losa and black hairy tongue.
radiolucency, which frequently causes the roots of the
l It is a condition of defective desquamation of filiform
adjacent teeth to diverge.
papillae that results from a variety of precipitating
l Treatment: Cyst should be surgically removed.
factors.
l Hairy tongue may appear as brown, green, pink or any Q.25. Gingival cysts of infants.
of a variety of hues depending on specific aetiology and
secondary factors. Ans.
l Filiform papillae in hairy tongue measures more than
l Gingival cyst of infants or newborn is an odontogenic
15 mm in length. cyst, which is developmental in nature.
l Over growth of Candida albicans may result in glosso-
l These cysts are seen in infants. These cysts are seldom
pyrosis (burning tongue). seen after 3 months of age.
Q.22. Natal teeth.
Origin
Ans. l They arise from the epithelial remnants of dental lamina
l Teeth present at birth are known as natal teeth. In these called cell rests of Serres.
teeth there is almost no root present. Clinical features
l Teeth that erupt within 30 days after birth are called l The cyst is seen on the crest of the maxillary and man-
neonatal teeth. dibular dental ridges and appears creamish-white in
l Preferably natal or neonatal tooth should not be ex- colour.
tracted for normal growth and uncomplicated eruption l These cysts are usually minute in size and rarely exceed
of the adjacent teeth. But in case it is hyper mobile and 3 mm in diameter and commonly occur on the maxillary
there is a danger of its avulsion and swallowing by the alveolar ridge.
child, it should be extracted.
l The mother may have some problem in breastfeeding Histopathology
the child with natal or neonatal teeth. If the mother can- l Histopathological evaluation reveals a keratin filled cyst
not bear this discomfort, she can use the breast pump. lined by parakeratinized epithelium.
Q.23. Peutz–Jeghers syndrome. Treatment
l Gingival cysts in infants need no treatment as they tend
Ans.
to undergo involution and disappear. Most cysts tend to
l This syndrome consists of familial generalized intesti- rupture spontaneously.
nal polyposis and pigmented spots on the face, oral
cavity and sometimes hands and feet. Q.26. What is fusion.
l The syndrome is due to a mutation of gene LKB 1,
Ans.
which has an autosomal dominant inheritance.
l Brown macules of varying number and size (usually l Fusion is a development disturbance in the shape of the
1–5 mm) are seen in buccal mucosa, gingiva and hard tooth.
palate. l Fused teeth arise through union of two normally sepa-
l Facial pigmentation tends to fade later in life, mucosal rated tooth germs.
pigmentation persists. l Fusion is defined as single enlarged tooth or joined
l Intestinal polyposis of colon may undergo malignant tooth in which the tooth count reveals a missing tooth
change. when the anomalous tooth is counted as one.
l Both permanent and deciduous dentitions are affected in Q.28. Gardner syndrome.
case of fusion, although it is more common in decidu-
Ans.
ous teeth.
l The incisor teeth are more frequently affected in both l It is autosomal dominant pattern of inheritance.
the dentitions.
Clinical features
Q.27. Oligodontia. l Multiple impacted supernumerary and permanent
teeth.
Ans.
l Multiple polyposis of large intestine that are prema-
l Oligodontia refers to lack of development of six or more lignant.

teeth. l Osteomas of bones.
l Damage to dental lamina before tooth formation can l Multiple epidermal sebaceous cysts.
result in hypodontia. l Desmoid tumours.
l May be caused by genetic factors, trauma, endocrine

Q.29. Mesiodens.
disturbances, infection, radiation and chemotherapeutic
medications. Ans.
l It may also occur in hereditary syndromes such as Crou-
l Mesiodens (maxillary) is the most common supernu-
zon syndrome, Down syndrome, ectodermal dysplasia,
merary teeth.
Hurler syndrome and Turner syndrome.
l Autosomal dominant-type of inheritance.
l It usually affects permanent third molars, second pre-
l 90% occur in maxilla.
molars and lateral incisors in that order. Associated mi-
l Develops from third tooth bud or splitting of permanent
crodontia may be observed.
tooth bud.
l Oligodontia and hypodontia may cause abnormal spac-
l More common in males compared to females.
ing of teeth, delayed tooth formation, delayed decidu-
l Occurrence is very less in deciduous teeth (Maxillary B .
ous tooth exfoliation and late permanent tooth eruption.
Maxillary C and D).
l Treatment: Prosthetic replacement of teeth may be
needed.
Topic 11
Orofacial Pain

LONG ESSAYS:
1 . Write about the aetiology, diagnosis, clinical features and management of trigeminal neuralgia.
2. Define pain. Classify facial pain. Describe the aetiopathogenesis, clinical features and management of atypical
facial pain.
3. Describe in detail aetiology, clinical features, differential diagnosis and management of periodic migrainous
neuralgia.
4. Discuss neuralgias affecting maxillofacial region. How would you treat trigeminal neuralgia? [Same as LE Q.1]
5. Describe aetiopathogenesis clinical features and management of trigeminal neuralgia. [Same as LE Q.1]
6. Describe in detail aetiology, clinical features and management of trigeminal neuralgia. [Same as LE Q.1]
7. What is neuralgia? Describe the different types of neuralgias of orofacial origin. And add a note on management
of orofacial neuralgia. [Same as LE Q.1]
8. Give the differential diagnosis of pain in and around the tooth. [Same as LE Q.2]
9. Describe the ‘pain in and around the tooth’. Mention the treatment. [Same as LE Q.2]
SHORT ESSAYS:
1. Aetiology, signs and symptoms of Bell palsy.
2. Pain in migraine and periodic migrainous neuralgia. [Ref LE Q.3]
3. Aetiology, signs and symptoms of trigeminal neuralgia.
4. Treatment of myofascial pain dysfunction syndrome.
5. List the differences between pain characteristics of trigeminal neuralgia and acute pulpitis.
6. Transelectric nerve stimulation.
7. Trismus.
8. Burning mouth syndrome (glossodynia).
9. Postherpetic neuralgia.
10. Bell palsy. [Same as SE Q.1]
11. Trigeminal neuralgia. [Same as SE Q.3]
SHORT NOTES:
1. Bell sign.
2. Burning mouth syndrome.
3. Clinical features of Bell palsy.
4. Name the neuralgias of orofacial origin.
5. Define atypical facial pain. [Ref LE Q.2]
6. Gamma knife stereotactic radio surgery in management of the tic douloureux.
7. Enumerate the two important differences between the paroxysmal neuralgias and atypical neuralgias.
8. PHN: mention two clinical manifestations.
9. Glossopharyngeal neuralgia.
10. Trismus. [Ref SE Q.7]
11. ‘TENS’ therapy. [Ref SE Q.6]
12. Types of migraine.
13. Alarm clock headache.
14. Trigger zones.
15. Classifications of headaches. [Ref LE Q.2]
16. Glossodynia. [Same as SN Q.2]
17. Atypical odontalgia. [Same as SN Q.5]
SOLVED ANSWERS
LONG ESSAYS: l Nicholaus Andre coined the term tic douloureux.
Q.1. Write about the aetiology, diagnosis, clinical fea- l John Fothergill in 1773 published detailed descrip-
tures and management of trigeminal neuralgia. tion of trigeminal neuralgia, hence it is known as
Fothergill disease.
Ans.
Different types of neuralgias
l Neuralgia is a clinical condition involving pain of a
l Paroxysmal neuralgia (trigeminal, glossopharyngeal,
severe intensity, with a throbbing or stabbing character
nervous intermedius and superior laryngeal)
in the course or distribution of a specific nerve.
l Occipital neuralgia, postherpetic neuralgia (PHN) and
l Trigeminal neuralgia is defined as sudden, usually uni-
post-traumatic neuropathic pain
lateral severe, brief, lancinating, recurring pain in the
distribution of one or more branches of 5th cranial Aetiology
nerve. l Unknown
l Trigeminal neuralgia is also called as tic douloureux. l Two categories:
l John Locke has given first full description with its a. Idiopathic
treatment. b. Secondary multiple origins
Probable aetiological factors are listed below: xi. Different stimuli can trigger pain – ‘trigger zones’.
l Vascular factors l Touching or applying heat/cold to cheek/gums, etc.
l Mechanical factors l Wind blowing on face.
l Anomaly of superior cerebellar artery l Gustatory stimuli and vibration.
i. Intracranial vascular abnormalities:

Diagnosis
l Pontine infarcts – compression/distortion at root
i. Well-taken history.
entry zone of 5th nerve at pons by arterial loop
ii. Clinical tests
l Arteriovenous malformation in the vicinity (ve-
l Blink reflex study
nous compression)
l Diagnostic nerve blocks with L.A. infiltration
l Compression of intracranial retrogasserian por-
(2% xylocaine)
tion of 5th nerve by a displaced vein/artery
l Response to treatment with tablet carbamazepine
l Aneurysm of the internal carotid artery
iii. Imaging techniques
ii. Intracranial tumours
l MRI – Imaging modality of choice, it reviews mul-
l May impinge on nerve, e.g. epidermoid tumours
tiple sclerosis plaques and pontine gliomas.
such as meningiomas of cerebellopontine region
l CT (pool resolution in posterior fossa) vascular com-
and Meckel’s cave
pressions.
l Trigeminal neuromas of middle cranial fossa
l Conventional angiogram (only if vascular malforma-
and posterior cranial fossa
tion is suspected)
iii. Inflammatory
l Multiple sclerosis, sarcoidosis – sclerotic plaque Treatment
located at root entry zone of trigeminal nerve, etc. Please refer the text given in the following box:
iv. Infections
l Granulomatous/nongranulomatous involving
5th cranial nerve Medical Surgical
v. Viral aetiology i. Carbamazepine Interruption of Intracranially
l Postherptic neuralgia, history of previous infec- (tegretol, carba- pain pathways be- i. Alcohol
tion by varicella zoster virus trol) – standard- tween centre and blockade
ized criteria for periphery a. Gasserian
l Viral lesions of the ganglion may be the aetio-
treatment of tri- Extracranially ganglion
logical factors geminal neuralgia i. Alcohol block ii. RFTC at
vi. Post-traumatic neuralgia (dose starts with in peripheral gasserian
vii. Dental aetiology 100 mg t.i.d. up nerve. ganglion
viii. Ratner’s jawbone cavities to large doses like ii. Nerve section iii. Retrogasse-
1000–1500 mg/ and avulsion, rian rhizot-
ix. Petrous bridge or basilar compression
day). i.e. peripheral omy
ii. Phenytoin (dilan- neurectomy iv. Medullary
Clinical features tin) 100 mg t.i.d. l Supraor- tractotomy
i. Incidence – Rare affliction 4 in 100,000 persons. iii. Oxcarbazepine – bital v. Midbrain
ii. Age – Late middle age/later in life (5th or 6th decade). 1200 mg/day l Infraorbital tractotomy
iii. Sex – more prediction in females. iv. Valproic acid – l Lingual vi. Intracranial
600 mg/day l Inferior nerve de-
iv. Prediction for right side in 60% of the cases. v. Clonazepam alveolar compression
v. Division of 5th nerve involved – V3 is more common, (Klonopin) not (Ginwalla’s Janetta’s and
V1 is rarely involved (5% of cases). recommended in technique) Dandy’s
vi. Trigeminal neuralgia manifest as – Sudden, unilateral, case of sedation iii. Electrosurgery approach
intermittent, paroxysmal, sharp, shooting, lancinating, and dependence iv. Cryosurgery
vi. Amitriptyline (cryoprobe at
shock-like pain. (Elavil): success temperature
vii. Pain is of short duration and lasts for few seconds. A rate is low. colder than
refractory period can be as short as a couple of seconds. Other least toxic 260°C causes
viii. Pain is unilateral and does not shift sides, although agents: Wallerian
l Baclofen (Liore- degeneration)
very rare bilateral cases have been described.
sal) 10 mg t.d.s. v. Selective
ix. Pain is usually confined to one part or one division of l Gabapentin radiofrequency
5th nerve mandible or maxilla but may occasionally (Neurontin) thermo-
spread to adjacent division or rarely involve all three l Lamotrigine coagulation
divisions. l Felbamate
l Topiramate
x. The characteristic of this disorder is that attacks do not
l Vigabatrin
occur during sleep.
New technique for trigeminal neuralgia Neurologic disorders

Gamma knife stereotactic radiosurgery l Paroxysmal neuralgias
l New minimally invasive technique for treatment of l Trigeminal neuralgia
trigeminal neuralgia. l Glossopharyngeal neuralgia
l It uses beams of radiation usually in doses of 70–90 Gy l Continuous neuralgias
units, converging in three dimensions to focus precisely l Atypical odontalgia
on a small volume. l Traumatic neuroma
l This method relies on precise MRI sequencing that helps l Neuritis
localization of the beam and allows a higher dose of ra- l PHN
diation to be given with more sparing of nerve tissue.
W.E. Bell (1989) has classified orofacial pain as follows:
l Advantage of this technique is that it is particularly
Axis I (physical conditions)
helpful for elderly patients with a high surgical risk.
Somatic pain
Q.2. Define pain. Classify facial pain. Describe the aetio- l Superficial somatic pain (cutaneous, mucogingival)
pathogenesis, clinical features and management of atyp- l Deep somatic pain
ical facial pain. l Musculoskeletal pain (muscle, TMJ, osseous and
periosteal, soft connective tissue and periodontal)

Ans.
l Visceral pain (pulpal, vascular, neurovascular,
Pain is defined as an unpleasant sensory and emotional ex- visceral mucosal, glandular, ocular and auricular)
perience associated with actual or potential tissue damage, Neuropathic pain
or described in terms of such damage. l Episodic (trigeminal, glossopharyngeal, genicu-
late, nervous intermedius neuralgias and neuro-

Classification of orofacial pain
vascular pains)
The American Academy of Orofacial Pain has classi-
l Continuous (neuritis, deafferentation pain and
fied orofacial pain as follows:
sympathetically maintained pain)
Intracranial structures
Axis II (psychologic conditions)
l Neoplasm
i. Mood disorders
l Aneurysm
ii. Anxiety disorders
l Haematoma
iii. Somatoform disorders
l Haemorrhage
iv. Other conditions
l Abscess
l Oedema
Differential Diagnosis of Orofacial Pain
Extracranial structures
Intracranial pain Neoplasms, aneurysms, abscess, haemor-
l Teeth
disorders rhage, haematoma, oedema
l Ears
Primary head- Migraine, migraine variants, cluster head-
l Eyes
ache disorders ache, cranial arteritis, carotidynia, tension-
l Nose
(neurovascular type headache
l Throat disorders)
l Sinuses
Neurogenic pain Paroxysmal neuralgias (trigeminal, glossopha-
l Tongue
disorders ryngeal, nervus intermedius, superior laryn-
l Glands geal), continuous pain disorders (neuritis, PHN,
Musculoskeletal disorders post-traumatic and postsurgical neuralgia)
l Temporo mandibular Joint (TMJ) disorders Intraoral pain Sympathetically maintained pain: dental
l Masticatory muscle disorders disorders pulp, periodontium, mucogingival tissues,
l Fibromyalgia tongue
l Cervical disorders Temporoman- Masticatory muscle, temporomandibular
l Generalized polyarthritides dibular disorders joint – associated structures
Neurovascular disorders Associated Ears, eyes, nose, paranasal sinuses, throat.
structures lymph nodes, salivary glands, neck
{SN Q.15}
l Migraine headaches {SN Q.5}
l Cluster headaches
l Tension-type headaches Atypical odontalgia (atypical facial pain)
l The term ‘atypical odontalgia’ is used when the pain
is confined to the teeth or gingivae, whereas the term

Cranial arteritis
l
l Symptoms may remain unilateral, cross the midline in

‘atypical facial pain’ is used when other parts of the
some cases, or involve both the maxilla and mandible.
face are involved.
l Feinmann characterized AFP as a nonmuscular or Diagnosis
joint pain that has no detectable neurologic cause. l A thorough history and examination including evalua-
l Atypical facial pain was described by Truelove and tion of the cranial nerves, oropharynx and teeth must be
colleagues as a condition characterized by the absence performed to rule out dental, neurologic or nasopharyn-
of other diagnoses and causing continuous, variable- geal disease.
intensity, migrating, nagging, deep and diffuse pain. l Examination of the masticatory muscles should also be
l Recent advances in the understanding of chronic performed to eliminate pain secondary to undetected
pain suggest that at least a portion of patients who muscle dysfunction.
have been diagnosed with AFP may be experiencing l Laboratory tests should be carried out when indicated
neuropathic pain. by the history and examination. Patients with AFP have
completely normal radiographic and clinical laboratory
studies.
Management
l There are several theories regarding the aetiology of
l Once the diagnosis is confirmed, it is important that the
Atypical odontalgia (AO) & Atypical facial pain (AFP).
symptoms are taken seriously and are not dismissed as
One theory considers AO and AFP to be a form of deaf-
imaginary.
ferentation or phantom tooth pain.
l Patients should be counselled regarding the nature of
l This theory is supported by the high percentage of patients
AFP and reassured that they do not have an undetected
with these disorders who report that the symptoms began
life-threatening disease and that they can be helped
after a dental procedure such as endodontic therapy or an
without invasive procedures.
extraction.
l When indicated, consultation with other specialists such
l Others have theorized that AO is a form of vascular,
as otolaryngologists, neurologists or psychiatrists may
neuropathic or sympathetically maintained pain.
be helpful.
l Other studies support the concept that at least some of
l Tricyclic antidepressants such as amitriptyline, nortrip-
the patients in this category have a strong psychogenic
tyline and doxepin, given in low to moderate doses, are
component to their symptoms and that depressive, so-
often effective in reducing or in some cases eliminating
matization and conversion disorders have been de-
the pain.
scribed as major factors in some patients. It is frequently
l Other recommended drugs include gabapentin and clon-
difficult to accurately study the psychological aspects of
azepam. Some clinicians report benefit from topical
a chronic pain.
desensitization with capsaicin, topical anaesthetics or
Clinical manifestations topical doxepin.
l The major clinical manifestation of AFP is a constant
Q.3. Describe in detail aetiology, clinical features, differ-
dull aching pain without an apparent cause that can be
ential diagnosis and management of periodic migrainous
detected by examination or laboratory studies.
neuralgia.
l It occurs most frequently in women in the fourth and
fifth decades of life, and women make up more than Ans.

80% of the patients.
l The pain is described as a constant dull ache. There are [SE Q.2]
no trigger zones, and lancinating pains are rare.
l The patient frequently reports that the onset of pain
l {Migraine is the most common of the vascular head-
aches, which may occasionally also cause pain of the
coincided with a dental procedure such as oral surgery
face and jaws. It may be triggered by foods such as nuts,
or an endodontic or restorative procedure.
chocolate and red wine; stress; sleep deprivation; or
l Patients also report seeking multiple dental procedures
hunger.
to treat the pain; these procedures may result in tempo-
rary relief, but the pain characteristically returns in days Aetiology and pathogenesis
or weeks. l The classic theory is that migraine is caused by vaso-
l Other patients will give a history of sinus procedures or constriction of intracranial vessels, which causes the
of receiving trials of multiple medications, including neurologic symptoms, followed by vasodilation which
antibiotics, corticosteroids, decongestants or anticon- results in pounding headache.
vulsant drugs. l Newer research techniques suggest a series of factors,
l The pain may remain in one area or may migrate, either including the triggering of neurons in the midbrain
spontaneously or after a surgical procedure. that activate the trigeminal nerve system in the medulla,
resulting in the release of neuropeptides such as sub- Treatment

stance P. l Patients with migraine should be carefully assessed to
l These neurotransmitters activate receptors on the ce- determine common food triggers. Attempts to mini-
rebral vessel walls, causing vasodilation and vasocon- mize reactions to the stress of everyday living by us-
striction. ing relaxation techniques may also be helpful to some
patients.
Types of migraine
l Drug therapy may be used either prophylactically to
There are several major types of migraine:
prevent attacks in patients who experience frequent
l Classic
headaches or acutely at the first sign of an attack.
l Common
l Drugs that are useful in aborting migraine include
l Basilar
ergotamine and sumatriptan, which can be given orally,
l Facial migraine (also referred to as carotidynia)
nasally, rectally or parenterally. These drugs must be
Clinical manifestations used cautiously since they may cause hypertension and
l Migraine is more common in women. other cardiovascular complications.
l Classic migraine starts with a prodromal aura that is l Drugs that are used to prevent migraine include pro-
usually visual but that may also be sensory or motor. pranolol, verapamil and TCAs. Methysergide or mono-
l The visual aura that commonly precedes classic mi- amine oxidase inhibitors such as phenelzine can be
graine includes flashing lights or a localized area of used to manage difficult cases that do not respond to
depressed vision (scotoma). safer drugs.}
l Sensitivity to light, haemianaesthesia, aphasia or other
Q.4. Discuss neuralgias affecting maxillofacial region.
neurologic symptoms may also be part of the aura,
How would you treat trigeminal neuralgia?
which commonly lasts from 20 to 30 min.
l The aura is followed by an increasingly severe unilateral Ans.
throbbing headache that is frequently accompanied by
[Same as LE Q.1]
nausea and vomiting.
l The patient characteristically lies down in a dark room Q.5. Describe aetiopathogenesis clinical features and
and tries to fall asleep. management of trigeminal neuralgia.
l Headaches characteristically last for hours up to 2 or [Same as LE Q.1]
3 days.
Q.6. Describe in detail aetiology, clinical features and
l Common migraine is not preceded by an aura, but pa-
management of trigeminal neuralgia.
tients may experience irritability or other mood changes.
[Same as LE Q.1]
l The pain of common migraine resembles the pain of
classic migraine and is usually unilateral, pounding and Q.7. What is neuralgia? Describe the different types of
associated with sensitivity to light and noise. Nausea neuralgias of orofacial origin. And add a note on man-
and vomiting are also common. agement of orofacial neuralgia.
l Basilar migraine is most common in young women. The
Ans.
symptoms are primarily neurologic and include aphasia,
temporary blindness, vertigo, confusion and ataxia. [Same as LE Q.1]
These symptoms may be accompanied by an occipital Q.8. Give the differential diagnosis of pain in and
headache. around the tooth.
l Facial migraine (carotidynia) causes a throbbing and/or
sticking pain in the neck or jaw. The pain is associated Ans.

with involvement of branches of the carotid artery rather [Same as LE Q.2]
than the cerebral vessels.
l The symptoms of facial migraine usually begin in indi- Q.9. Describe the ‘pain in and around the tooth’.
viduals who are 30–50 years of age. Mention the treatment.
l Patients often seek dental consultation, but unlike Ans.
toothache, facial migraine pain is not continuous but
lasts minutes to hours and recurs several times per [Same as LE Q.2]
week. Examination of the neck will reveal tenderness of
the carotid artery. SHORT ESSAYS:
l Face and jaw pain may be the only manifestation of
Q.1. Aetiology, signs and symptoms of Bell palsy.
migraine, or it may be an occasional pain in patients
who usually experience classic or common migraine. Ans.
i. Bell palsy is an abrupt, isolated and unilateral periph- l Circulatory insufficiency or reflex vasoconstriction of
eral facial nerve paralysis. Gasserian ganglion.
ii. Aetiology: l An area of demyelination as found in patients with mul-
l May be idiopathic or due to viral infections (HSV) tiple sclerosis may be the precipitant.
or ischaemia of the nerve near the stylomastoid
Clinical features
foramen.
l More common in older adults compared to young
iii. Clinical features:
persons.
l Paralysis of the facial musculature, usually unilater-
l Pain is confined to area of distribution of trigeminal
ally causing mask-like expressionless face.
nerve.
l Middle-aged women are more commonly affected.
l Right side of the face is affected in more patients com-
l Drooping of corners of mouth, epiphora, drooling
pared to left side.
of saliva, inability to close or wink the eye, loss
l The pain is usually searing, stabbing or lancinating
of wrinkling of forehead, ‘mask-like expressionless
type, which lasts only for few seconds or minutes and is
face’.
unilateral, seldom crosses the midline.
l Taste sensation is lost.
l The term tic douloureux is applied only when the pa-
iv. Treatment:
tient suffers from spasmodic contractions of the facial
l There is no universally preferred treatment for Bell
muscles.
palsy.
l ‘Trigger zone’ is characteristic feature of the trigeminal
l The only medical treatment that may influence the
neuralgia. The ‘trigger zones’, which precipitate an
outcome is the administration of systemic cortico-
attack when touched are usually common on the vermil-
steroids within the first few days after the onset of
ion border of the lips, ala of nose and around eyes.
paralysis, but this therapy should be avoided if Lyme
l Stimulation of trigger zone due to touching, laughing or
disease is suspected. Combining steroids with anti-
eating precipitate an attack of pain. In some cases, even
herpetic drugs such as acyclovir may decrease the
exposure to strong breeze or simply the act of eating or
severity and length of paralysis.
smiling has been known to precipitate the pain.
l It is also helpful to protect the eye with lubricating
drops or ointment and a patch if eye closure is not Treatment

possible. The treatment of trigeminal neuralgia is extremely var-
l When paralysis-induced eye opening is permanent, ied over the years. The various treatment modalities are as
intrapalpebral gold weights are inserted, thus closing follows:
the upper eyelid. i. Medical management
l Surgical decompression of the infratemporal facial Commonly used drugs are as follows:
nerve. l Carbamazepine (up to a dose of 600–1200 mg/
l Facial plastic surgery and the creation of an anasto- day): This drug is frequently used as therapeutic
mosis between the facial and hypoglossal nerves can challenge to the diagnosis of trigeminal neuralgia.
occasionally restore partial function and improve l Phenytoin (dilantin 100 mg t.d.s.): Use of this
appearance of patients with permanent damage. drug has been found be efficacious in some
cases.
Q.2. Pain in migraine and periodic migrainous neuralgia. l Anticonvulsants.
l Baclofen (50–60 mg/day).

Ans.
ii. Injection of alcohol or boiling water in to peripheral
[Ref LE Q.3] nerve area or centrally in to the Gasserian ganglion has
been reported to be beneficial in causing respite from
Q.3. Aetiology, signs and symptoms of trigeminal neu-
pain.
ralgia.
iii. Surgical treatment
Ans. l Peripheral neurectomy.
l Is one of the earliest forms of the treatment for tri-

l Trigeminal neuralgia is a disease of trigeminal nerve or
geminal neuralgia, which includes sectioning of
fifth cranial nerve. It is otherwise known as tic doulou-
nerve at mental foramen, or at supraorbital or infra-
reux or Fothergill disease or trifacial neuralgia.
orbital foramen.
Aetiology l Microsurgical decompression of trigeminal nerve
l Most cases are idiopathic. root is one of the newest procedures for the manage-
l Sometimes it occurs due to pressure over trigeminal ment of trigeminal neuralgia. It has been reported to
nerve, e.g. by tumours or vascular anomalies, etc. produce good results.
Q.4. Treatment of myofascial pain dysfunction syn- Diazepam

drome. Diazepam 2 mg 3 times daily and 5 mg at bed time dur-
ing a 2-week trial period is commonly advocated for its
Ans.
anxiety reducing and muscle relaxing properties.
l Treatment of MPDS should include the treatment Occlusal splints
of emotional as well as physical components of the Should be fabricated if pain and dysfunction persist
disorder. without improvement, following the treatment and rec-
l In acute stages, conservative noninvasive treatment ommendations of the initial visit.
is usually successful in alleviating the pain and dys- Splints most often used:
function. l Maxillary night guard
l Treatment of MPDS should begin by showing concern l A Hawley appliance with an anterior platform
and strong doctor–patient relationship empathy when Benefits derived from occlusal splints have most com-
reviewing the history of patient problems. monly attributed to greater freedom in mandibular
l Patient should be told that they are not suffering movement and to an increase in muscle balance.
from more serious, life-threatening disorder like ma- Biofeedback
lignancy. l It is helpful when the primary reason for the failure
in initial treatment appears to be the inability to con-

Conservative treatment and recommendations at the trol stress and anxiety.
initial visit should include following: l Biofeedback is a valuable therapeutic aid that per-
Limitation of parafunctional habits mits patients to treat themselves while decreasing

l Patient should attempt to limit parafunctional habits their dependence on therapists as it provides them
by becoming more aware of clenching and grinding with information concerning bodily functions that
of the teeth during the day. are usually not discernible or controllable.
Hot moist packs Nerve stimulation
l Warm to hot, moist compresses should be applied l Transcutaneous electrical nerve stimulation (TENS)
over the involved muscles for 15–20 min three times treatment appears to be more effective in alleviating
a day. chronic pain than acute pain.
Soft diet l The mode of action of TENS in reducing pain is
l A relatively soft diet should be advised and limit uncertain but it is attributed to neurologic, physio-
wide opening of mouth while eating. logic, pharmacologic and psychologic effects.
Pharmacotherapy or drugs to be prescribed l The pharmacologic action of TENS may involve the
l Aspirin or NSAID should be recommended for anal- stimulated release of endorphins, which are endoge-
gesic and anti-inflammatory actions. nous morphine like substance.
l Breaking up stress–pain–stress cycle with L.A. injec- l TENS also has a placebo effect in relieving pain.
tions without epinephrine: Other treatments

l Injecting the trigger points of muscles that are in Acupuncture
spasm with a local anaesthetic not containing This procedure is used in treatment of chronic
epinephrine is often beneficial in breaking up MPDS. Here brief intense stimulation is applied to
the spasm and in disrupting the stress pain stress designated points using needles with or without elec-
cycle. trical current.
Ethyl chloride spray on the skin The release of endorphins may be involved in the
The skin overlying the affected muscles can be sprayed pain relief area with acupuncture.
with ethyl chloride or fluoromethane or ultrasound can Hypnosis
be used in an attempt to relieve muscle spasms. Used as an adjunct to other treatments.
The effectiveness of local anaesthetic injections, ethyl Psychological counselling and antidepressant
chloride refrigerant spray and ultrasound in allowing drugs
patients to open wide without pain may be noted im- They are indicated in the treatment of MPDS if
mediately following treatment. anxiety or neurotic behaviour appears to be signifi-
Jaw exercise cant component of facial pain.
Isometric exercises are often beneficial, e.g. placing
Q.5. List the differences between pain characteristics of
the tip of the tongue is the back of the palate and then
trigeminal neuralgia and acute pulpitis.
opening and closing may help in retraining spastic
muscles. Ans.
Trigeminal neuralgia Acute pulpitis l TENS has been proven to be useful in controlling mas-
ticatory muscle and neurogenic pains.
l Trigeminal neuralgia is l Caused due to noxious
defined as sudden, usually stimulation of the nerve Q.7. Trismus.
unilateral severe, brief, endings
lancinating, recurring pain l May be intermittent or con- Ans.
in the distribution of one tinuous, depending upon
or more branches of 5th the stage of pathology
{SN Q.10}
cranial nerve l May manifest at any age,
l Aetiology unknown may from youngsters to elderly Trismus is defined as the prolonged spasm of the masti-
be idiopathic l Not associated with any
catory muscles, which leads to limited mouth opening.
l Probable aetiological particular habits
factors are vascular fac- l May or may not respond
tors, mechanical factors or to cold test
anomaly of superior cere-
Aetiology
bellar artery i. Congenital – Birth injury
ii. Traumatic – Injury to masticatory muscles
Q.6. Transelectric nerve stimulation. Jaw fractures – Condylar fracture, depressed zygo-
matic arch fracture
Ans. iii. Neoplastic – Benign – Osteoma and chondroma of
condyle
Malignant – Osteosarcoma and chondrosarcoma of
{SN Q.11}
condyle
l TENS treatment appears to be more effective in iv. Neuromuscular disorders – Parkinson disease
alleviating chronic pain than acute pain. v. Reactive disorders
l The mode of action of TENS in reducing pain is
uncertain but it is attributed to neurologic, physio- Acute Chronic

logic, pharmacologic and psychologic effects.
l Septic arthritis l Rheumatoid arthritis
l The pharmacologic action of TENS may involve the
l Masticatory compartment l Ankylosing spondylitis
stimulated release of endorphins, which are endoge- infections l Osteoarthritis
nous morphine-like substances. l Tetanus l TMJ ankylosis
l TENS also has a placebo effect in relieving pain. l Tonsillitis l Radiation therapy
l Peritonsillar abscess l Oral Submucous Fibrosis
l Mumps (OSMF)
l Meningitis l MPDS
l TENS is often used to start physical therapy, reduce l Osteomyelitis
pain and allow the patient to perform jaw exercises that
promote recovery. vi. Psychogenic, e.g. hysterical trismus
l TENS uses a low-voltage biphasic current of varied
vii. Drugs, e.g. strychnine poisoning.
frequency and is designed for sensory counter stimula-
tion for the control of pain. Clinical examination
l It is thought to increase the action of the modulation that l Difficulty in opening mouth
occurs in pain processing at the dorsal horn of the spinal l Decreased inter-incisal distance (normal 3 cm)
cord and in the case of the face, the trigeminal nucleus l Extrusive and protrusive movements (normal .6 cm)
of the brainstem. l Facial swelling or asymmetry
l TENS temporarily activates afferent nerves, thereby
modulating pain.
l The electrical impulses are produced in a hand-held {SN Q.10}
battery-operated device.
Treatment
l The impulses generated have a duration of 2 min with
l Treatment of underlying cause
an interval of 0.5–1.5 s. The operating voltage is about
l Anti-inflammatory drugs
4 V.
l Muscle relaxants
l TENS is believed to have physiological (rhythmic con-
l Physiotherapy
tractions of muscles increases blood supply), neurologi-
l Heat application
cal (electrical stimulation inhibits pain conduction),
l Warm saline gargles
pharmacological (releases endorphins) and psychologi-
l Forceful mouth opening with gag
cal (placebo effects).
Q.8. Burning mouth syndrome (glossodynia). l It should be stressed to the patient that these drugs are
being used not to manage psychiatric illness, but for
Ans.
their well-documented analgesic effect. Clinicians pre-
The term burning mouth syndrome is reserved for describ- scribing these drugs should be familiar with potential
ing oral burning that has no detectable cause. The burning serious and annoying side effects.
symptoms in patients with BMS do not follow anatomic l Burning of the tongue that results from parafunctional
pathways, there are no mucosal lesions or known neuro- oral habits may be relieved with the use of a splint cov-
logic disorders to explain the symptoms, and there are no ering the teeth and/or the palate.
characteristic laboratory abnormalities.
Q.9. Postherpetic neuralgia.
l The cause of BMS remains unknown, but a number of Ans.
factors have been suspected, including hormonal and l Herpes zoster (shingles) is caused by the reactivation
allergic disorders, salivary gland hypofunction, chronic of latent varicella zoster virus infection that results in
low-grade trauma and psychiatric abnormalities. both pain and vesicular lesions along the course of the
l It is likely that some cases of BMS have a strong psy- affected nerve.
chological component, but other factors, such as chronic l Herpes zoster of the maxillary and mandibular divisions
low-grade trauma resulting from parafunctional oral of trigeminal nerve is a cause of facial and oral pain as
habits (e.g. rubbing the tongue across the teeth or press- well as of lesions.
ing it on the palate), are also likely to play a role. l In a majority of cases, the pain of herpes zoster re-
solves within a month after the lesions heal. Pain that

Clinical manifestations
persists longer than a month is classified as PHN,
l Women experience symptoms of BMS seven times
although some authors do not make the diagnosis of
more frequently than men.
PHN until the pain has persisted for longer than 3 or
l The tongue is the most common site of involvement, but
even 6 months.
the lips and palate are also frequently involved.
l PHN may occur at any age, but the major risk factor is
l The burning can be either intermittent or constant, but
increasing age. Few individuals younger than 30 years
eating, drinking or placing candy or chewing gum in the
of age experience PHN whereas more than 25% of indi-
mouth characteristically relieves the symptoms.
viduals older than 55 years of age and two-thirds of
l Patients presenting with BMS are often apprehensive
patients older than over 70 years of age will suffer from
and admit to being generally anxious or ‘high-strung’.
PHN after an episode of herpes zoster.
They may also have symptoms that suggest depression,
l Elderly patients also have an increased risk of experi-
such as decreased appetite, insomnia and a loss of inter-
encing severe pain for an extended period of time. The
est in daily activities.
pain and numbness of PHN results from a combination
l Patients complaining of a combination of xerostomia
of both central and peripheral mechanisms. This combi-
and burning should be evaluated for the possibility of a
nation of peripheral and central injury results in the
salivary gland disorder, particularly if the mucosa ap-
spontaneous discharge of neurons and an exaggerated
pears to be dry and the patient has difficulty swallowing
painful response to nonpainful stimuli.
dry foods without sipping liquids.
l When indicated, laboratory tests should be carried out Clinical manifestations
to detect undiagnosed diabetic neuropathy, anaemia or l Patients with PHN experience persistent pain, paraes-
deficiencies of iron, folate or vitamin B12. thesia, hyperaesthesia and allodynia months to years
after the zoster lesions have healed.
Treatment
l The pain is often accompanied by a sensory deficit, and
l Once the diagnosis of BMS has been made by eliminat-
there is a correlation between the degree of sensory
ing the possibility of detectable lesions or underlying
deficit and the severity of pain.
medical disorders, the patient should be reassured of the
benign nature of the symptoms. Management
l Counselling and reassurance may be adequate manage- l Many treatment options are available for the manage-
ment for individuals with mild burning sensations, but ment of PHN. Treatment includes topical and systemic
patients with symptoms that are more severe often re- drug therapy and surgery.
quire drug therapy. l Topical therapy includes the use of topical anaesthetic
l The drug therapies that have been found to be the most agents, such as lidocaine or analgesics, particularly cap-
helpful are low doses of TCAs, such as amitriptyline saicin. Lidocaine used either topically or injected gives
and doxepin, or clonazepam. short-term relief from severe pain.
l Combinations of topical anaesthetics such as EMLA l Women experience symptoms of BMS seven times
Cream (AstraZeneca) have also been reported as helpful. more frequently than men.
l Capsaicin, an extract of hot chili peppers that depletes l The tongue is the most common site of involvement, but
the neurotransmitter substance P when used topically, the lips and palate are also frequently involved.
has been shown to be helpful in reducing the pain of l Once the diagnosis of BMS has been made, the pa-
PHN, but the side effect of a burning sensation at the site tient should be reassured of the benign nature of the
of application limits its usefulness for many patients. symptoms.
l The use of tricyclic antidepressants such as amitripty- l The drug therapies that have been found to be the
line, nortriptyline, doxepin and desipramine is a well- most helpful are low doses of TCAs, such as amitrip-
established method of reducing the chronic burning pain tyline and doxepin or clonazepam (a benzodiazepine
that is characteristic of PHN. derivative).
l Because a significant number of elderly patients cannot l Burning of the tongue that results from parafunctional
tolerate the sedative or cardiovascular side effects as- oral habits may be relieved with the use of a splint cov-
sociated with tricyclic antidepressants, the use of other ering the teeth and/or the palate.
drugs, particularly gabapentin, has been advocated.
Q.3. Clinical features of Bell palsy.
l When medical therapy has been ineffective in managing
intractable pain, nerve blocks or surgery at the level of Ans.

the peripheral nerve or dorsal root have been effective
Clinical manifestations
for some patients.
l Bell palsy begins with slight pain around one ear, fol-
l The best therapy for PHN is prevention. There is evi-
lowed by an abrupt paralysis of the muscles on that side
dence that the use of antiviral drugs, particularly Famci-
of the face.
clovir, along with a short course of systemic corticoste-
l The eye on the affected side stays open, the corner of
roids during the acute phase of the disease may decrease
the mouth drops and there is drooling.
the incidence and severity of PHN.
l As a result of masseter weakness, food is retained
Q.10. Bell palsy. in both the upper and lower buccal and labial folds.
The facial expression changes remarkably, and the
Ans.
creases of the forehead are flattened. Due to im-
[Same as SE Q.1] paired blinking, corneal ulcerations from foreign
bodies can occur. Involvement of the chorda tym-
Q.11. Trigeminal neuralgia.
pani nerve leads to loss of taste perception on the
Ans. anterior two-thirds of the tongue and reduced sali-
vary secretion.
[Same as SE Q.3]
Q.4. Name the neuralgias of orofacial origin.
SHORT NOTES: Ans.
Q.1. Bell sign. Various neuralgias of orofacial region are as follows:

l Paroxysmal neuralgias such as trigeminal, glossopha-
Ans. ryngeal, nervus intermedius and superior laryngeal
l Occipital neuralgia
l Bell sign is one of the diagnostic features of Bell palsy.
l PHN
l When a patient is asked to close the eyes, the patient is
l Post-traumatic neuropathic pain, etc.
unable to do so and the eye ball goes upwards in the
attempt, it is known as Bell sign. Q.5. Define atypical facial pain.
Q.2. Burning mouth syndrome. Ans.
Ans. [Ref LE Q.2]
l The term burning mouth syndrome (glossodynia) is re- Q.6. Gamma knife stereotactic radio surgery in man-
served for describing oral burning sensation that has no agement of the tic douloureux.
detectable cause. The burning symptoms in patients
Ans.
with BMS do not follow anatomic pathways, there are
no mucosal lesions or known neurologic disorders to l Gamma knife stereotactic radio surgery is a new tech-
explain the symptoms, and there are no characteristic nique for treatment of tic douloureux.
laboratory abnormalities. l Masseter.
l It uses beams of radiation usually in doses of 70–90 Gy l The age of onset varies from 15 to 85 years but the aver-
units, converging in three dimensions to focus precisely age age is 50 years.
on a small volume. l No sex predilection and rarely there is bilateral
l This method relies on precise MRI sequencing that involvement.

helps localization of the beam and allows a higher l Sharp shooting pain in ear, pharynx, nasopharynx, ton-
dose of radiation to be given with more sparing of sil and posterior portion of tongue, i.e. at base of tongue
nerve tissue. and fauces on one side.
l Advantage of this technique is that it is particularly l Trigger zone is present in posterior oropharynx or ton-
helpful for elderly patients with a high surgical risk. sillar fossa. It is stimulated during swallowing, talking,
coughing or yawning.
Q.7. Enumerate the two important differences between
l May be associated with vagal symptoms such as syn-
the paroxysmal neuralgias and atypical neuralgias.
cope, hypotension and arrhythmias or cardiac arrest
Ans. may accompany the paroxysmal pain as may coughing
or excessive salivation.
Paroxysmal neuralgias Atypical neuralgias Treatment
l Paroxysmal neuralgias (tri- l AFP is a condition charac- l Approximately 80% of patients experience immediate
geminal, glossopharyn- terized by the absence pain relief when topical anaesthetic agent is applied
geal, nervus intermedius, of other diagnoses and to tonsil and pharynx on the side of pain. It is used as
superior laryngeal). causing continuous, vari-
diagnostic tool and can aid in distinguishing it from the
l Neuralgia is a clinical able intensity, migrating,
condition involving a pain nagging, deep and diffuse pain of other neuralgias.
of a severe intensity, with pain. l No therapy is considered to be uniformly effective or
a throbbing or stabbing l In the TMD classification even adequate.
character in the course or of the AAOP, AFP it is l Glossopharyngeal neuralgia is considerably less respon-
distribution of a specific defined as ‘a continuous
sive than trigeminal neuralgia to treatment with anticon-
nerve. unilateral deep aching
pain sometimes with a vulsant medications.
burning component’. l If the patient fails drug therapy, then surgical options
should be considered.
l The preferred neurosurgical treatments are microvascular
Q.8. PHN: mention two clinical manifestations.
decompression or surgical sectioning of the glossopharyn-
Ans. geal nerve and the upper two rootlets of the vagus nerve.
l Herpes zoster (shingles) is caused by the reactivation of Q.10. Trismus
latent varicella zoster virus infection.
l In a majority of cases, the pain of herpes zoster resolves
Ans.
within a month after the lesions heal. Pain that persists [Ref SE Q.7]
longer than a month is classified as PHN, although some
authors do not make the diagnosis of PHN until the pain Q.11. ‘TENS’ therapy.
has persisted for longer than 3 or even 6 months. Ans.
Clinical manifestations [Ref SE Q.6]
l Patients with PHN experience persistent pain, paraes-
thesia, hyperaesthesia and allodynia months to years Q.12. Types of migraine.

after the zoster lesions have healed. Ans.
l The pain is often accompanied by a sensory deficit, and
there is a correlation between the degree of sensory There are several major types of migraine:
l Classic
deficit and the severity of pain.
l Common
Q.9. Glossopharyngeal neuralgia. l Basilar
l Facial migraine (also referred to as carotidynia)

Ans.
l Glossopharyngeal neuralgia is the disease of ninth cra- Q.13. Alarm clock headache.
nial nerve, i.e. glossopharyngeal nerve.
Ans.
l It is a rare condition that is associated with paroxysmal
pain, which is similar to, though less intense than, the Alarm clock headache is a pain syndrome referable to
pain of trigeminal neuralgia. the nasal ganglion. It may be caused either due to irritation
of nasal (sphenopalatine) ganglion or irritation to vidian l For example:

nerve. l Touching or applying heat/cold to cheek/gums, etc.
l Wind blowing on face

Clinical features
l Gustatory stimuli and vibration
l Unilateral paroxysm of severe pain at or near eyes, max-
illa, ear, mastoid and nose base. Q.15. Classifications of headaches.

l No trigger zone is present.
Ans.
l Usually pain occurs at least once in a day. Interestingly,
in some patients the onset of the paroxysm occurs ex- [Ref LE Q.2]
actly at the same time of day and for this reason, the
Q.16. Glossodynia.
disease has been referred to as ‘alarm clock headache’.
l Sneezing and watering from eyes are other complaints. Ans.
Treatment [Same as SN Q.2]
l Alcohol injection of sphenopalatine ganglion.
Q.17. Atypical odontalgia.
l Ergotamine or methysergide often provides complete
relief of symptoms. Ans.

Q.14. Trigger zones. [Same as SN Q.5]
Ans.
l In case of trigeminal neuralgia, different stimuli can
trigger pain; they are known as ‘trigger zones’.
Topic 12
Bacterial, Viral and Infectious Diseases
of the Oral Cavity Including AIDS
LONG ESSAYS:
1. Describe the aetiology, clinical features, radiographic features and histological features of periapical granuloma
and mention its sequelae.
2. What are the aetiological factors of osteomyelitis of mandible.
3. Enumerate viral lesions occurring in the oral cavity and discuss in detail about acute herpetic gingivostomatitis.
4. What are the predisposing factors of acute necrotizing ulcerative gingivostomatitis? How will you diagnose and
treat a patient suffering from this disease?
5. Describe the clinical features and treatment of actinomycosis of the jaw.
6. Ludwig angina.
7. Classify osteomyelitis. Write in detail about the aetiology, clinical features, radiographic features and manage-
ment of chronic suppurative osteomyelitis. [Same as LE Q.2]
8. What are the viral infections in the oral cavity? Write about the aetiology, clinical features, diagnosis and dif-
ferential diagnosis of acute herpetic gingivostomatitis. [Same as LE Q.3]
SHORT ESSAYS:
1 . Pyogenic granuloma.
2. Classify types of osteomyelitis. [Ref LE Q.2]
3. Secondary stage of syphilis.
4. Oral manifestations of HIV infection.
5. Cellulitis.
6. Chancre.
7. Herpes zoster infection.
8. Clinical appearance of actinomycosis.
9. Chancre. [Same as SE Q.3]
10. Oral manifestations of syphilis. [Same as SE Q.3]
11. Clinical features of gumma in palate. [Same as SE Q.3]
SHORT NOTES:
1. Oral manifestations of HIV infection. [Ref SE Q.4]
2. Clinical features of gumma in palate.
3. Pyogenic granuloma.
4. Focal infection.
5. Lipschutz bodies.
6. Hutchinson triad.
7. Treponema pallidium.
8. Mucous patches.
9. Koplik spots.
10. Garre osteomyelitis.
11. Herpangina.
12. Scrofula.
13. Oral hairy leukoplakia.
14. Enumerate periapical lesions.
15. Treatment of candidiasis.
16. Treatment plan of herpes zoster.
17. Behcet syndrome.
SOLVED ANSWERS
LONG ESSAYS: Clinical features
● The involved tooth is usually nonvital and may be
Q.1. Describe the aetiology, clinical features, radio-
slightly tender to percussion.
graphic features and histological features of periapical
● Percussion may produce dull sound instead of normal
granuloma and mention its sequelae.
metallic sound because of the presence of granulation
Ans. tissue around the root apex.
● The involved tooth feels slightly elongated from the
● Periapical granuloma or chronic apical periodontitis or
socket.
dental granuloma is a localized mass of chronic granu-
● Patients may complain of pain on biting or chewing
lation tissue formed in response to infection around the
solid food.
root apex of nonvital tooth.
● The sensitivity is due to hyperaemia, oedema and in-
● It is a low-grade infection and one of the most com-
flammation of the apical periodontal ligament.
mon of all sequelae of pulpitis, i.e. acute periapical
● The early or even the severe chronic periapical granu-
periodontitis.
loma rarely presents with any severe clinical features.
Aetiology ● Most of the cases are asymptomatic. If pus has formed,
● Extension of pulpal inflammation. a small reddish swelling may be found on the buccal
● Acute trauma due to blows on the tooth. gum or a sinus may be present.
● Spread of periodontal infection into the tooth. ● If the lesion undergoes an acute exacerbation then there
● Perforation of root apex in endodontic therapy. will be perforation of the overlying bone and oral mu-
● Orthodontic tooth movements with excessive uncon- cosa with the formation of a fistulous tract.
trolled force. ● Granuloma remains attached to the extracted tooth.
● Enlargement and tenderness of regional lymph nodes. [SE Q.2]

● Fever and malaise occurs.
● {Osteomyelitis is defined as an inflammatory condition
Radiographic features of the bone that begins as an infection of medullary
● The earliest changes in the periodontal ligament appear cavity and the Haversian system and extends to involve
as thickening of the periodontal ligament at the root the periosteum of the affected area.
apex and loss of lamina dura.
Classification of osteomyelitis
● It appears as a radiolucent area of variable size usually
Based on location
less than 1.5 cm in diameter attached to root apex.
● Intramedullary
● In some cases, radiolucency is well-circumscribed, defi-
● Subperiosteal
nitely demarcated from surrounding bone.
● Periosteal
● In some instances it appears as a diffuse blending of
the radiolucent area with the surrounding bone. Some Based on duration and severity
degree of root resorption is also seen. ● Acute
● Chronic
Histologic features
● Periapical granuloma consists of inflamed granula- Based on presence or absence of suppuration
tion tissue surrounded by a fibrous connective tissue a. Suppurative
wall. ● Acute suppurative osteomyelitis
● The granulation tissue demonstrates a variably dense ● Chronic suppurative osteomyelitis:
lymphocytic infiltrate that is intermixed with neutro- i. Primary

phils, plasma cells, and eosinophils. ii. Secondary
● When numerous plasma cells are present, scattered eo- ● Infantile osteomyelitis
sinophilic globules of g globulin (Russell bodies) may b. Nonsuppurative

be seen. ● Chronic nonsuppurative
● There is presence of epithelial islands, cholesterol clefts, i. Focal sclerosing

foam cells, plasma cells and T lymphocytes in the ii. Diffuse sclerosing
lesion. ● Radiation osteomyelitis
● The epithelial cell rests of Malassez proliferate in re- ● Garre sclerosing osteomyelitis
sponse to chronic inflammation and these proliferating ● Osteomyelitis due to specific infection like actino-
cells undergo liquefaction. mycosis, tuberculosis, syphilis, etc.}

● In addition, cluster of lightly basophilic particles (pyro- Chronic suppurative osteomyelitis
nine bodies) may also be seen with the plasmacytic in- ● Chronic osteomyelitis is the persistent abscess of
filtrate. the bone characterized by the complex inflamma-

● Collection of cholesterol clefts, with associated multi- tory process including necrosis of mineralized
nucleated giant cells and areas of red blood cell extrava- and marrow tissues, suppuration, resorption, scle-
sation with haemosiderin pigmentation, may be seen. rosis and hyperplasia.
● Small foci of acute inflammation with focal abscess ● Chronic suppurative osteomyelitis exists when the
formation may be seen. defensive response leads to the production of granu-

lation tissue, which subsequently forms dense scar
Treatment and prognosis tissue in an attempt to wall of the infected areas.
● Successful treatment depends on the reduction and con-
● The encircled dead space acts as a reservoir for
trol of the offending organisms. If tooth can be main- the bacteria and antibiotic medication will have
tained then root canal therapy with apical curettage difficulty in reaching the site.
should be performed. ● The disease may be acute, subacute or chronic
● Nonrestorable teeth must be extracted, followed by
and presents with a different clinical course, de-
curettage of all apical soft tissue. pending on its nature.
● In symptomatic cases, NSAIDs are beneficial.
● Use of antibiotic is not recommended, unless systemic
● Fractures due to trauma and road traffic accidents,
symptoms or swelling is not visible. gunshot wounds, radiation damage, Paget disease
Q.2. What are the aetiological factors of osteomyelitis of and osteoporosis.
● Systemic conditions like malnutrition, acute leu-
mandible.
kaemia, uncontrolled diabetes mellitus, sickle cell
Ans. anaemia and chronic alcoholism.
Pathogenesis can demonstrate significant osteogenic periosteal

hyperplasia.
Infection of bone marrow from infected pulp
● The main radiographic feature of suppurative os-
g
teomyelitis is an expanding radiolucent osteolytic
Extension of infection into cancellous bone changes instead of the potential for peripheral
g sclerosis.
Thrombus formation in nutrient vessels of the living bone Treatment and prognosis
● Chronic osteomyelitis is difficult to manage med-
g
ically, presumably because pockets of the dead
Death of cancellous bony trabeculae with formation bone and organisms are protected from antibiotic
of sequestrum drugs by the surrounding walls of the fibrous con-
g nective tissue.
● Surgical intervention is mandatory.
Spread of infection via Volkmann’s canal in cortical plates
● The most frequently used antibiotics are penicil-
g
lin, clindamycin, cephalexin, cefotaxime, tobra-
Periostitis mycin and gentamicin, but these antibiotics
g should be used intravenously and in high doses.
● The extent of the surgical intervention depends
Multiple sinus tract formation
on the spread of the process; removal of all the
g
infected material down to good bleeding bone is
Necrosis of cortical bone mandatory in all cases.
g ● For small lesions, curettage, removal of necrotic
Discharge of the pus from involucrum through sinuses bone and saucerization are sufficient.
● In patient with more extensive osteomyelitis, de-
known as ‘cloacae’
cortication or saucerization is combined with
Clinical features transplantation of cancellous bone chips.
● If the acute osteomyelitis is not resolved expedi- ● In case of persisting osteomyelitis, resection of
tiously, the entrenchment of chronic osteomyelitis the diseased bone followed by immediate recon-
occurs, or the process may arise primarily without struction with an autologous graft is required.
a previous acute episode. ● Weakened jaw bones must be immobilized.
● Swelling, pain, sinus formation, purulent dis- ● The goal of the surgery is removal of all infected
charge, sequestrum formation, tooth loss or patho- tissue.
logic fractures may occur. ● Persistence of chronic osteomyelitis is typically
● Patients may experience acute exacerbations or the result of diseased tissue.
periods of decreased pain associated with chronic
smoldering progression. Q.3. Enumerate viral lesions occurring in the oral cav-
● The molar area of mandible is more frequently ity and discuss in detail about acute herpetic gingivo-
affected. stomatitis.
● Pain is usually mild and insidious and is not re-
Ans.
lated to the severity of the disease.
● Jaw swelling is common feature but mobility of The viral infections of oral cavity are classified depending
teeth and sinus tract formation are rare. on the presence of the major viruses as follows:
● Regional lymphadenopathy is common.
● There is thickened, woodened feeling of bone and RNA viruses
slow increase in jaw size. a. Orthomyxovirus
Radiographic features ● Influenza
● Radiography reveals a patchy, ragged and ill- b. Paramyxovirus
defined radiolucency that often contains a central ● Measles (rubeola)
radiopaque sequestra. ● Mumps
● On CT scan, the osteolytic changes are continu- c. Rhabdovirus
ous and may exhibit spread to the periosteum by ● Rabies
direct extension. d. Arena virus
● Occasionally, the surrounding bone may exhibit ● Lassa fever
increased radiodensity, and the cortical surface ● Lymphocytic choriomeningitis
e. Calicivirus Herpetic gingivostomatitis

f. Corona virus Clinical features
● Upper respiratory tract infection ● Herpetic gingivostomatitis is a common oral dis-
g. Bunya virus ease transmitted by droplet spread or contact with

h. Picornavirus the lesions.
i. Reovirus ● This infection occurs in the persons who are not
j. Toga virus infected previously with herpes virus or they do

k. Retro virus not have circulatory antibodies against virus.
DNA viruses ● It affects children and young adults.
a. Herpes virus ● Disease occurring in children is frequently the
● Herpes simplex virus 1 and 2 primary attack and is characterized by the devel-
● Varicella zoster virus opment of fever, irritability, headache, pain up on
● Cytomegalovirus swallowing and regional lymphadenopathy.
● Epstein–Barr virus ● Within a few days mouth becomes painful, and
● Human herpes virus 6–8 the gingiva becomes intensely inflamed and ap-
b. Poxvirus pears erythematous and oedematous.
● Smallpox ● Lips, tongue, buccal mucosa, palate and tonsils
● Molluscum contagiosum may be involved. Shortly, yellowish fluid filled

c. Adeno virus vesicles develop in oral cavity.
● Pharyngoconjunctival fever ● These vesicles rupture to form painful ulcers cov-
d. Parvovirus ered by grey membrane and surrounded by ery-

e. Iridovirus thematous halo.
f. Papovavirus ● Healing occurs in 7–14 days and leave no scar.
● Human warts or papillomas ● Herpetic whitlows in hands of hospital staff and
Herpes simplex virus disseminated infection of new born are examples

● Herpes simplex is a DNA virus, which causes the of primary herpetic infections.
disease in the man. Histological features
● The tissues preferentially involved by herpes simplex ● Intraepithelial fluid-filled vesicles.
virus are often referred to as herpes virus hominis and ● Ballooning degeneration.
are derived from ectoderm principally the skin, mu- ● Intranuclear inclusions known as Lipschutz bod-
cous membranes, eyes and central nervous system. ies are present, these are eosinophilic, ovoid ho-
● Two types of infections occur with herpes simplex virus: mogeneous structures within the nucleus.
A. Primary infection ● Perinuclear halo in nucleus produced by displace-
B. Secondary or ‘recurrent’ infection ment of chromatin peripherally by Lipschutz bodies.

Primary infection occurs in persons who do not have ● Cytoplasm of infected cells forms giant cells and
circulating antibodies whereas secondary or ‘recur- subjacent connective tissue is usually infiltrated
rent’ infection occurs in persons who have circulat- by inflammatory cells.
ing antibodies. Diagnosis
● Primary herpetic infections may manifest clinically ● It can be diagnosed by both clinical and labora-
as primary gingivostomatitis, primary vulvovaginitis, tory procedures.

inoculation herpes simplex, varicelliform eruption, ● HSV can be demonstrated in laboratory by isola-
meningoencephalitis and disseminated herpes sim- tion of virus in tissue culture or by DNA in the
plex. Subclinical primary infection is common in scrapings from the lesion.
99% of cases; the primary infection is subclinical ● Most sensitive and accurate method for diagnosis
with no visible clinical disease. is PCR technique.

● Recurrent herpetic manifestations include fever Treatment
blister, genital herpes simplex and dendritic corneal ● Antiviral drugs: If diagnosed early, the antiviral
ulcers. drugs have significant impact on the course of the

● HSV2 is associated with carcinoma of uterine cervix; disease.
HSV does not remain latent at site of original infec- ● Antibiotics: They help in the prevention of sec-
tion; reaches regional ganglia along the nerve path; ondary infection.
HSV1 seen in trigeminal and HSV2 in lumbosacral ● NSAIDs and topical anaesthetic gel: May relieve
ganglions. the discomfort considerably.

Differential diagnosis subsequently involving marginal gingival and

● Herpes zoster rarely attached gingiva.
● Impetigo ● Craters are covered by greyish pseudomembra-
● Epidermolysis bullosa nous slough with a marked demarcation of linear

● Erythema multiforme erythema from the normal mucosa.
● Smallpox ● Spontaneous bleeding from gingival tissue
● Pemphigus ● Fetid odour and increased salivation.
● Food or drug allergies Symptoms

● Drug or chemical burns ● Extremely tender with radiating pain on eating
hot and spicy foods

Q.4. What are the predisposing factors of acute necro- ● Metallic foul taste
tizing ulcerative gingivostomatitis? How will you diag- ● Pasty saliva
nose and treat a patient suffering from this disease? Extraoral and systemic signs and symptoms
Mild-to-moderate stages
Ans.
● Local lymphadenopathy
● Acute necrotizing ulcerative gingivitis (ANUG) is an ● Slight elevation of temperature
inflammatory and destructive endogenous oral infection Severe cases

which is characterized by the necrosis of gingival tissue. ● High fever with increased pulse rate
● It is also known as trench mouth, Vincent infection, ● Loss of appetite and general lassitude
acute ulceromembranous gingivitis and acute ulcerative Systemic reactions

gingivitis. ● They are severe in children.
Aetiology ● Rarely noma, gangrenous stomatitis, fusospiro-
Role of bacteria chetal meningitis, peritonitis, toxaemia and fatal

● It is caused mainly by specific bacteria: Fusiform brain abscess may occur.
bacillus and spirochaetes. Histopathology
● The constant flora is composed of Prevotella in- ● It involves both stratified squamous epithelium and
termedia, in addition to Fusobacterium, Trepo- underlying connective tissue.

nema and Selenomonas species. ● The surface epithelium is destroyed and is replaced
Local predisposing factors by pseudomembranous meshwork of fibrin, necrotic

● Poor oral hygiene, pre-existing marginal gingivi- epithelial cells, polymorphonuclear neutrophils and
tis and faulty dental restoration. various microorganism that appears as a surface
● Area of gingiva traumatized by opposing in mal- pseudomembrane.
occluded teeth such as the palatal surface behind ● The underlying connective tissue is hyperaemic with
maxillary incisors and labial gingival surface of numerous engorged capillaries and dense infiltration
mandibular incisors. of polymorphonuclear neutrophils, which appears as
● Smoking – due to direct toxic effect of nicotine. a linear erythema.
● Emotional stress. ● Numerous plasma cells may appear in periphery of
Systemic predisposing factors infiltrate.

● Nutritional deficiency - vitamins A, C and B2. Treatment
● Marked malnutrition ● The conservative treatment is superficial cleaning of
● Chronic diseases – syphilis and cancer oral cavity by chlorhexidine, diluted hydrogen per-
● Gastrointestinal diseases – ulcerative colitis oxide or warm salt water. This is followed by scaling
● Blood dyscrasias – leukaemia, aplastic anaemia and polishing under topical anaesthesia.
and AIDS ● Use of antibiotics is coupled with local treatment in
Clinical features patients with toxic systemic complications.

● It is identified as an acute disease characterized by ● Nutritional supplements like vitamin B and vitamin C.
sudden onset, sometimes followed by an episode

of debilitating diseases or acute respiratory tract Q.5. Describe the clinical features and treatment of ac-
infections. tinomycosis of the jaw.
● It is seen commonly in age group 16–30 years.
Ans.
Oral signs and symptoms
Signs ● Actinomycosis is subacute to chronic, suppurative gran-
● Characterized by punched out, crater-like de- ulomatous disease that tends to produce draining sinus
pressions at the crest of the interdental papillae, tracts.
● It is caused by anaerobic Gram-positive, nonacid-fast ● A diagnosis is usually made by identifying the typical
bacilli. actinomycotic colonies in a surgical specimen.
● Occasionally, the periapical actinomycotic lesion may
Clinical features appear radiopaque mimicking condensing osteitis.

● Actinomycosis is mostly found in young adults. Women
Management
are less frequently affected than men.
● The sinus tracts have to surgically excised and abscess
● Based on the site of involvement, actinomycosis can be
drainage should be facilitated.
grouped into the cervicofacial, pulmonary, abdominal
● Long-term antibiotic therapy with penicillin or tetracy-
and pelvic and cutaneous and genitourinary actinomy-
cline is recommended.
cosis.
● Cutaneous actinomycosis is extremely rare and these Q.6. Ludwig angina.
are said to arise from wounds contaminated with saliva Ans.
or as a consequence of haematogenous dissemination
following a dental procedure. ● Ludwig angina is a form of firm, acute, toxic and severe
● However, primary cutaneous actinomycosis have also
diffuse cellulitis causing board like swelling of subman-
been reported. dibular, sublingual and submental spaces bilaterally.
● It is a potentially life-threatening, rapidly expanding,
● The genitourinary form has been reported in patients
using intrauterine contraceptive devices. diffuse inflammation of the submandibular and sublin-
● The presenting symptoms of pulmonary actinomycosis
gual spaces that occurs most often in young adults with
are fever, cough thoracic pain and dyspnoea. dental infections.
● It is a disease primarily of dental origin following infec-
● The sputum is mucopurulent or even sanguineous. With
the appearance of fistulae, the disease spreads to the tion of second and third mandibular molars.
mediastinum, the pericardium and finally to the skin of Aetiology
the chest. ● Odontogenic infections – Common teeth involved are
● Actinomycosis is believed to be acquired by endoge- mandibular second and third molars
nous implantation into deep tissues where anaerobic ● Vincent angina
conditions prevail. ● Periodontal disease
● Actinomyces israelii is an anaerobic normal inhabitant ● Acute tonsillitis
of the mouth, especially in the teeth and tonsils. ● Peritonsillar abscess (Quinsy)
● In the cervicofacial region, puncture wounds, dental ● Pericoronitis
extractions or compound fractures are some of the ● Fracture of the mandible
routes of infection. ● Erysipelas
● The cervicofacial variant is characterized by the appear- ● Submandibular and sublingual sialadenitis
ance of solid sub- or supramandibular nodules or swell-
ings and the overlying skin becoming purple to violet. Predisposing factors
● Lowered resistance and poor oral hygiene
● Clinical presentation of cervicofacial actinomycosis is
characterized by the presence of suppurative or ‘wooden’ Clinical findings
indurated mass with discharging sinuses. ● Ludwig angina begins as a mild infection and can rap-
● Pus from the discharging sinuses contains tiny yellow idly progress to brawny induration of the floor of the
sulphur granules. mouth and upper neck.
● Common initial symptoms of infection including ● Elevation of tongue and enlarged painful lymph nodes.
pain, fever, erythema, oedema and suppuration may Difficulty in swallowing and opening the mouth.
be absent. ● Headache, malaise and other signs of toxaemia.
● Actinomycosis often involves lymphatic nodes but by ● High fever, rapid pulse and fast breathing.
the direct extension of a primary lesion. ● Oedema of glottis causing respiratory obstruction. Stri-
● Occasionally, the masticatory muscles and tongue may dor suggests an impending airway crisis.
be involved resulting in trismus and dysphagia. ● Anxiety, cyanosis and sitting posture are late signs of
● Radiographs reveal ill-defined radiolucencies with a impending airway obstructions and indicates the need
radiopaque periphery. for an immediate artificial airway.
● Periapical actinomycosis is believed to be a nonresolv- ● Infection may spread to pharyngeal spaces, to carotid
ing periapical lesion associated with actinomycotic in- sheath or to pterygopalatine fossa.
fection and has been suggested as a contributing factor ● Complications such as descending necrotizing medias-
in the perpetuation of periapical radiolucencies after tinitis usually occurs through the retropharyngeal space
root canal treatment. and carotid sheath.
● Cavernous sinus thrombosis with subsequent meningitis ● The pyogenic granuloma is a distinctive clinical entity
is sequel to this type of spread of infection. originating as a response of the tissue to a nonspecific
infection.
Microbiology
● It is a tumour-like growth that is considered as an exag-
● Causative bacteria include many Gram-negative and
gerated, conditioned response to minor trauma.
anaerobic organisms, streptococci and staphylococci.
● Alpha haemolytic streptococci, staphylococci and bac- Aetiology
teroides are commonly reported. ● It arises as a result of minor trauma to the tissues, which
● Other anaerobes such as peptostreptococci, peptococci, provides pathway for the invasion of nonspecific types
Fusobacterium nucleatum, Veillonella species and spi- of microorganisms.
rochaetes are also seen.
Clinical features
Treatment ● Pyogenic granuloma occurs more frequently on gingiva.
● The treatment plan for each patient should be individu- It may also occur on lips, tongue and buccal mucosa and
alized and based on a number of factors. occasionally on the other areas.
● Treatment includes assessment and protection of air- ● It is common in maxillary anterior region and on the
way, use of intravenous antibiotics, surgical evaluations facial aspect than the lingual or palatal aspect.
and if necessary, operative decompression. ● Lesion may vary in size from few millimetres to centi-
● Incision and drainage of pus. metres or more in diameter.

● The lesion is usually elevated, pedunculated or sessile
Antibiotic therapy
vascular mass with a smooth, lobulated or even a warty
● Recommended initial antibiotics are high doses peni-
surface, which commonly is ulcerated and shows a ten-
cillin G, sometimes used in combination with metroni-
dency for haemorrhage either spontaneously or upon
dazole.
slight trauma.
● In penicillin allergic patient, clindamycin hydrochloride
● It is deep red or reddish purple, depending upon its vas-
is the drug of choice.
cularity, painless and rather soft consistency.
● Alternative choices are ceftizoxime sodium or combina-
● The lesion develops rapidly, reaches full size and then
tion drugs such as ticarcillin–clavulanate, piperacillin–
remains static for an indefinite period.
tazobactum or amoxicillin–clavulanate (Augmentin).
● Intravenous dexamethasone sodium phosphate given for Histologic features
48 h reduces oedema, which helps maintain airway in- ● It is similar to granuloma except that it is exuberant and
tegrity and enhances antibiotic penetration. is usually well localized.

● Mouth washes. ● The overlying epithelium if present may be thin or atro-
● Liquid diet. phic, but may be hyperplastic also.

● Emergency tracheostomy for establishment of a defini- ● If lesion is ulcerated it shows a fibrinous exudate of
tive airway, if symptoms of asphyxia are present. varying thickness over the surface.
● Vast number of endothelium-lined vascular spaces and
Q.7. Classify osteomyelitis. Write in detail about the
the extreme proliferation of fibroblast and budding en-
aetiology, clinical features, radiographic features and
dothelial cells are seen.
management of chronic suppurative osteomyelitis.
● In addition, there is usually a moderately intense infil-
Ans. tration of polymorphonuclear leukocytes, lymphocytes

and plasma cells, but this finding varies, depending
[Same as LE Q.2]
upon the presences or absence of ulcerations.
Q.8. What are the viral infections in the oral cavity? ● Both clinically and microscopically, an old lesion may
Write about the aetiology, clinical features, diagnosis and resemble a fibro-epithelial polyp or even a typical
differential diagnosis of acute herpetic gingivostomatitis. fibroma.
Ans. Treatment
● Treated by surgical excision.
[Same as LE Q.3]
● Recurrence is common because the lesion is not encap-
sulated.
SHORT ESSAYS: Q.2. Classify types of osteomyelitis.
Q.1. Pyogenic granuloma. Ans.

Ans. [Ref LE Q.2]
Q.3. Secondary stage of syphilis. ● Palatal perforation by ulcer after vigorous antibiotic
use, known as Herxheimer reaction.
Ans.
● Atrophic/interstitial glossitis is most characteristic
● Syphilis is caused by Treponema pallidum, a spirochaete/ lesion and has malignant potential to squamous cell
demonstrated best by dark field microscopy in silver carcinoma.
impregnation.
Q.4. Oral manifestations of HIV infection.
● Syphilis may be classified as:
a. Acquired Ans.
b. Congenital
[SE Q.1]
Acquired syphilis
It has three stages: {Lesions strongly associated with HIV infection
i. Primary ● Candidiasis – erythematous and pseudomembranous
ii. Secondary ● Hairy leukoplakia
iii. Tertiary ● Kaposi sarcoma
● Primary and secondary stages are infectious and ● Non-Hodgkin lymphoma
painless. ● Periodontal diseases: For example, linear gingival
erythema, necrotising ulcerative gingivitis and nec-
Primary stage (chancre)
rotizing ulcerative periodontitis}
● Chancre develops at the site of inoculation approxi-
Lesions seen in HIV infection
mately 3–90 days after contact with the infection.
Bacterial infections
● Chancre is usually solitary but may be multiple at
● Actinomyces israelii
times. It occurs mainly on genitalia, may occur on
● Escherichia coli
oral mucosa and fresh extraction wound, as painful
● Klebsiella pneumoniae
ulcers.
● Cat-scratch disease
● Highly infectious, and exhibits positive serologic
● Epithelioid (bacillary) angiomatosis
reaction despite the presence of spirochaete.
Fungal infections other than candidiasis
● Unilateral lymphadenopathy, nontender and rubbery
● Cryptococcus neoformans
nodes.
● Geotrichum candidum
● The chancre appears microscopically as a superficial
● Histoplasmosis capsulatum
ulcer showing intense inflammatory infiltrate espe-
● Mucormycosis
cially plasma cells.
● Aspergillus flavus
● Chancre heals spontaneously in 3 weeks to 2 months’
Neurologic disturbances
time.
● Facial palsy
Secondary or metastatic stage (mucous patches)
● Trigeminal neuralgia
● Usually commences 6 weeks after primary lesions.
Viral infections
● The lesions are typically multiple and occur on skin as
● Recurrent aphthous stomatitis
painless macules or papules. The oral lesions are called
● Cytomegalo virus (CMV), etc.
‘mucous patches’ and are usually painless, multiple,
greyish white plaques overlying an ulcerated surface. Q.5. Cellulitis.
● The mucous patches occur more frequently on
Ans.
tongue, gingiva or buccal mucosa or as a split papule
on lips and are highly infectious. ● Cellulitis is an inflammation and infection of cellular
● Serologic reaction is always positive. tissue especially of loose subcutaneous tissue.
● Secondary syphilis can present as explosive and wide ● The soft tissue filling the facial planes and spaces is
spread form known as ‘lues maligna’. the common site. It occurs in the facial spaces or
Tertiary or late syphilis muscular spaces or takes the form of deep-seated
● Tertiary or late syphilis is noninfectious and occurs phlegmons.
several years later. ● It occurs due to spread of dental infection, i.e. from api-
● Diffuse form may involve cardiovascular and central cal abscess, osteomyelitis, pericoronal infection, peri-
nervous system that is cardiosyphilis and neuro- odontal infection, after extraction of tooth, fracture of
syphilis. the jaw followed by secondary infection.
● Gumma is classic of tertiary or late syphilis, it is a ● The condition may progress rapidly, leading to serious
granuloma with central necrosis occurring most complications, which are surgical emergencies, requir-
commonly on tongue or palate. ing incision and drainage.
● Infection may be localized to one space or may spread ● To avoid the further spread of infection or solidification
along the various facial planes at the same time. of abscess, the patients should be advised not to mas-
● This type of reaction occurs as a result of infection by sage the affected area with any medication.
microorganisms that produces significant amounts of ● Although this condition is extremely serious, the resolu-
streptokinase, hyaluronidase and fibrinolysins, which tion is usually prompt with adequate treatment, and
act to breakdown or dissolve hyaluronic acid, the inter- untoward sequelae are uncommon.
cellular cement substance and fibrin.
Q.6. Chancre.
Aetiopathogenesis Ans.
● Streptococci are particularly potent producers of hyal-
uronidase and are therefore a common causative organ- ● Primary syphilis is characterized by the chancre that
ism in cases of cellulitis. develops at the site of inoculation.
● The anaerobes such as Prevotella and Porphyromonas ● This becomes clinically evident 3–90 days after the
spp. destroy collagen. initial exposure.

● Cellulitis of face and neck are common from dental ● The majority of chancres are solitary, although multiple
infection, either as a sequalae of an apical abscess or lesions may be seen occasionally.

osteomyelitis. ● The external genitalia and anus are the most common
sites.
Clinical features ● The affected area begins as a papular lesion, which de-
● Patient will be moderately ill and has elevated tempera- velops a central ulceration.
ture and leukocytosis. ● Less than 2% of chancre occurs in other locations, but
● Patient will have painful swelling of the soft tissue in- the oral cavity is the most common extragenital site.
volved that are firm and brawny. ● Oral lesions are seen most commonly on the lips, but
● Most of the swelling is due to inflammatory oedema. other sites included are tongue, palate, gingiva and
● If superficial spaces are involved, the skin is inflamed, tonsils.
has an orange peel appearance and is even more pur- ● The upper lip is affected more in males, whereas lower
plish sometimes. lips involvement is more in females.
● In cases of inflammatory spread of infection along the ● The oral lesions appear as a painless, clean-based ulcer-
deeper planes of cleavage, the overlying skin may be of ation or, rarely, as a vascular proliferation resembling a
normal colour. pyogenic granuloma.
● In addition, regional lymphadenitis is usually present. ● Regional lymphadenopathy, which may be bilateral, is
● Infection when arises from maxilla perforates the outer seen in most of the patients.
cortical layer of the bone above the buccinator attach- ● At this time, the organism is spreading systemically
ment and causes swelling, initially of the upper half of through the lymphatic channels, setting the stage for
the face. future progression.
● The diffuse spread soon involves the entire facial area. ● If untreated, then the initial lesion heals within 3–8
● Extension towards the eyes is a potentially serious com- weeks.
plication because of the cavernous sinus thrombosis
through the veins of the inner canthus of the eye. Q.7. Herpes zoster infection.
● When infection in the mandible perforates the outer Ans.
cortical plate below the buccinators attachment, there is
a diffuse swelling of the lower half of the face, which is ● Herpes zoster is also known as shingles or Zona.
then seen as superior as well as cervical spread. ● It is an acute infectious viral disease of an extremely
● Spread to cervical tissue can cause respiratory discomfort.
painful and incapacitating nature.
● The viral infection affects sensory nerves with trigemi-
● As the infection persists. The facial cellulitis tends to
become localized, and a facial abscess may form. When nal nerve most frequently involved and other sensory
this happens, the suppurative material present seeks to nerves involved are C3, T5, Ll and L2.
point or discharge upon a free surface. Aetiology
● If early treatment is instituted, resolution usually occurs ● Virus causing infection is ‘varicella zoster’ virus.
without drainage through a break in the skin.
Clinical features
Treatment ● Clinical features can be grouped into three phases:
● Cellulitis is treated by administration of proper antibiot- i. Prodrome
ics including antimicrobials and also the removal of the ii. Acute
cause of infection. iii. Chronic
● The disease is most common in adult life and affects accelerate healing of the cutaneous and mucosal
both the sexes equally. lesions, reduce the induration of acute pain and
● Initially adult patient exhibits fever, a general malaise, decrease the duration of the postherpetic neuralgia.
pain and tenderness along the course of involved sensory ● For the treatment of postherpetic neuralgia.
nerves, usually unilaterally. Often the trunk is affected. ● Intralesional corticosteroids.
● Within few days, the patient has a linear papular or ve- ● Topical application of capsaicin.
sicular eruption of the skin or mucosa supplied by the ● The newer antiviral drugs are under intensive clinical
affected nerves. It is typically unilateral and derma- testing for potential effectiveness in treatment of
tomic in distribution. herpes zoster.
● The acute phase begins as the involved skin develops
Q.8. Clinical appearance of actinomycosis.
clusters of vesicles set on an erythematous base.
● Within 3–4 days the vesicle becomes pustular and ulcer- Ans.
ate, with crust developing after 7–10 days.
● Actinomycosis is a chronic granulomatous suppurative
● The lesions tend to follow the path of the affected nerve
and fibrosing disease.
and terminate at the midline.
● Endogenous, opportunistic infection.
● The dorsal root ganglion is also inflamed with vesicular
● Actinomycosis is mostly found in young adults. Men
eruptions unilaterally along the sensory nerve path, over
are more frequently affected than women.
the skin or mucosa.
● Chronic phase of herpes zoster is characterized by pain Aetiology
that persists longer than 3 months after the initial pre- ● It is caused most commonly by Actinomyces israelii, al-
sentation of the acute rash. though A. naeslundii, A. viscosus, A. odontolyticus and A.

● The pain is described as burning, throbbing, aching, itch- propionica have been shown to cause the human disease.
ing or stabbing, often with flares caused by light stroking ● This bacterium is anaerobic Gram-positive, fungus-like
of the area or from contact with adjacent clothing. filamentous and branched and normally present in
● Triggering factors for infections are malignancy, trauma crypts of tonsils and cavities over teeth.
and radiations, etc.
a. Clinical featuresa. Actinomycosis is classified ana-
tomically into three forms according to location of le-
Oral manifestations
sion as cervicofacial (most common)
● Lesions of oral mucosa are fairly common, and ex-
b. Abdominal
tremely painful vesicles may be found on the buccal
c. Pulmonary
mucosa, tongue, uvula, pharynx and larynx. They gen-
● Cervicofacial actinomycosis is characterized by
erally rupture to leave the areas of erosion.
‘lumpy jaw’ and swelling of the soft tissue with for-
● One of the characteristic clinical features of the disease
mation extraoral draining sinuses over skin or muco-
involving the face or oral cavity is the unilaterality of
sal surface.
the lesions. Typically when large, the lesions will extend
● Pus collected from sinus shows typical ‘sulphur
up to midline and stop abruptly.
granules’ or tiny yellow grains which are colonies of
James Ramsay Hunt syndrome
organism.
● A special form of zoster infection of the geniculate
● The skin over the sinus is scarred. No lymphade-
ganglion with the involvement of external ear and
nopathy is present.
oral mucosa, has been termed as James Ramsay Hunt
● The infection of soft tissues may extend to involve
syndrome.
the mandible or maxilla resulting in osteomyelitis if
● The clinical manifestations include facial paralysis,
not treated.
pain in external auditory meatus and pinna of the ear.
● Abdominal actinomycosis is an extremely serious
In addition, vesicles occur in the oral cavity and oro-
form of the disease and carries high mortality rate.
pharynx with hoarseness, tinnitus, vertigo and other
● Radiographs reveal ill-defined radiolucencies with a
disturbances.
radiopaque periphery. Occasionally, the periapical
Diagnosis
actinomycotic lesion may appear radiopaque mim-
● Characteristic distribution of lesions
icking condensing osteitis.
● Cytological smears
● A diagnosis is usually made by identifying the typi-
● Fluorescent antibody staining techniques
cal actinomycotic colonies in a surgical specimen.
● Viral culture and serologic diagnosis
Treatment Treatment
● Appropriate antiviral medications such as acyclo- ● Treatment of this disease is difficult and has not been
vir, valacyclovir and famciclovir have been found to uniformly successful.

● Long-standing fibrosis cases are treated by draining ● Intravenous pyogenic granuloma occurs on neck and
the abscess, excising the sinus tract with high doses of upper extremities.
antibiotics. ● It is deep red or reddish-purple, painless and soft in
● Antibiotics such as penicillins and tetracyclines have consistency.

been most frequently used. ● Pregnancy tumour is a lesion histologically similar to
pyogenic granuloma, occurs in pregnancy.

Q.9. Chancre.
Treatment
Ans.
● Surgical excision.
[Same as SE Q.3] Q.4. Focal infection.

Q.10. Oral manifestations of syphilis. Ans.
Ans. ● A focal infection is a localized or generalized infection
[Same as SE Q.3] caused by the dissemination of microorganisms or toxic
products from a focus of infection.
Q.11. Clinical features of gumma in palate. ● Two mechanisms of focal infection: by either haema-
Ans. togenous or lymphogenous spread.

● Metastasis of microorganisms from infected focus.
[Same as SE Q.3] ● Toxins are carried from focus to distant site.
Q.5. Lipschutz bodies.

SHORT NOTES: Ans.
Q.1. Oral manifestations of HIV infection. ● Lipschutz bodies are characteristic histological feature
Ans. of primary herpetic gingivostomatitis.
● Intranuclear inclusions known as Lipschutz bodies are
[Ref SE Q.4] present; these are eosinophilic, ovoid homogeneous
Q.2. Clinical features of gumma in palate. structures with in the nucleus.
● Perinuclear halo in nucleus produced by displacement
Ans. of chromatin peripherally by Lipschutz bodies.
● Gumma is classic lesion of tertiary or late syphilis. Q.6. Hutchinson triad.
● It is a granuloma with central necrosis occurring most
commonly on tongue or palate. Ans.
● Palatal perforation by ulcer after vigorous antibiotic ● Pathognomonic of the congenital syphilis is the occur-
use, known as Herxheimer reaction. rence of Hutchinson triad, which includes:
● Atrophic/interstitial glossitis is most characteristic i. Hypoplasia of incisors and molars (screw driver-
lesion and has malignant potential to squamous cell shaped incisors, mulberry molars/Moon’s/Fournier’s
carcinoma. molar)
● The palatal lesions shows ulcerations frequently perfo- ii. Eighth nerve deafness
rating through to the nasal cavity. iii. Interstitial keratitis
Q.3. Pyogenic granuloma. Q.7. Treponema pallidum.
Ans. Ans.
● Pyogenic granuloma or Granuloma pyogenicum origi- ● Treponema pallidum is the causative agent of syphilis.
nates as a response to nonspecific infection. ‘Trepo’ means to turn, ‘nema’ means thread and ‘palli-
dum’ refers to its pale staining.
Aetiology
● It is a thin delicate spirochaete with tapering ends. It has
● Infection either by staphylococci or streptococci.
about 10 regular spirals, which are sharp and angular, at
● Sulphhydryl radical is most essential stimulating agent.
regular intervals of about 1 micron.
Clinical features ● It can be seen by dark ground microscope or negative
● Arises more frequently on gingiva, may also occur on staining. It can be stained by silver impregnation meth-
lips, tongue and buccal mucosa. ods. It stains light rose red with Giemsa stain.
● Overzealous proliferation of a vascular type of connec- ● Pathogencity: Natural infection with T. pallidum occurs
tive tissue. only in human beings.

Q.8. Mucous patches. ● Herpangina is a specific viral infection caused by cox-

sackie group A virus.
Ans.
Clinical features
● A superficial greyish area of mucosal necrosis is seen in
● In herpangina or aphthous pharyngitis, the clinical fea-
secondary syphilis. This lesion is termed a mucous
tures are mild and are of short duration (1 week).
patch.
● It is commonly seen in young children.
● Secondary syphilis usually develops within 6 weeks
● The incubation period is probably 2–10 days.
after the primary lesion and is characterized by diffuse
● It begins with sore throat, cough, rhinorrhoea, low-
maculopapular eruptions of the skin and mucous mem-
grade fever, headache, sometimes vomiting, prostration
branes.
and abdominal pain.
● On the skin, these lesions may present as macules or
● Small vesicles that rupture to form crops of ulcers are
papules.
more common on pharynx and posterior oral mucosa and
● In the oral cavity, the lesions are usually multiple pain-
are less frequent on tongue, buccal mucosa and palate.
less greyish-white plaques overlying an ulcerated ne-
● The ulcers do not tend to be extremely painful although
crotic surface.
the patients will have dysphagia.
● The lesion occur on the tongue, gingiva, palate and
● A permanent immunity develops to the infecting strains
symptoms (including fever, sore throat, general malaise
rapidly and antibodies are found.
and headache) may also be present.
● The mucous patches of the secondary stage of syphilis Laboratory findings
resolve within a few weeks but are highly infective be- ● The coxsackie virus can be isolated in suckling mice or
cause they contain large numbers of spirochaetes. hamsters by inoculation of scrapings from throat lesions
or stool specimens.
Q.9. Koplik spots.
Treatment
Ans.
● No treatment is necessary as the disease appears to be
● Measles is a disease with a prodromal phase that is self-limiting.

characterized by symptoms of upper respiratory infec-
Q.12. Scrofula.
tion, tonsillopharyngitis and small white lesions with
erythematous bases on the buccal mucosa and inner Ans.
aspect of the lower lip (Koplik spots).
● These lesions are pathognomonic of early measles
● Tuberculosis is a specific infectious granulomatous
infection. disease.
● In India, tuberculosis is the most common opportunistic
Q.10. Garre osteomyelitis. infection caused by mycobacterium tuberculosis, an
Ans. acid-fast bacillus.
● General clinical signs and symptoms are remarkably
● Garre osteomyelitis is also known as chronic osteomy- inconspicuous. The patient may suffer from episodic
elitis with proliferative periostitis or periostitis ossificans fever and chills, but easy fatigability and malaise are
or Garre chronic nonsuppurative sclerosing osteitis. often the chief early features of the disease.
● It represents a reactive periosteal osteogenesis in re- ● Tuberculous lymphadenitis of submaxillary and cervi-
sponse to low-grade infection or trauma. cal lymph nodes is known as scrofula.
● It is common in young children and adults in the poste-
rior region of mandible. Q.13. Oral hairy leukoplakia.

● The involved jaw bone has a carious nonvital tooth.
Ans.
● Lymphadenopathy, slight pyrexia and leukocytosis may
be present but ESR is normal. ● The most common (Epstein-Barr virus) EBV-related
● Radiologically, it exhibits characteristic onion-skin ap- lesions in patient with AIDS is oral hairy leukoplakia.
pearance. ● This lesion clinically presents as a white mucosal
● Treatment consists of elimination of causative agent plaque that does not rub off and is characterized histo-
and extraction of carious infected tooth and antibiotic pathologically by a distinctive pattern of hyper keratosis
therapy. and epithelial hyperplasia.
● Prognosis is good. ● Most cases occurs on lateral border of the tongue and
ranges in appearance from faint white vertical streaks to
Q.11. Herpangina.
thickened and furrowed areas of leukoplakia, exhibiting
Ans. a shaggy keratotic surface.
● The lesion may become extensive and cover the entire Q.16. Treatment plan of herpes zoster.
dorsal surface of the tongue.
Ans.
● Histopathologically, OHL exhibits thickened para-
keratin that demonstrates surface corrugations or thin ● In healthy patients, if diagnosis occurs within 72 h of
projections. initiation of the disease, a course of acyclovir or valaci-
● The epithelium is acanthotic and exhibits a band-like clovir can be administered.
zone of lightly stained cells with abundant cytoplasm in ● If patient is seen later during the course of the disease,
the upper spinous layer. symptomatic relief in the form of magic mouthwash can
● Treatment is usually not needed, although slight dis- be prescribed.
comfort or aesthetic concerns may necessitate therapy. ● In immunosuppressed patients, a prescription of acyclo-
● Surgical excision or cryotherapy has been used sometimes. vir or valaciclovir can be administered.
● It is belief that prescription of antiviral and corticoste-
Q.14. Enumerate periapical lesions.
roids therapy prevents postherpetic neuralgia.
Ans.
Q.17. Behcet syndrome.
Acute periradicular diseases
Ans.
● Acute alveolar abscess
● Acute apical periodontitis ● The lesions in Behcet are similar to aphthous ulcer-
ations occurring in otherwise healthy individual.
Chronic periradicular diseases with areas of rarefaction
● The Behcet syndrome includes triad of clinical features:
● Chronic alveolar abscess
recurrent oral and genital ulcers, ocular inflammation
● Granuloma
and skin lesions.
● Cyst
● Cause: PPLO virus; autoimmune.
● Condensing osteitis
● Oral involvement is an important component of Behcet
Q.15. Treatment of candidiasis. syndrome. Lesions commonly involve soft palate and
oropharynx.
Ans.
● Genital lesions appear on the vulva, vagina, glans penis,
The treatment of candidiasis is as follows: scrotum and perianal area.

● Rectify the underlying cause. ● Common cutaneous lesions include erythematous pap-
Topical agents used are as follows: ules, vesicles, pustules, folliculitis, acneiform eruptions
● Clotrimazole 1% cream 5 times/day for 2 weeks. and erythema nodosum-like lesions.
● Clotrimazole 2% gel 5 times/day for 2 weeks. ● Ocular involvement is seen in 70%–85% cases.
● Clotrimazole 1% solution 5 times/day for 2 weeks. ● The most common secondary ocular complications are
● Nystatin 5 lakh units tablets (mycostatin) 4 times/day cataracts, glaucoma and neovascularization of the iris
for 14 days – crush and mix with water and use as and retina.
mouth rinse and swallow.
Treatment
● Fluconazole dispersible tablets (Nuforce) with water –
● The oral and genital ulcers respond well to potent
use mouth rinse 3 times/day for 14 days.
topical or intralesional corticosteroids or topical tacro-
Parenteral route
limus.
● Amphotericin B i.v. infusion 0.3 mg/kg can be
● In most severe cases, this therapy can be combined with
infused over 4–8 h.
oral colchicine or dapsone.
Oral route
● Severe ocular or systemic lesions often needs systemic
● Fluconazole 150 mg b.i.d. for 14 days/fluconazole
immunomodulatory and immunosuppressive drugs, e.g.
200 mg b.i.d. for 14 days.
corticosteroids, cyclosporine, azathioprine, interferon-
● Ketoconazole 200 mg OD for 1–4 weeks.
a2a and cyclophosphamide.
● Itraconazole 100 mg OD for 14 days.
Topic 13
Diseases of the Endocrine and Respiratory
System: CVS and GIT
LONG ESSAYS:
1 . Hyperparathyroidism.
2. Oral manifestations of diabetes mellitus.
3. Describe general, oral and dental manifestations of various endocrine disorders.
4. Discuss the role of oral diagnosis in diagnosing endocrinal disorders.
5. Acromegaly.
SHORT ESSAYS:
1 . Hyperthyroidism.
2. Management of cardiac patient in dental extraction.
SHORT NOTES:
1 . Hyperparathyroidism.
2. Oral manifestations of diabetes mellitus. [Ref LE Q.3]
3. Addison disease – aetiology.
4. Acromegaly. [Ref LE Q.5]
5. Radiographic appearance of hyperparathyroidism.
6. Dental considerations for a patient with a history of gastritis.
7. Koplik spots.
8. Grinspan syndrome.
SOLVED ANSWERS
LONG ESSAYS: stimulate thyroid hormone production and goitre

formation.
Q.1. Hyperparathyroidism. ● Graves disease is characterized by diffuse enlargement
of the thyroid gland, infiltrative ophthalmopathy (ex-
Ans.
ophthalmos) and pretibial myxoedema (dermopathy).
● A state of excessive thyroid hormone due to hyper func- ● Important manifestations of hyperthyroidism are
tion of the thyroid gland is called hyperthyroidism or weight loss with increased appetite, heat intolerance,
thyrotoxicosis. sweating, palpitation, tremors and nervousness.
● The signs are tachycardia, atrial fibrillation, fine fin-
Clinical features ger tremors, moist warm skin, lid retraction, wide
● The most common cause of thyrotoxicosis is palpebral fissure, lid lag and exophthalmos.
Graves disease (Basedow disease) in 60%–80% of ● Ophthalmopathy is present in 20%–50% patients of
people. Graves disease. It may precede the development of
● Graves disease is an autoimmune disorder with thyrotoxicosis or may develop after successful treat-
genetic predisposition. The antibodies (TSH-R an- ment of hyperthyroidism of Graves disease. It usually
tibodies) bind Thyroid Stimulating Harmone consists of chemosis, scleral injection, periorbital
(TSH) receptors on thyroid follicular cells and oedema and proptosis.
Proptosis may cause corneal drying and damage. In

● ● Serum total and unbound (free) T3 and T4 are in-
severe cases, exophthalmos, diplopia and optic nerve creased.
compression may occur. ● The uptake of radioactive iodine by thyroid is high in
● Dermopathy occurs in about 5% of patient with Graves disease and toxic nodular goitre whereas it is
Graves disease. Purple or pink patches over anterior low in subacute thyroiditis.
and lateral aspect of the leg (pretibial myxoedema) ● Ultrasonography of thyroid gland reveals diffuse
are commonly seen. enlargement of thyroid gland, which helps us to dif-

● Thyroid acropathy is unusual feature of Graves dis- ferentiate Graves disease from nodular goitre.
ease and manifests as digital clubbing and swelling Treatment
of fingers and toes. ● Hyperthyroidism or Graves disease is treated by an-
Symptoms tithyroid drugs, radioactive iodine (131I) or subtotal

● Excitability, hyperactivity, irritability and dysphoria. thyroidectomy.
● Heat intolerance and swelling ● The choice of treatment depends on the cause and
● Hyper reflexia, muscle wasting and proximal myopa- severity of hyperthyroidism, the age of the patient
thy without fasciculation and clinical situation.
● Profuse sweating, fatigue and weakness I. Symptomatic
● Weight loss with increased appetite ● b-blockers (e.g. propranolol) can be used to in-
● Diarrhoea and polyuria hibit the sympathetic nervous system symptoms

● Oligomenorrhoea and loss of libido like tachycardia until antithyroid treatments
● Goitre/enlarged thyroid gland start to take effect.
Signs II. Antithyroid drugs
● Tachycardia. ● Antithyroid medication is recommended to
● Systolic hypertension. be given for 6 months to 2 years. Upon cessa-

● Hot moist palms. tion of the drugs, the hyperthyroid state may
● Presence of fine tremors, i.e. involuntary movement recur.
of body parts is present. ● The main antithyroid drugs are carbimazole,
● Cardiac arrhythmias, i.e. atrial fibrillation and atrial methimazole and propylthiouracil (PTU).
tachycardia develop. ● These drugs block the binding of iodine and
● Diaphoresis is present, i.e. excessive sweating is coupling of iodotyrosines. The most dangerous
present. side effect is agranulocytosis. Other potential
● There is presence of powerful wide pulse pressure side effects include granulocytopenia and aplas-
and good bounding pulse is present. tic anaemia. The most common side effects are
● Exaggerated deep tendon reflexes are seen. rash and peripheral neuritis.
● Ophthalmopathy. ● If treatment with antithyroid drugs fails to induce
● Pretibial myxoedema: thickening of skin due to mu- remission, radioactive iodine (131I) or surgery
cin deposition on tibia. must be considered.
Eye signs include III. Radioiodine
131
● Exophthalmos with staring look. ● Radioiodine (radioactive iodine – I, abbrevi-
● Lid lag/Von Graefe’s sign: Lagging of upper eyelids. ated as RAI) is suitable for most patients, al-
● Lid retraction. though some prefer to use it mainly for older
● Moebius sign: Absence of convergence of eyeballs. patients.
● Joffroy’s sign: Absence of wrinkling of forehead ● Indications for RAI include failed medical ther-
when patient is asked to look upward. apy or surgery, or when medical or surgical
● Stellwag’s sign: Staring look of patient. therapies are contraindicated.
● Ophthalmoplegia: Paralysis of ocular muscles. ● Contraindications to RAI are pregnancy (abso-
Diagnosis lute), ophthalmopathy (relative; it can aggra-

● TFT: Elevation of T3, T4 and decrease in TSH vate thyroid eye disease) and solitary thyroid
levels. nodules.
● Thyroid scan: Radioisotope scan using 131 Iodine or ● The radio-iodine treatment acts slowly (over
99Tc. months to years) to partially or completely de-

● Ultrasound: For search of cyst or STN. stroys the thyroid gland.
Investigations ● Patients must therefore be monitored regularly
● Serum TSH level is suppressed and is the initial with thyroid blood tests to ensure that they do
diagnostic test. not evolve to hypothyroidism.
IV. Surgery before the age of 40 years and results in ketoaci-

● This modality is suitable for young patients and dosis when patients are without insulin therapy.
pregnant patients. ● This account for 10% of cases of DM. Type 1 DM
● Indications for surgery are a large goitre, suspi- is caused by b islet cell failure, which is of multi-
cious nodules or suspected cancer and patients factorial causes such as genetic predisposition,
with ophthalmopathy. viral and autoimmune attacks on the b islet cells.
● Preoperative administration of Lugol’s iodine ● The abrupt onset of symptoms, with polyuria,
solution, decreases intraoperative blood loss polydypsia, polyphagia and weight loss develop-
during thyroidectomy in patients with Graves ing over days or weeks.
disease. ● Some cases may present as ketoacidosis during an
● Choice can be made between partial or total re- intercurrent illness or following surgery.
moval of the thyroid gland (subtotal thyroidec- ● Occasionally, an initial episode of ketoacidosis is
tomy vs. total thyroidectomy). A total removal followed by a symptom-free interval known as
excludes the difficulty in determining how much ‘honeymoon period’ during, which no treatment is
thyroid tissue must be removed. required.
V. Thyroid hormones ● Characteristically, the plasma insulin is low or
● Many Graves disease patients will become life- unmeasurable.

long thyroid patients, due to the surgical removal ● Glucagon levels are elevated but suppressible
or radioactive destruction of their thyroid. with insulin.

● In effect, they are then hypothyroid patients, Type 2 DM
requiring perpetual intake of artificial thyroid ● Type 2 DM formerly known as noninsulin-depen-
hormones. dent DM usually begins after the age of 40 years

● Given the 1-week plasma half-life of levothy- and 60% of the patients are obese. However, type
roxine (T4), it takes about 5–6 weeks (half- 2 DM is being increasingly seen in the teenage
lives) before a steady state is attained after the years.
dosage is initiated or changed. ● Type 2 DM occurs with intact b islet cell function
● After the optimal thyroxine dose has been de- but there is peripheral tissue resistance to insulin.
fined, long-term monitoring of patients with an ● There may be some decrease in insulin production
annual clinical evaluation and serum TSH mea- or a hyperinsulin state. These patients are not ke-
surement is appropriate. tosis prone but may develop it under conditions of
stress.
Q.2. Oral manifestations of diabetes mellitus.
● The symptoms begin gradually, over a period of
Ans. months to years. Frequently, hyperglycaemia is

detected in an asymptomatic person on a routine
● Diabetes mellitus (DM) is hyperglycaemia secondary to
examination.
decreased insulin production or peripheral tissue resis-
● These patients usually do not develop ketoacido-
tance to insulin.
sis. In the decompensated state, they are suscep-
● Classification and aetiology is based on 1997 Report of
tible to the syndrome of hyperosmolar hypergly-
the Expert Committee on the diagnosis and classifica-
caemic state, i.e. hyperosmolar nonketotic coma.
tion of diabetes mellitus.
● The plasma insulin levels are normal to high. Glu-
● Comprises a group of disorders that share a common
cagon levels are elevated, but resistant to insulin.
phenotype of hyperglycaemia.
● Symptoms of complications – burning feet, noctu-
Classification ria and diminished vision.

i. Type 1 DM Gestational onset DM (GODM)
ii. Type 2 DM ● Gestational onset DM occurs when diabetes onset
iii. Gestational diabetes is during pregnancy and resolves with delivery.

iv. Other causes – Cushing syndrome, hypothyroidism, ● These patients are at a higher risk for developing
genetic causes and viral infections of the pancreas DM at a later date.

Clinical features Other specific types of DM
l The clinical features of type 1 and type 2 DM are They include diseases of the exocrine pancreas,
distinctive. various endocrinopathies (Cushing syndrome, pheo-
Type 1 DM chromocytoma), drug or chemical-induced DM
● Type 1 DM/insulin-dependent DM usually occurs (b-blockers, oral contraceptives) or genetic syn-
in childhood or early adulthood that is usually dromes (lipodystrophies) associated with diabetes.
Complications Food habits

●
● Neuropathy Containing more of complex carbohydrates

●
● Retinopathy ● Exercise
● Nephropathy Dietary regimen for a diabetic patient

● Coronary artery disease The preparation of a dietary regimen for a diabetic can
● Peripheral artery disease be considered under three steps:
Diagnosis First step
History ● This involves the estimation of the total daily ca-
● Clinical presentations of DM may include poly- loric requirement of the individual patient based
uria, polydypsia and polyphagia associated with on a number of variable factors like age, sex,
weight loss, blurred vision, recurrent candidal weight, activity and occupation of the patient. An
vaginitis, soft-tissue infections or dehydration. approximate total daily caloric requirement can
Many cases will be asymptomatic and picked up be calculated as:
on routine screening. ● Sedentary individuals 30 kcal/kg/day
Diagnosis of diabetes mellitus based on various test ● Moderately active individual 35 kcal/kg/day
results is as follows: ● Heavily active individuals 40 kcal/kg/day
a. Random plasma glucose of .200 mg/dL along Second step

with symptoms of diabetes are present. ● This involves allocation of the calories in a proper
b. Two readings of fasting plasma glucose of proportion to carbohydrate, protein and fat.
.126 mg/dL. ● The recommended proportion of calories to be
c. The 2-h postprandial plasma glucose 200 mg/ derived from each of them is given as:
dL during oral glucose tolerance test, after a
glucose load of 75 g. Carbohydrate 50%–60%
d. Elevated HbA1c. However, the HbA1c is not
Protein 10%–20%
an adequate screening tool for DM because it
may be normal in those with impaired glucose Fats 10%–20%
tolerance.
e. The patient is said to have impaired glucose However, a few more important factors need be con-
tolerance if the fasting plasma glucose is .110 sidered at this stage are
and ,126 mg/dL. ● The minimal protein requirement for a good
f. Impaired glucose tolerance: 2-h plasma glu- nutritious diet is about 0.9 g/kg/day.
cose values between 140 and 200 mg/dL. ● The carbohydrates should be taken in the form
Differentiating type 1 and type 2 DM of starches and other complex sugars.
● Occasionally, it may be difficult to differenti- ● Rapidly absorbed simple sugars like glucose
ate between type 1 and type 2 DM based on the should generally be avoided. Use of caloric
clinical situation. The diagnosis can be clari- sweeteners including sucrose is acceptable in
fied by the use of the C-peptide, a product of many patients.
the cleavage of proinsulin to insulin. This will ● Fish oils containing omega-3 fatty acids have
be present in those with type 2 DM and low or been reported to be beneficial, as antiathero-
absent in those with type 1 DM. genic.
● If the C-peptide is border line, checking it after ● A high-fibre diet is beneficial as it has an anti-
a glucose load may help. In those with type 2 atherogenic effect mediated through lowering
DM, it will increase significantly after glucose of blood lipids.
load, this response will be absent in those with Third step
type 1 DM. ● This involves distribution of the calories through-
Treatment out the day. This is particularly important in insu-
● Oral antidiabetics lin-requiring diabetics, to avoid hypoglycaemia.
● Glibenclamide ● Different distributions may be required for differ-
● Glimiperide ent lifestyles, a typical pattern of distribution of
● Metformin calories is:
● Acarbose ● 20% of the total calories for breakfast
● Insulin ● 35% of the total calories for lunch
● Short/intermediate/long-acting insulin ● 30% of the total calories for dinner
● Modification of life style ● 15% of the total calories for late-evening feed
Q.3. Describe general, oral and dental manifestations of Thyroid acropathy is unusual feature of Graves dis-
●
various endocrine disorders. ease and manifests as digital clubbing and swelling
of fingers and toes.
Ans.
Hyperparathyroidism
Oral and dental manifestations of various endocrine disor- ● Diaphoresis is present, i.e. excessive sweating is
ders are as follows: present.

● There is presence of powerful wide pulse pressure
and good bounding pulse.

{SN Q.2}
● Exaggerated deep tendon reflexes are seen.
Diabetes mellitus ● Opthalmopathy.
● Gingivitis ● Pretibial myxoedema: Thickening of skin due to
● Polyuria mucin deposition on tibia.
● Polydypsia Hypothyroidism
● Polyphagia ● Enlargement of the thyroid gland.
● Periodontitis ● General manifestations: Weakness, tiredness, cold
● Bones loss intolerance, dry coarse skin pallor, hair loss, puffy
● Compromised healing face, hand and feet, myxoedema, weight gain, poor
● More accumulation of plaque appetite, hypothermia, goitre and hoarse voice.
● Gastrointestinal: Decreased appetite, constipation
Acromegaly and ascites.

● Face becomes enlarged and mandible is prominent ● Cardiorespiratory: Angina, bradycardia, hyperten-
with teeth widely spaced. sion, cardiac failure, pericardial effusion and pleural
● Coarse facial features. effusion.
● Temporal headaches, photophobia and reduction in ● Neuromuscular: Aches and pains, muscle stiffness,
vision. delayed relaxation of tendon reflexes, carpal tunnel

● Lips are thick and voice is coarse and husky. syndrome, deafness, depression, psychosis, cerebel-
● There is brownish pigmentation of face. lar ataxia and myotonia.
● General features like fatigue and weight gain are ● Dermatological: Myxoedema (nonpitting oedema of
present. the skin of hands, feet and eyelids), dry flaky skin and
● Cardiac effects: Coronary artery disease, hyperten- hair, alopecia, vitiligo, purplish lips and malar flush,
sion and left ventricular hypertrophy are present. carotenaemia, erythema abigne and xanthelasmas.
● Metabolic effects: Intolerance or clinical diabetes ● Reproductive: Menorrhagia, infertility, galactorrhoea
mellitus. and impotence.

● Soft tissue changes like thickening of skin, increased ● Haematological: Macrocytosis and anaemia.
skin tags, acanthosis nigricans, increased sweat and ● Miscellaneous: Tiredness, somnolence, cold intoler-
sebum resulting in moist and oily skin, enlargement ance, hoarseness of voice, low-pitched voice and
of lips, nose and tongue (macroglossia), increased slurred speech.
heel pad thickness, visceral enlargement (viscero- ● Myxoedema coma is a rare complication of hypothy-
megaly), e.g. thyroid, heart (cardiomegaly) and liver, roidism, seen usually in elderly patients.
carpal tunnel syndrome, myopathy and sleep apnoea. Dental considerations
Hyperthyroidism ● Impaired ability of small vessels to contract when
● Important manifestations of hyperthyroidism are cut due to deposition of subcutaneous mucopoly-

weight loss with increased appetite, heat intolerance, saccharides in hypothyroidism may result in ex-
sweating, palpitation, tremors and nervousness. cessive bleeding. Hence, local pressure is required
● The signs are tachycardia, atrial fibrillation, fine fin- for longer period to control bleeding.
ger tremors, moist warm skin, lid retraction, wide ● Due to poor healing in hypothyroidism there is
palpebral fissure, lid lag and exophthalmos. a delayed wound healing and increased risk of
● Proptosis may cause corneal drying and damage. In infection.
severe case, exophthalmos, diplopia and optic nerve ● In patients with hypothyroidism use of sedatives,
compression may occur. opioid analgesics and tranquillizers may precipi-

● Dermopathy occurs in about 5% of patient with tate myxoedema coma.
Graves disease. Purple or pink patches over anterior ● Well-controlled hyperthyroidism and hypothy-
and lateral aspect of the leg (pretibial myxoedema) roidism do not pose any additional risk for dental
are commonly seen. procedures.
Addison disease More likely to have candida and fungal infections, pos-
●
● Clinical features of Addison disease result from glu- sibly due to abnormal flora on the skin and mucosa.
cocorticoid deficiency, mineralocorticoid deficiency, ● There can also be osteoporosis.
androgen deficiency and ACTH excess. Hyperpituitarism

● The cardinal features of Addison disease are hypo- Acromegaly
tension, pigmentation and previous history of acute Mandibular prognathism and thickening of cortical
adrenal crisis following stress, or slow recovery from plates.
illness. ● Connective tissue proliferation and oedema of
● Glucocorticoid deficiency results in malaise, weakness, the face. Lips and nose are enlarged.
weight loss, anorexia, nausea, vomiting, diarrhoea or ● Flaring of teeth due to increased jaw development.
constipation, postural hypotension and hypoglycaemia. ● Macroglossia or enlarged tongue.
● Mineralocorticoid deficiency manifests as hypo- Gigantism

tension. ● Maxilla and mandible are enlarged with marked
● ACTH excess results in pigmentation of exposed ar- increase in vertical dimension.

eas, pressure areas like elbows, knees and knuckles, ● There may be accelerated dental development and
palmar creases, mucous membranes, conjunctivae eruption of teeth.

and recently acquired scars. ● Other features may be macroglossia, hyperce-
● Androgen deficiency results in diminution of body mentosis and macrodontia.

hair, especially in females. Hyperthyroidism
● Increased susceptibility to caries and periodontal
Q.4. Discuss the role of oral diagnosis in diagnosing en-
docrinal disorders. disease
● Enlargement of extraglandular thyroid tissue
Ans. (mainly in the lateral posterior tongue)
Diabetes mellitus ● Maxillary or mandibular osteoporosis
● Periodontal disease is the most consistent finding in ● Accelerated dental eruption(s)
patients with poorly controlled diabetes mellitus. Ap- ● Burning mouth syndrome
proximately, 75% of these patients have periodontal Hypothyroidism

disease, with increased alveolar bone resorption and Childhood hypothyroidism (CRETINISM)
inflammatory gingival changes. Common oral findings in hypothyroidism are
● Diabetics whose disease is under good control also ● Thick lips.
have a higher incidence and greater severity of peri- ● Macroglossia.
odontal disease. ● Long-term effects include impaction of man-
● Diabetics may demonstrate xerostomia and recurrent dibular second molars.

abscesses. ● Dysgeusia.
● Enamel hypoplasia and hypocalcification can result ● Macroglossia.
in an increased frequency of caries. ● Delayed eruption.
● The oral flora is often altered by colonization with ● Poor periodontal health.
Candida albicans, haemolytic streptococci and ● Altered tooth morphology.
staphylococci. ● Delayed wound healing.
● Abnormal eruption patterns may be noted in children ● Glossitis.
with diabetes. Advanced eruption may be seen before ● Mouth breathing.
the age of 10, whereas delayed eruption occurs after ● Anterior open bite.
the age of 10. ● Salivary gland enlargement.
Cushing syndrome Hyperparathyroidism (Brown tumour)

● Results from excess of adrenocorticoid hormone ● Results in poorly mineralized bone with giant cell
production. tumour or cystic lesions in the jaw.

● Characterized by adiposity of upper portion of the ● There is usually osteoporosis and drifting and
body, buffalo hump, muscular weakness, vascular spacing of teeth.

hypertension, glycosuria and albuminuria. ● Bone resorption.
● Patients with Cushing syndrome tend to bleed and Hypoparathyroidism

bruise easily. ● It usually occurs following surgical removal of
● Wound healing is also impaired, and scar formation the thyroid gland.
is less timely and less vigorous than in the normal ● Deficiency of parathyroid secretion can cause
subject. aplasia or hypoplasia of teeth.

Q.5. Acromegaly. b. Radiotherapy

● Irradiation is advised when initial attempts at surgery
Ans.
do not reduce growth hormone levels to 5 MU/L.
● Implantation of radioactive isotope yttrium 90
{SN Q.4} causes major reduction in growth hormone levels.
Acromegaly occurs due to excess secretion of Growth c. Medical therapy
Harmone (GH) later In the life after epiphyseal closure. ● Somatostatin analogues:
● Bromocriptine 20–30 mg/day orally in divided
doses is given.
Causes ● Octreotide 0.05–0.1 mg subcutaneously is given.
● Pituitary adenomas – In 95% of cases.
● Pancreatic islet cell tumours – Excessive growth hor-
mone secreting pancreatic islet cell tumours. SHORT ESSAYS:

● Hypothalamic tumours. Q.1. Hyperthyroidism.
● Bronchial carcinoid.
● Small cell carcinoma of lung.

Ans.
Clinical features ● A state of excessive thyroid hormone due to hyperfunc-
tion of the thyroid gland is called hyperthyroidism or
thyrotoxicosis.
{SN Q.4}
Clinical features
Acromegaly is characterized by: ● The most common cause of thyrotoxicosis is Graves
● Increased hand and foot size and enlargement of disease (Basedow disease) 60%–80%.
terminal phalanges of limbs. ● Graves disease is an autoimmune disorder with
● The ribs also increase in size. genetic predisposition. The antibodies (TSH-R an-
● Face becomes enlarged and mandible is prominent tibodies) bind TSH receptors on thyroid follicular
with teeth widely spaced. cells and stimulate thyroid hormone production
● Coarse facial features. and goitre formation.
● Temporal headaches, photophobia and reduction ● Graves disease is characterized by diffuse enlargement
in vision. of the thyroid gland, infiltrative ophthalmopathy (ex-

● Lips are thick and voice is coarse and husky. ophthalmos) and pretibial myxoedema (dermopathy).
● There is brownish pigmentation of face. ● Important manifestations of hyperthyroidism are
● General features like fatigue and weight gain are weight loss with increased appetite, heat intolerance,
present. sweating, palpitation, tremors and nervousness.
● Cardiac effects: Coronary artery disease, hyperten- ● The signs are tachycardia, atrial fibrillation, fine fin-
sion and left ventricular hypertrophy are present. ger tremors, moist warm skin, lid retraction, wide
palpebral fissure, lid lag and exophthalmos.
● Ophthalmopathy is present in 20%–50% patients of
● Metabolic effects: Intolerance or clinical diabetes Graves disease. It may precede the development of
mellitus. thyrotoxicosis or may develop after successful treat-
● Soft tissue changes like thickening of skin, increased ment of hyperthyroidism of Graves disease.
skin tags, acanthosis nigricans, increased sweat and ● Proptosis may cause corneal drying and damage. In
sebum resulting in moist and oily skin, enlargement severe case, exophthalmos, diplopia and optic nerve
of lips, nose and tongue (macroglossia), increased compression may occur.
heel pad thickness, visceral enlargement (viscero- ● Dermopathy occurs in about 5% of patient with
megaly), e.g. thyroid, heart (cardiomegaly) and liver, Graves disease. Purple or pink patches over anterior
carpal tunnel syndrome, myopathy and sleep apnoea. and lateral aspect of the leg (pretibial myxoedema)
Investigations are commonly seen.
● IGF-1 (insulin-like growth factor-1) is elevated. ● Thyroid acropathy is unusual feature of Graves dis-
● GH is elevated. ease and manifests as digital clubbing and swelling
Treatment of fingers and toes.
a. Surgical Investigations
● Surgery is the treatment of choice. Surgical resec- ● Serum TSH level is suppressed and is the initial
tion of the adenoma is done by trans-sphenoidal diagnostic test.
route followed by radiotherapy. ● Serum total and unbound (free) T3 and T4 are increased.
The uptake of radioactive iodine by thyroid is high

● Patient on long-term anticoagulant therapy should
●
in Graves disease and toxic nodular goitre whereas discontinue the anticoagulant at least 4–5 days, prior
it is low in subacute thyroiditis. to surgery with physician’s concern.
● Ultrasonography thyroid gland reveals diffuse en- ● If discontinuation of oral anticoagulant therapy is not
largement of thyroid gland. advisable, the patient should be shifted to intrave-

Treatment nous anticoagulants like heparin.
● Hyperthyroidism or Graves disease is treated by: ● The patient’s bleeding time and clotting time is
a. Antithyroid drugs checked on the day of the surgery after omission of

b. Radioactive iodine (131I) the anticoagulant.
c. Subtotal thyroidectomy Intra- and postoperative care
● The choice of treatment depends on the cause and ● All the patients should be monitored intra- and post-
severity of hyperthyroidism, the age of the patient operatively by means of an ECG, pulse oximetre and
and clinical situation. arterial line.
Antithyroid drugs ● A central venous pressure (CVP) cut down may be
● The commonly used drugs are carbimazole, me- performed if necessary.

thimazole and propylthiouracil. ● The patient should be maintained on intravenous
● The drugs are given for prolonged periods of about cardiac drugs till oral feeds are given.
1–2 years. After stopping treatment, relapse occurs in ● Fluids overload should be avoided, especially in
about 50% of patients. cases of congestive cardiac failure.

● Rash, fever and arthralgia are common side effects, ● The fluid volume can be judged by CVP.
whereas agranulocytosis is a serious side effect.

Radioactive iodine (131I)
● Iodine (
131
I) causes progressive destruction of thy-
SHORT NOTES:
roid cells. It can be used as initial treatment after Q.1. Hyperparathyroidism.
antithyroid drugs or surgery.
Ans.
Thyroid surgery (subtotal thyroidectomy)
● In cases of relapse after antithyroid drugs and in ● Primary hyperparathyroidism is caused by hypersecre-
young males with large goitre or severe hyperthy- tion of Parathormone (PTH). In majority of cases, this
roidism surgery is indicated. This is also preferred in is due to autonomous hypersecretion of PTH.
pregnant women. ● Primary hyperparathyroidism (adenoma or hyperplasia)
may be familial and part of multiple endocrine neopla-

Q.2. Management of cardiac patient in dental extrac- sia (MEN types I, 2a).
tion. ● Secondary hyperparathyroidism is characterized by
the hypersecretion of PTH due to stimulation by hy-

Ans.
pocalcaemia. There is hyperplasia of parathyroid
Preoperative investigations glands.
● Routine chest radiograph – Posteroanterior view. ● In tertiary hyperparathyroidism, hyperplastic parathy-
● Electrocardiogram. roid glands may result in adenoma formation autono-

● Echocardiogram. mous PTH secretion.
● Stress test. ● Majority of patients may be asymptomatic. However,
● Blood investigations like rapid profile and bleeding symptoms are generally due to hyperkalaemia. Bone
time, clotting time and prothrombin time. resorption occurs due to ‘brown tumours’ or cysts of
● PTH activity may lead to demineralized pathological the jaw.
fractures and generalized cystic lesions (osteitis and
Q.2. Oral manifestations of diabetes mellitus.
fibrosa cystica).
Preoperative medication Ans.
● If the patient is a case of rheumatic heart disease or
[Ref LE Q.3]
has undergone valve replacement, ‘PTH activity. This
may lead to demineralized pathological fractures and Q.3. Addison disease – aetiology.
generalized cystic, ions (osteitis fibrosa cystica)’ a
Ans.
suitable antibiotic prophylaxis must be given.
● If the patient is on injection penidure every 3 weeks, Addison disease is a primary disease of the adrenal
the surgery should be scheduled after the scheduled glands, which is unable to elaborate sufficient quantity of
doses to reduce the risk of infective endocarditis. hormones.
Aetiology ● Since stress can accentuate stomach acid production, a

● Idiopathic stress reduction protocol should be employed. Wherever
● Infections possible, lengthy procedures should be spread over sev-
● Haemorrhage eral appointments.
● Autoimmune adrenalitis and tuberculous adrenalitis ● Adjunctive sedation techniques should be considered
● Bilateral adrenalectomy when appropriate for minimization of stress. Sedation

● Adrenal haemorrhage or infarction techniques might include the use of nitrous oxide/
● Drugs (e.g. ketoconazole) oxygen inhalation, oral antianxiety medications
● Amyloidosis, etc. such as Diazepam (valium) or intravenous sedation
techniques.
Q.4. Acromegaly.
● Antacid therapy is commonly utilized. It should be
Ans. borne in mind that the efficacy of a number of antibiot-

ics prescribed by the dentist is compromised if given
[Ref LE Q.5]
together with antacids.
Q.5. Radiographic appearance of hyperparathyroidism. ● Antibiotics such as tetracycline, ciprofloxacin and other
quinolones, and metronidazole (flagyl) should not be

Ans.
given together with antacids.
● The bones of the affected persons show a general radio-
Q.7. Koplik spots.
lucency as compared with those of normal people.
● Later, sharply defined round or oval radiolucent areas Ans.
develop, which may be lobulated.
● Koplik spots are seen in measles. These lesions are
● Small cystic areas may be seen in the calvarium, and
pathognomonic of the early measles infection.
large or small sharply defined radiolucencies may
● Measles is a disease with a prodromal phase that is
present the maxilla or mandible. These lesions must dif-
characterized by symptoms of upper respiratory tract
ferentiated from the lesions of multiple myeloma and
infection, tonsillopharyngitis and small white lesions
eosinophilic granuloma.
with erythematous bases on the buccal mucosa and in-
● Ground-glass appearance can be seen in the jaw radio-
ner aspect of the lower lip (Koplik spot).
graph.
● The lamina dura may be partially lost. Q.8. Grinspan syndrome.
Q.6. Dental considerations for a patient with a history of Ans.
gastritis.
● This syndrome is associated with oral lichen planus.
Ans. ● Association of lichen planus, diabetes mellitus and
vascular hypertension described by Grinspan, the
● Drugs that cause gastrointestinal irritation should be
triad being described as Grinspan syndrome by
avoided. This includes aspirin, NSAIDs, corticosteroids
Grupper.
and erythromycin.
Topic 14
Metabolic Disorders
SHORT ESSAYS:
1 . Dental management of rheumatic fever patient.
2. What are the oral manifestations of hypovitaminosis?
3. Describe in detail about rickets.
4. Scurvy.
5. Dental considerations in asthmatic patients.
6. Discuss the oral manifestations of avitaminosis. [Same as SE Q.2]
SHORT NOTES:
1. Dental management of rheumatic patient. [Ref SE Q.1]
2. Paul–Bunnell test.
3. Multiple myeloma.
4. Avitaminosis A.
5. Oral manifestations of vitamin D deficiency. [Ref SE Q.3]
6. Infective endocarditis.
7. Bronchial asthma.
8. Dental considerations in pregnancy.
9. Scorbutic gingivitis.
10. Riboflavin deficiency.
11. Hypervitaminosis A.
12. Bence–Jones proteinuria.
13. Dental significance of hypertension.
14. Oral manifestations of vitamin A deficiency. [Same as SN Q.4]
SOLVED ANSWERS
SHORT ESSAYS: ● All dental surgical procedures should be carried out
Q.1. Dental management of rheumatic fever patient. under antibiotic chemoprophylaxis to prevent infec-
tive endocarditis in patient with history of congenital
Ans.
or valvular defects, prosthetic heart valves, previous
● Rheumatic fever is primarily a disease of childhood and history of infective endocarditis, etc.
adolescence.
● It is assumed that it is an infection caused by group A The following is the standard regimen of antibiotic
beta hemolytic streptococci. prophylaxis to be employed:
● One or two weeks before the appearance of the disease,
Oral medications
the individual manifests tonsillitis and pharyngitis.
● Adults: Amoxicillin 2 g orally 1 h before procedure
● Rheumatic fever is characterized by arthritis and/or
● Children: 50 mg/kg amoxicillin 1 h before procedure
carditis and involvement of central nervous system.
Clinical features In patients with allergic to penicillin
● Pain, swelling and stiffness in one or more joints, tachy- ● Adults:
cardia, fatigue and weight loss. ● 600 mg clindamycin 1 h before procedure or
● The typical feature of rheumatic fever is migrating poly- ● 2.0 g cephalexin 1 h before
arthritis. ● Children:
● Patient may manifest retrosternal pain due to pericarditis. ● 20 mg/kg clindamycin orally 1 h before proce-
● Small painless, subcutaneous nodules may be palpable dure or

over bony prominences such as elbow, knees, etc. ● 50 mg/kg cephalexin or cephadroxil 1 h before
● Another feature is pink patches on the trunk. procedure or

● Sydenham chorea is yet another clinical feature. ● 15 mg/kg azithromycin or clarithromycin 1 h
● ESR may be raised in these patients. before procedure

Treatment
● Bed rest, NSAIDs such as prednisolone (60–80 or 3 mg/kg
in children) Q.2. What are the oral manifestations of hypovitaminosis?
Ans.
{SN Q.1}
● Vitamins are essential for growth and normal body
Dental consideration
functions and deficiency of vitamins causes various
● A patient with recent history of rheumatic fever or
clinical manifestations as follows:
rheumatic heart disease requires antibiotic chemopro-
i. Thiamine
phylaxis prior to dental procedures. Precautions to be
● Cardiac beriberi – High output cardiac failure
taken in these patients during dental treatment
● Dry beriberi – Polyneuropathy
● Wernicke encephalopathy – Confusion, nystagmus,

● The wrist and ankles are swollen and the changes in
ophthalmoplegia, ataxia and polyneuropathy
bone are found in epiphyseal plates, metaphysis and
● Korsakoff psychosis – Amnesia with confabulation
shaft.
ii. Riboflavin
● Localized area of thinning are sometime present in
● Angular stomatitis, glossitis and cheilosis
skull so that a finger can produce indentation. This
● Seborrhoeic dermatitis
condition is called as craniotabes.
● Photophobia, lacrimation and visual fatigue
● Pigeon breast.
iii. Niacin (Pellagra)
● Developmental abnormalities of dentine, hypoplasia
● Dermatitis
of enamel and delayed eruption.
● Diarrhoea
● Higher caries index.
● Dementia
● Malocclusion of teeth is present.
iv. Pyridoxine
● Angular stomatitis, glossitis and cheilosis Treatment
● Convulsions, peripheral neuropathy ● Dietary enrichment of vitamin D in form of milk.
● Hypochromic, microcytic anaemia ● If tetany is present, give i.v. calcium gluconate. Daily
v. Pantothenic acid dose is 1000–2000 IU of vitamin D combined with

● Apathy, depression, paraesthesia, muscle weak- 500–1000 mg of calcium.
ness, burning feet and personality changes
vi. Biotin
● Periorofacial dermatitis, conjunctivitis, alopecia,
ataxia, deafness, optic atrophy ● Curative treatment includes 2000–4000 IU of calcium

vii. Cyanocobalamin daily for 6–12 weeks followed by daily maintenance
● Megaloblastic anaemia, peripheral neuropathy,
dose of 2000–4000 IU for long period.
subacute degeneration of spinal cord and megalo-
blastic madness Q.4. Scurvy.
viii. Folic acid Ans.
● Megaloblastic anaemia
● Psychosis and neural tube defects i. Scurvy is caused due to deficiency of vitamin C, which
ix. Ascorbic acid (scurvy) results in defective collagen formation in connective
● Bleeding gums, petechiae, ecchymosis, purpura, tissue.
arthralgia and joint effusions ii. It is of two types:
● Depression, hysteria and postural hypotension a. Adult scurvy
x. Vitamin A b. Infantile scurvy
● Night blindness, Bitot spots, corneal ulceration, iii. In adult scurvy:
blindness and follicular keratosis ● Swollen spongy gums – scurvy buds
● Recurrent respiratory tract infections ● Scorbutic gingivitis
xi. Vitamin D ● Perifollicular haemorrhages
● Rickets and osteomalacia ● Petechial haemorrhages, ecchymoses, epistaxis and
xii. Vitamin E Gastro intestinal (GI) bleeding

● Haemolytic anaemia, macrocytic anaemia, spinocere- ● Nail beds: Splinter haemorrhages
bellar syndrome, myopathy and peripheral neuropathy ● Haemorrhages into muscles and joints
xiii. Vitamin K ● Poor wound healing
● Ecchymosis, mucosal bleeding and internal haem- iv. Infantile scurvy:

orrhage ● Scorbic child usually assumes a frog-like position
and this may reflect as subperiosteal haemorrhage in

Q.3. Describe in detail about rickets.
to shafts of long bone
Ans. ● Scorbutic rosary – i.e. enlargement of costochondral
joints
{SN Q.5} ● Lassitude and anorexia
● Painful limbs giving rise to pseudoparalysis

Vitamin D deficiency – Rickets occurs generally in
growing children. v. Management:
● Consumption of citrus fruits and vegetables
Clinical features ● Vitamin C 500 mg daily initially
● In first 6 months of life, tetany and convulsions are
common; these manifestations are due to hypocal- Q.5. Dental considerations in asthmatic patients.
caemia. Ans.
● The major goal for the dentist in the management of the Q.3. Multiple myeloma.
patient with asthma is to minimize the likelihood of the
Ans.
precipitating an asthmatic attack.
● A detailed history of the severity of the asthma, precipi- ● Multiple myeloma is a malignant neoplasm, which is
tating factors and the medications used is very helpful characterized by the production of pathogenic M pro-
in the management of these patients. teins, bone lesions, kidney diseases, hyperviscosity and
● Patients with asthma can occasionally have an exacer- hypercalcaemia.
bation under stress, and efforts should be made to iden- ● Skeletal pain is the most common presenting symptom.
tify patients whose bronchospasm is precipitated by ● These plasma cells produce abnormal M proteins that
emotional stress. are useful in the diagnosis of the disease due to their
● Minimize stress: wherever possible, lengthy procedures characterized electrophoretic pattern but useless in
should be spread over several appointments. functioning as normal antibodies.
● Adjunctive sedation technique should be considered ● The most common radiographic abnormality is the pres-
when appropriate for minimization of stress. ence of ‘punched-out’, radiolucent lesions, but general-
● Sedation technique might include the use of N 2O/O 2 ized osteoporosis may occur in the absence of these
inhalation, diazepam or other oral antianxiety medi- discrete punched-out lesions.
cation.
Oral manifestation
● Avoid antihistaminic drugs such as promethazine or di-
● Patient may experience pain, swelling, numbness of
phenhydramine.
the jaw, epulis formations or unexplained mobility of
● Minimize epinephrine use.
the teeth.
● Avoid erythromycins and clarithromycin: These drugs
● Skull lesions are very common than jaw lesions.
should be avoided in patient on methylxanthines prepa-
● Mandible is more frequently involved because of its
rations, e.g. theophyllines in order to minimize the
greater content of marrow.
likelihood of the arrhythmias.
● Extraoral lesions also occurs in a significant number of
● Local symptomatic lesions are treated with radiotherapy.
patients, although a majority of them are asymptomatic.
Q.6. Discuss the oral manifestations of avitaminosis.
Treatment
Ans. ● The alkylating agents, such as melphalan or cyclophos
phamide, are the treatment of choice for patients with

[Same as SE Q.2]
extensive bone lesions or rising level of M proteins.
● Local symptomatic lesions are treated with radiotherapy.
SHORT NOTES:
Q.4. Avitaminosis A.
Q.1. Dental management of rheumatic patient.
Ans.
Ans.
● Deficiency of vitamin A causes interference with
[Ref SE Q.1]
growth, reduced resistance to infections and interfer-
Q.2. Paul–Bunnell test. ence with nutrition of cornea, conjunctiva, trachea, hair
follicle and renal pelvis.
Ans.
● Vitamin A deficiency interferes with ability of eyes to
● Paul–Bunnell test is the diagnostic test for infectious adapt to darkness and impairs visual affinity.
mononucleosis. ● Children with vitamin A deficiency will experience im-
● The patient exhibits atypical lymphocytes in the circu- paired growth and development.
lating blood, as well as antibodies to EB virus and an
Aetiology
increased heterophil antibody titre.
● Poor intake
● The increased heterophils are present only in small
● Malabsorption
minority of children with the disease.
● Disease of liver and intestine
● The normal titre of agglutinins and haemolysins in
human blood against sheep red blood cells does not Clinical features
exceeds 1:8. ● Earliest sign of deficiency of vitamin A is difficulty in
● In infectious mononucleosis, the titre may rise to reading or sewing at night times or finding anything in
1:4096. darkness.
● This is referred to as positive Paul–Bunnell test and is ● Conjunctiva becomes dry and small greyish white raised
both characteristic and pathognomonic of the disease. spots known as Bitot spots appear.
● Cornea subsequently becomes lustreless and if there is ● It is characterized by recurrent and reversible airflow
lack of treatment the changes are irreversible. limitation due to underlying inflammatory process.
● Keratomalacia involving the cornea leading to the ulcer-
Aetiology
ation and blindness may result.
l Unknown, but allergic sensitivity is seen in most of the
● The children with vitamin A deficiency not only have
patients.
retarded growth but also increased tendency to chest
infection. Clinical features
● Microcytic anaemia. ● Clinical feature of asthma is due to the underlying
● Skin becomes dry and rough. chronic inflammatory process.

● Imperfect enamel formation of teeth. ● Hallmark clinical feature of asthma are recurrent revers-
ible airflow limitation and airways hyper responsiveness.

Treatment
● These factors lead to the development of the signs and
● Vitamin A deficiency can be prevented by giving good
symptoms of asthma, which includes intermittent
nutrition, intake of fresh leafy green vegetables and ad-
wheezing, coughing, dyspnoea and chest tightness.
dition of vitamin A to food stuffs.
● Symptoms of asthma tends to worsen at night and in
● Vitamin A may be administered orally as retinol 30 mg
early morning hours.
daily for 3 days.
● In advanced cases where absorption is effected vitamin Management
A in dose of 50,000 IU parenterally for 3 days. ● Pharmacotherapy is based on the severity of the disease.
Q.5. Oral manifestations of vitamin D deficiency. Q.8. Dental considerations in pregnancy.

Ans. Ans.
[Ref SE Q.3] The dentist must be aware of and cautious about the
following:
Q.6. Infective endocarditis.
● Treatment strategies and limitations
Ans. ● Limitation on radiographic examination
● The safest trimester for the dental treatment

● Infective endocarditis is a serious infection of the heart
● Limitations on the drug therapy prescribed by the dentist
valve or the endothelial surfaces of the heart.
● Potential increased risk to fetus in the presence of peri-
Dental considerations odontal diseases during pregnancy

● The risk of endocarditis primarily depends upon the
Q.9. Scorbutic gingivitis.
pre-exisiting underlying cardiac condition.
● The dental health and hygiene of the patient also con- Ans.
tributes to the relative risk.
● It chiefly affects the gingival and periodontal structures.
● Patient with active periodontal disease and active peri-
● The interdental and marginal gingival becomes bright
apical infection are more likely to have transient bacte-
red, swollen, smooth, shiny producing appearance known
raemia.
as scurvy bud.
● The likelihood of transient bacteraemia from the oral
● There is a typical fetid breath of a patient with fusospi-
cavity is related directly to the degree of the oral inflam-
rochetal stomatitis.
mation and infection.
● The greater the soft tissue trauma, the greater the risk of Q.10. Riboflavin deficiency.
bacteraemia.
Ans.
Prevention
● Riboflavin (vitamin B2) is part of the oxidation chain in
● All dental surgical procedure should be carried out un-
the mitochondria, acting as a coenzyme in oxidation
der antibiotic chemoprophylaxis to prevent infective
reduction reactions.
endocarditis in patient with history of congenital or
● It is widely distributed in animal and vegetable foods,
valvular defects, prosthetic heart valves, previous his-
the richest supply coming from milk and its nonfat
tory of infective endocarditis, etc.
products.
Q.7. Bronchial asthma. ● Levels of the vitamin are low in staple cereals but ger-
mination increases its content.

Ans.
● Clinical deficiency is rare in developed countries. It
● Asthma is a chronic disease that affects the lower mainly affects the tongue and lips and manifests as glos-
airways. sitis, angular stomatitis and cheilosis.
● The genitals may be affected, as well as the skin areas Q.13. Dental significance of hypertension.
rich in sebaceous glands, causing nasolabial or facial
Ans.
dyssebaceous.
● Rapid recovery occurs with oral intake of 10 mg ● In the dental clinic to determine the blood pressure in
daily. suspected cases and to check whether the blood pres-
sure is under control prior to any dental procedures in
Q.11. Hypervitaminosis A.
patient undergoing any hypertensive therapy, a blood
Ans. pressure apparatus or sphygmomanometer must be
readily available.
i. Acute toxicity has been reported after excess consump-
● A patient with moderate or severe hypertension requires
tion or intake of more than 150 mg vitamin A.
evaluation and treatment by physicians.
ii. Clinical presentation of acute toxicity includes in-
● Uncontrolled hypertension is a contraindication for oral
creased intracranial pressure, vertigo, diplopia, seizures
surgical procedures as there can be excessive bleeding.
and exfoliative dermatitis.
● Diuretics, a-adrenergic and ganglionic channel blockers
iii. Chronic toxicity (ingestion of 15 mg/day for several
can cause orthostatic hypotension or a fall in the blood
months) manifests as dry skin, cheilosis, glossitis, alo-
pressure due to the sudden change of the posture from a
pecia, bone pain, hypercalcaemia and increased intra-
supine position as on a dental chair to an upright posi-
cranial pressure.
tion, which leads to fainting.
iv. High dose of carotenoids may cause yellowing of skin
● Therapy with methyldopa can lead to oral ulcerations.
but not the sclera.
● Some of the antihypertensive drugs can cause lichenoid
Q.12. Bence–Jones proteinuria. reactions in the oral cavity.

● Calcium channel blockers such as nifedipine can cause
Ans.
gingival enlargement.
● Bence–Jones proteinuria is a diagnostic test for multiple
Q.14. Oral manifestations of vitamin A deficiency.
myeloma.
● Bence–Jones proteins are monoclonal immunoglobulin Ans.
light chains detected in 24 h urine specimens of multiple
[Same as SN Q.4]
myeloma patients.
Topic 15
Haematologic Diseases
LONG ESSAYS:
1 . Define purpura. Discuss in detail the clinical features and investigations of purpura.
2. Describe the laboratory investigations for bleeding and clotting disorders.
3. What are the aetiological factors for the spontaneous bleeding from gingiva? Describe the oral manifestations
of myelogenous leukaemia.
4. Classify anaemias. Discuss in detail the oral manifestations, diagnosis and management of pernicious anaemia.
5. Enumerate various causes of bleeding in oral cavity. How would you manage a case of haemophilia?
6. How do you manage a case of myeloid leukaemia patient visiting dental hospital. [Same as LE Q.3]
7. Define and classify anaemias. Discuss in detail about iron deficiency anaemia. [Same as LE Q.4]
8. Classify anaemias. Describe clinical features and laboratory diagnosis of iron deficiency anaemia. [Same as LE Q.4]
SHORT ESSAYS:
1 . Causes of bleeding in the oral cavity. [Ref LE Q.5]
2. Agranulocytosis.
3. Infectious mononucleosis.
4. Pernicious anaemia. [Ref LE Q.4]
5. Iron deficiency anaemia.
6. Cooley anaemia.
7. Oral manifestation of acute leukaemia.
8. Thrombocytopenic purpura. [Ref LE Q.1]
9. Haemophilia A.
10. Thalassaemia major. [Same as SE Q.6]
SHORT NOTES:
1 . Bleeding time.
2. Mention causes of eosinophilia.
3. Oral manifestations of haemophilia.
4. Four oral manifestations of aplastic anaemia.
5. Oral manifestations of leukaemia.
6. Cyclic neutropenia.
7. Schilling test.
8. Plummer–Vinson syndrome.
9. Polycythaemia rubra vera.
SOLVED ANSWERS
LONG ESSAYS: Treatment
● For mild cases, no treatment is required.
Q.1. Define purpura. Discuss in detail the clinical fea- ● Severe cases need transfusion of platelets, steroid treat-
tures and investigations of purpura. ment and splenectomy.}
Ans.
Q.2. Describe the laboratory investigations for bleeding
[SE Q.8] and clotting disorders.
● {Purpura is defined as purplish discolouration of skin Ans.
and mucus membrane due to subcutaneous and submu-
cus extravasation of blood. Various laboratory diagnostic tests for bleeding and clotting
● In thrombocytopenic purpura due to thrombocytopenia, disorders are as follows:
purpuric spots of focal haemorrhages may occur in skin
and mucous membranes. Investigation of disordered vascular haemostasis
● This is of two types: Disorders of vascular haemostasis may be due to vascu-
i. Idiopathic/primary thrombocytopenic purpura lar permeability, reduced capillary strength and failure to
ii. Secondary (due to various other causes) contact after injury.
Bleeding time
Clinical features ● This simplest test is based on the principle of hae-
● Petechiae in skin, mucous membrane occurs.
mostatic plug formation following standard incision
● Epistaxis (bleeding from nose).
on volar surface of forearm and the time the incision
● Bleeding from Gastrointestinal tract (GIT) (melena,
takes to stop bleeding is measured; the test is depen-
haematemesis). dent upon capillary function as well as on platelet
● Intracranial haemorrhages.
number and ability of platelets to adhere to form
● Gingival bleeding and palatal petechiae.
aggregates.
Investigations ● Normal range is 3–8 min
3
● Platelet count is below 150,000/mm (usually below ● A prolonged bleeding time may be seen due to
50,000/mm3). ● Thrombocytopenia
● Bleeding Time (BT) prolonged, Clotting Time (CT) normal. ● Disorder of platelet function, for example von
● Increased megakaryocytes in bone marrow. Willebrand disease

Vascular abnormalities, for example Ehlers–

● Congenital hamartomas – Haemangioma, hereditary
●
Danlos syndrome haemorrhagic telangiectasia

● Severe deficiency of factor V and II ● Arteriovenous malformation
Hess capillary resistance test (tourniquet test) Haemorrhage due to platelet disorders
● This test is done by placing sphygmomanometer cuff ● Thrombocytopenia
to the upper arm and raising the pressure in it be- ● Thrombocytosis
tween diastolic and systolic for 5 min. ● Thrombasthenia
● After deflation, the number of petechia appearing in ● Glanzmann disease
the next 5 min in 3 cm area over the cubital fossa is ● Aldrich syndrome
counted. Haemorrhage due to coagulation diseases

● Presence of more than 20 petechiae is considered a ● Haemophilia
positive test. The test is positive in increased capil- ● Christmas disease
lary fragility as well as in thrombocytopenia. ● von Willebrand disease
● Deficiency of Stuart factor

Investigation of platelet and platelet function
● Multiple myeloma
● Haemostatic disorder is most commonly due to abnor-
● Systemic lupus erythematosus
malities in platelet number, morphology or function.
● Diffuse intravascular coagulation
● Screening tests carried out for assessing peripheral
● Macroglobulinaemia
blood platelet count is bleeding time.
Haemorrhage due to systemic diseases
● Examination of fresh blood film to see the morphologic
● Scurvy
abnormalities of platelets.
● Diabetes mellitus
Special tests
● Septic embolism in bacterial endocarditis
● If these screening tests suggest a disorder of platelet
● Meningococcemia
function, the following platelet function tests may be
● Systemic viral infection
carried out.
● Anticoagulant therapy
i. Platelet adhesion test: Retention in a glass bead
● Graft versus host reaction
column, and other sophisticated techniques.
● Sturge–Weber syndrome
ii. Aggregation test: Turbidimetric techniques using
ADP, collagen or ristocetin.
Leukaemia
iii. Granular content of platelets and their release
Leukaemia is a disease characterized by the progressive
can be assessed by electron microscopy.
over production of white blood cells, which usually appear
Tests for coagulative defect in the circulating blood in an immature form.
● Clotting time Classification
● Thrombin time ● Depending on the onset and the course of the leukae-
● Prothrombin time mia it is classified as:

● Thromboplastin generation time a. Acute leukaemia
● Partial thromboplastin time b. Chronic leukaemia
● Depending on the type of cell of origin leukaemia is
Q.3. What are the aetiological factors for the spontane- also classified into:
ous bleeding from gingiva? Describe the oral manifesta- a. Myeloid (myelogenous) leukaemia
tions of myelogenous leukaemia. b. Lymphoid (lymphoblastic, lymphocytic) leukaemia
Acute and chronic leukaemias are broadly classified as:
Ans.
i. Acute lymphoblastic leukaemia (ALL)
The various causes of bleeding in the oral cavity are as ii. Acute myeloblastic leukaemia (AML)
follows: iii. Chronic lymphocytic leukaemia (CLL)
Local causes iv. Chronic myelocytic leukaemia (CML)
● Postextraction, postsurgical, posttraumatic Aetiology
● Infections – Viral, bacterial fungal, parasitic and ● Unknown.
spirochete ● However, some are associated with ionizing radia-
● Oral ulcerative lesions – Stomatitis, glossitis, etc. tion, cytotoxic drugs, chemical carcinogens and in-
● Oral exophytic soft tissue lesions – Pyogenic granu- fectious origin of unknown organism.
loma, pregnancy tumour ● Other predisposing factors may be chromosomal
● Local irritants leading to gingivitis and periodontitis abnormalities, genetics, age, hormones, immune
● Rupture of blood containing bulla competence and stress.
Clinical features Treatment

Acute leukaemia ● The management of acute leukaemia consists of sup-
● Acute lymphoblastic leukaemia is common in portive and specific treatment.

children while acute myeloid leukaemia is com- Supportive treatment
mon in adults. ● Anaemia is managed with infusion of red cell
● Sudden onset. concentrate. Platelet transfusion is needed to treat

● Characterized by weakness, fever, headache, pete- bleeding manifestations and to maintain platelet
chial or ecchymotic haemorrhages in the skin and count above 10,000–20,000/mm3.
mucous membranes. Specific treatment
● Lymphadenopathy is often the first sign of the ● The objective of specific treatment is to eliminate
disease. leukaemic cells without affecting the normal

● Gingival bleeding, epistaxis, haemorrhage may cells. However, the therapy may be associated
occur due to thrombocytopenia. with high morbidity and mortality. Hence, the
● Bleeding may occur due to disseminated intravas- decision to administer a specific therapy to a par-
cular coagulation (DIC), which is mainly in pa- ticular patient is based on the age, type of leukae-
tients with acute promyelocytic leukaemia. mia and the presence of other associated illnesses.
● Hepatomegaly, splenomegaly, gum hyperplasia, Chemotherapy
stomatitis, sternal tenderness, enlargement and ● In chemotherapy, a combination of various cyto-
infiltration of skin may be seen. toxic drugs is given under a standard protocol.
Chronic leukaemia The first step is to achieve remission (normal
● Disease is present before the symptoms are seen. blood counts, normal bone marrow and normal
● Patient may appear with excellent health or ex- clinical status). The initial induction phase is fol-
hibit emaciation suggestive of a chronic debilitat- lowed by the consolidation phase and the mainte-
ing disease. nance phase.
● Lymph node enlargement common in CLL but Radiotherapy
uncommon in CML. ● Cranial irradiation along with intrathecal meth-
● Splenomegaly and hepatomegaly are fully devel- otrexate is given in ALL patients for CNS pro-
oped due to protracted course of the disease. phylaxis.
● Enlargement of salivary glands and tonsils lead- Bone marrow transplantation
ing to leukaemic infiltration and xerostomia. ● If a patient relapses after chemotherapy, remission
● Petechiae, ecchymosis of skin. Papules, pustules, is difficult to induce, then bone marrow transplan-
bullae, areas of pigmentation, herpes zoster, itch- tation is advised in such cases.
ing and burning sensations are also seen.
Oral manifestations Q.4. Classify anaemias. Discuss in detail the oral mani-
● Oral lesions occur in both acute and chronic
festations, diagnosis and management of pernicious
forms. anaemia.
● Gingivitis, gingival hyperplasia, haemorrhage,
Ans.
petechiae and ulceration of the mucosa.
● Rapid loosening of the teeth due to necrosis Anaemia is defined as an abnormal reduction in the number
of PDL. of circulating red blood cells, the quantity of haemoglobin
● Alterations in the developing tooth crypts. and the volume of packed red cells in a given unit of blood.
● Osseous changes in jaws. The normal haemoglobin level varies from 14 to 16 g/dL in
Diagnosis the adult male and 12 to 14 g/dL in the female.
a. Peripheral blood examination reveals the presence of
Classification
blast cells with high, low or normal total leukocyte
Anaemia has been traditionally classified into:
count.
● Dyshematopoietic
b. There is also the evidence of anaemia and thrombo-
● Haemorrhagic
cytopenia.
● Haemolytic anaemia
c. The bone marrow examination shows hypercellular-
ity along with the presence of .20% leukaemic blast According to the morphology (MCV, MCH and MCHC)
cells. into the following types:
d. Cytochemical staining, cytogenetics and immune ● Normocytic
phenotyping of the cells help in differentiating dif- ● Microcytic
ferent types of leukaemia. ● Macrocytic

● Normochromic ● The four major cardinal features of pernicious

● Hypochromic anaemia are as follows:
a. Abnormally large RBCs
However, the recent classification is based on reticulocyte
b. Hypochlorhydria
index, which is a measure of RBC production:
c. Neurologic and gastrointestinal symptoms
● The reticulocyte index is increased (.2.5) due to in-
d. A fatal outcome unless the patient receives
crease in erythropoiesis in haemolytic and haemor-
life-long injections of vitamin B12
rhagic anaemias.
● Generalized weakness, fatigue, headache, palpita-
● A low reticulocyte index ,2% shows decreased
tion, nausea, vomiting, anorexia and diarrhoea.
marrow production or maturation defects during
● Shortness of breath, dyspnoea, loss of weight,
erythropoiesis.
pallor and abdominal pain.
Aetiologic classification of the anaemias ● Patients have smooth, dry and yellow skin.
I. Blood loss ● Neurological manifestations include tingling sen-
● Acute posthaemorrhagic blood loss sation in hands and feet, paraesthesia of extremi-
● Chronic posthaemorrhagic blood loss ties due to peripheral nerve degeneration.
II. Deficiency of haemopoietic factors Oral manifestations
● Iron deficiency ● Glossitis, glossodynia (painful tongue) and glos-
● Folate and vitamin B12 deficiency sopyrosis (itching and burning tongue).
● Protein deficiency, i.e. diarrhoea, malabsorption ● Tongue appears beefy red in colour.
III. Bone marrow aplasia ● Sometimes loss of papilla produces a bald appear-
● Aplastic anaemia ance of tongue which is referred to as Hunter

● Pure red cell aplasia glossitis or Moeller glossitis.
IV. Anaemia due to systemic infections or systemic ● Sometimes hyperpigmentation occurs in mucosa.
disorders Histopathology
● Anaemia due to chronic infection ● Oral epithelial cells in pernicious anaemia reveal
● Anaemia due to chronic renal disease enlarged and hyperchromatic nuclei with promi-
● Anaemia due to chronic liver disease nent nucleoli and serrated nuclear membrane.
● Disseminated malignancy ● There is atrophy of epithelium with intra- or sub-
● Endocrinal diseases epithelial chronic inflammatory cell infiltration.

V. Anaemia due to bone marrow infiltration ● Cellular atypia is sometimes present.
● Leukaemias Laboratory findings

● Lymphomas i. Blood
● Myelofibrosis/myelosclerosis ● RBC count is seriously decreased to 1,000,000
● Congenital sideroblastic anaemia or less per mm3.

VI. Anaemia due to increased red cell destruction (hae- ● Macrocytosis, haemoglobin content of RBCs
molytic anaemia) is increased proportional to their size.

● Intracorpuscular defect (hereditary or acquired) ● Great many red blood cell abnormalities have
● Extracorpuscular defect (acquired) been described in advanced cases of anaemia-

Pernicious anaemia like polychromatophilic cells, stippled cells,
(Vitamin B12 deficiency, Addisonian anaemia) nucleated cells, Howell–Jolley bodies and
Cabot rings punctuate basophilia.
[SE Q.4] ● Mild-to-moderate thrombocytopenia.
{Pernicious anaemia is a type of a chronic progressive, ● Iron deficiency.
megaloblastic anaemia of adults and is caused by defi- ii. Serum

ciency of intrinsic factors in stomach. ● The indirect bilirubin may be elevated.
● It is probably an autoimmune disorder with a ge- ● Serum lactic dehydrogenase usually is mark-
netic predisposition and the disease is associated edly increased.

with human leukocyte antigen (HLA) types A2, ● The serum potassium, cholesterol and skeletal
A3, B7 and A blood group. alkaline phosphatase are often decreased.

Clinical features ● Serum antibodies for Intrinsic Factor (IF) are
● Occurs rarely before 30 years of age and increases highly specific.

in frequency with advancing age. iii. Gastric secretions
● No racial predilection; in all countries, except the ● Total gastric secretions are decreased to 10%
USA, females are more commonly affected. of reference range.

● Achlorhydria. Aetiology
● IF is either absent or markedly decreased. Haemophilia types
iv. Bone marrow i. Haemophilia A – Due to deficiency of factor
● Bone marrow biopsy and aspirate are hyper- VIII known as antihaemophilic globulin (AHG)
cellular and show trilineage differentiation. which is a clot promoting factor.
● Erythroid precursors are large and oval, their ii. Haemophilia B or Christmas disease – Due to
nucleus is large and contains coarse motley deficiency of factor IX known as Christmas factor.
chromatin clumps, providing a checker board iii. Haemophilia C – Due to deficiency of factor XI
appearance. and plasma thromboplastin antecedent.
Treatment Clinical features
● Administration of folic acid and vitamin B12. ● It occurs only in males, while females are only the
● Early recognition and treatment of pernicious anae- carriers.

mia provides a normal uncomplicated life span. ● Haemorrhagic tendency even in infancy.
● Delayed treatment permits progression of the ● Ecchymoses even from minor trauma.
anaemia and neurological complications.} ● Persistent oozing of blood and sudden bleeding into
the muscles and joints (knee).

Q.5. Enumerate various causes of bleeding in oral cav-
● Joint becomes swollen and painful.
ity. How would you manage a case of haemophilia?
● Symptoms of anaemia.
Ans. ● Blood test shows prolonged clotting time and normal
bleeding time.
[SE Q.1] ● Haemophilia is classified according to the clinical
severity as mild moderate and severe.

{Various causes of bleeding in the oral cavity are as Oral manifestations
follows:
● Gingival haemorrhage
A. Local causes
● Eruption and exfoliation of teeth associated with
● Postextraction, postsurgical, posttraumatic
severe haemorrhage
● Infections – Viral, bacterial, fungal
● Mandibular pseudotumour
● Oral ulcerative lesions – stomatitis, glossitis, etc.
● Oral exophytic soft tissue lesions – Pyogenic granu-
● There is no known cure for haemophilia. The affected
loma, pregnancy tumour
persons should be protected from traumatic injuries.
● Local irritants leading to gingivitis and periodontitis
● Replacement of clotting factors.
B. Haemorrhage due to platelet disorders
● Thrombocytopenia Q.6. How do you manage a case of myeloid leukaemia
● Thrombocytosis patient visiting dental hospital.
● Thrombasthenia
Ans.
C. Haemorrhage due to coagulation diseases
● Haemophilia [Same as LE Q.3]
● von Willebrand disease
Q.7. Define and classify anaemias. Discuss in detail
● Multiple myeloma
about iron deficiency anaemia.
● Systemic lupus erythematosus
● Diffuse intravascular coagulation Ans.

D. Haemorrhage due to systemic disease
[Same as LE Q.4]
● Scurvy
● Diabetes mellitus Q.8. Classify anaemias. Describe clinical features and

● Anticoagulant therapy, etc.} laboratory diagnosis of iron deficiency anaemia.
Haemophilia Ans.
● Haemophilia is also known as bleeder’s disease, the
[Same as LE Q.4]
disease of kings.
l It is a blood disease characterized by a prolonged co-
agulation time and haemorrhagic tendencies. SHORT ESSAYS:

● The disease is hereditary, the defect being carried by Q.1. Causes of bleeding in the oral cavity.
the X chromosome, and is transmitted as a gender-
linked Mendelian recessive trait, thus it occurs only in Ans.
males. [Ref LE Q.5]
Q.2. Agranulocytosis. Aetiology

● It is caused by EBV.
Ans:
Clinical findings
● Agranulocytosis is also known as granulocytopenia. It is
● Chiefly occurs in children and young adults.
a serious disease involving white blood cells.
● Oral lesions include stomatitis, acute gingivitis, appear-
● It is characterized by decreased number of circulating
ance of a white or grey membrane in various areas,
granulocytes, especially neutrophils.
palatal petechiae and occasional ulcers.
Classification
Laboratory findings
i. Primary agranulocytosis
● Increased neutrophil antibody titre (1:4096), that is
ii. Secondary agranulocytosis
positive Paul–Bunnell test
Aetiology ● Thrombocytopenia
● Ingestion of drugs (antithyroid, macrolides, procain-

Treatment
amide, sulphonamide, dipyrone, digitalis, corticoste-
● Bed rest.
roids, salicylates and others)
● Adequate diet and short-term steroid therapy is the
● Infections
usual form of therapy.
Clinical features
Q.4. Pernicious anaemia.
● It occurs at any age but common in adults particularly in
women. Ans.
● It frequently affects workers in the health professions
[Ref LE Q.4]
and in hospitals.
● Commences with high fever, chills and sore throat, mal- Q.5. Iron deficiency anaemia.
aise, weakness and prostration.
Ans.
● Skin appears pale anaemic and sometime jaundiced.
● Presence of infection in oral cavity, entire GIT, respira- Iron deficiency anaemia is the most common form of anae-
tory tract and skin. mia worldwide.
● Regional lymphadenitis.
Aetiology
Oral manifestations Causes of iron deficiency anaemia are as follows:
● Necrotizing ulcers on oral mucosa, tonsils and i. Blood loss:
pharynx a. Acute blood loss: accident and surgery
● No purulent discharge noticed b. Chronic blood loss: gastritis, peptic ulcer, hook-
● Tooth extraction is contraindicated worm infestation, haemorrhoids and menstrual loss
ii. Increased demand, e.g. during infancy, adolescence
Laboratory findings
3 and pregnancy
● WBC count is below 2000 cells/mm with an almost
iii. Malabsorption conditions, e.g. postgastrectomy,
absence of polymorphonuclear cells.
sprue, and Crohn disease
● RBC and platelet count is normal.
iv. Inadequate diet
● Bone marrow is relatively normal except absence of
granulocytes, metamyelocytes and myelocytes. Clinical features

● Promyelocytes and myeloblasts are near normal ● It occurs at any age, presenting general symptoms of
numbers. anaemia.
● Pagophagia, i.e. craving for ice, cheilosis and spoon-
Treatment
shaped nails (koilonychia).
● Not specific
● Dysphagia due to formation of cricoid web (Plummer–
● Removal of the cause
Vinson or Patterson–Kelly syndrome).
● Administration of broad spectrum antibiotics for oral
● Angular cheilitis, pallor of the skin, smooth red painful
ulcers should be prescribed
tongue with atrophy of filiform and fungiform papillae.
● Postcricoid web is a premalignant lesion.
Q.3. Infectious mononucleosis.
● Splenomegaly is uncommon.
Ans.
Laboratory findings
● Infectious mononucleosis is also known as glandular ● The general blood picture is microcytic hypochromic.
fever or kissing disease. ● Serum iron and ferritin are low while total iron-binding
capacity (TIBC) is increased.

● Transferrin saturation is below 16%. ● Increased serum bilirubin.

● Bone marrow stains for iron reveal decreased or absent ● Cellular hyperplasia of bone marrow.
iron stores.
● Stool examination for parasites and occult blood is
● Extreme thickening of diploe producing ‘crew-cut’ or
useful.
‘hair-on-end’ appearance of surface of skull.
Treatment ● Osteoporosis of skull and long bones.
i. Oral iron therapy ● Intraoral radiographs show ‘salt and pepper appearance’.
● The drug of choice is ferrous sulphate 200 mg thrice

Treatment
a day (elemental iron 60 mg thrice a day) orally
● Blood transfusion
taken in between meals.
● Desferrioxamine is given for iron overload
● The treatment with oral iron is usually given for a
long duration and is sustained for 6–12 months even Q.7. Oral manifestation of acute leukaemia.
after normalization of haemoglobin.
Ans.
ii. Parenteral iron therapy
● Intravenous iron therapy is indicated when the pa- ● Acute leukaemia is a disorder in which there is failure
tient is unable to tolerate oral iron, or when his needs of maturation of leukocytes. As a result there is an ac-
are relatively acute. cumulation of immature cells with in bone marrow and
● Previously used iron compound, iron dextran has later in blood.
been associated with the risk of anaphylaxis which is ● Acute lymphoblastic leukaemia is common in children
almost never seen with newer preparations like so- while acute myeloid leukaemia is common in adults.
dium ferric gluconate and iron sucrose. ● Sudden onset.
● Red blood cell transfusion: It is indicated in patients ● Characterized by weakness, fever, headache, petechial
with severe anaemia where cardiorespiratory condi- or ecchymotic haemorrhages in the skin and mucous
tions warrant immediate intervention or when there membranes.
is continued and excessive blood loss. ● Lymphadenopathy is often the first sign of the disease.
Q.6. Cooley anaemia. Oral manifestations of acute leukaemia

Ans. Site
l Submental, cervical and pre- and postauricular
Thalassaemia is also called Cooley anaemia. lymph nodes may be enlarged and tender.
Clinical features Symptoms
● Paraesthesia of lower lip and chin. There may be
● Congenital disorder that is characterized by deficient
synthesis of haemoglobin, either a- or b-chain. toothache due to leukaemic cell infiltration dental
● Types: pulp.
(a) Heterozygous or thalassaemia minor or thalassae- Signs
● Oral mucous membrane shows pallor, ulceration
mia trait
(b) Homozygous or b-thalassaemia or thalassaemia major with necrosis, petechiae, ecchymosis and bleeding
● Two forms of a-thalassaemia: tendency.
● There may be massive necrosis of lingual mucosa
(a) Hb-H disease (mild)
(b) Hb Bart’s disease with hydrops fetalis with sloughing gingiva shows hypertrophy and cya-
● Mongoloid features, flaring of maxillary anteriors de- notic discolouration.
● The hypertrophy may be due to leukaemic cell infil-
pressed bridge of nose, unusual prominence of premax-
illa, poor spacing of teeth, a marked open bite, promi- tration within gingiva or due to local irritants.
● Rapid loosening of the teeth due to necrosis of PDL.
nent malar bone.
● Alterations in the developing tooth crypts.
● Ashen grey skin due to combination of pallor, jaundice
● Osseous changes in jaws.
and haemosiderosis.
● Oral infections (candida, viral and bacterial) are seri-
Laboratory findings ous and potentially fatal complication in leukaemic
● Hypochromic microcytic anaemia. patients.
● WBC count elevated.
● Presence of nucleated RBCs, ‘safety-pin’ cells and Q.8. Thrombocytopenic purpura.

‘target cells’.
Ans.
● Heinz bodies are formed by the precipitation of
a-chains. [Ref LE Q.1]

Q.9. Haemophilia A. Interpretation

● An abnormal B.T. is usually the result of abnormalities
Ans.
in the structure or ability of capillary blood vessels to
● Haemophilia is a potentially fatal inherited bleeding contract.
disorder characterized by the profuse haemorrhage due ● Abnormalities in the number or functional integrity of
to deficiency of clotting factors. the platelets.
● Haemophilia A or classic haemophilia is a condition
Q.2. Mention causes of eosinophilia.
where factor VIII (AHG) deficiency is present.
Ans.
Clinical features of haemophilia A
● Mild cases are asymptomatic with prolonged bleeding ● Eosinophilia is an absolute eosinophil count exceeding
after tooth extraction and any major surgery. The levels 500/mL3.
of factor ‘VIII’ lie between 7% and 50% (normal level
The common causes of eosinophilia are as follows:
is 50%–150%).
● Helminthic infestations
● In moderate cases, haematoma formation occurs after
● Loeffler syndrome
minor trauma or surgery (level 1%–7 %).
● Tropical eosinophilia
● In severe case level of factor ‘VIII’ is less than 1%. This
● Allergic conditions such as hay fever, asthma, serum
causes spontaneous bleeding in muscles (haematomas)
sickness, etc.
and weight bearing joints (haemarthroses).
● Drugs, e.g. sulphonamides, aspirin, penicillins, cephalo-
Oral findings sporins, etc.
● Haemorrhage from many sites in oral cavity ● Collagen vascular diseases, e.g. rheumatoid arthritis,
● Tumour-like outgrowth in mandible (due to sub perios- Churg–Strauss syndrome
teal bleeding and subsequent new bone formation) ● Malignancies, e.g. Hodgkin disease, chronic myeloid
● TMJ – Haemarthroses leukaemia, etc.
● Idiopathic hypereosinophilic syndrome
Treatment
● Factor ‘VIII’ concentrate Q.3. Oral manifestations of haemophilia.
● Fresh frozen plasma (FFP)
Ans.
● Cryoprecipitate
● Desmopressin acetate (in mild cases) Oral manifestations of haemophilia

● Haemorrhage from many sites in oral cavity
Q.10. Thalassaemia major. ● Gingival haemorrhage
Ans. ● Eruption and exfoliated with severe haemorrhage
● Mandibular pseudotumours
[Same as SE Q.6] ● Tumour-like outgrowth in mandible (due to subperios-
teal bleeding and subsequent new bone formation)

SHORT NOTES: ● TMJ – Haemarthroses
Q.1. Bleeding time. Q.4. Four oral manifestations of aplastic anaemia.
Ans. Ans.
● Bleeding time (B.T.) is defined as the time lapse be- Four oral manifestations of aplastic anaemia are as
tween skin puncture and the arrest of bleeding. follows:
● Oral mucosa – Mucosa shows pallor
● B.T. is the time from the onset of bleeding to the stop-
● Symptoms – Spontaneous gingival bleeding, related to
page of bleeding. Bleeding stops due to the formation of
a temporary haemostatic plug. blood platelet deficiency
Signs
Indications ● Petechiae, purpuric spots or frank haematomas of oral
● It is a useful screening test in patients with a history of mucosa.
prolonged bleeding. ● Large ragged ulcers covered by black necrotic mem-
● In patients with bleeding disorders before any surgical brane may be present, which are result of generalized
procedures. lack of resistance to infection and trauma.
Q.5. Oral manifestations of leukaemia. ● The flushing dose is the essence of Schilling test, which
allows vitamin B12 absorption measurement to be made
Ans.
with acceptable doses of radioactivity.
The oral manifestations of leukaemia in both acute and ● Patients with pernicious anaemia excrete less than 5%
chronic forms are as follows: of orally administered dose in comparison with excre-
● Gingivitis, gingival hyperplasia, haemorrhage, pete- tion of 8%–25% by normal individuals.
chiae and ulceration of the oral mucosa
Q.8. Plummer–Vinson syndrome.
● Rapid loosening of the teeth due to necrosis of PDL
● Alterations in the developing tooth crypts Ans.

● Osseous changes in jaws
● Plummer–Vinson syndrome is one of the manifestations
● Petechiae, bullae and burning sensation
of the iron deficiency anaemia.
Q.6. Cyclic neutropenia. ● It is also called as ‘Paterson–Brown–Kelly’ syndrome.
● Occurs at any age chiefly in women in the 4th or 5th

Ans. decades of life.
● Presents general symptoms of anaemia.
● Cyclic neutropenia is also known as periodic neutrope-
● Cracks or fissures at the corner of mouth (angular
nia or periodic agranulocytosis.
● It is characterized by a periodic or cyclic diminution in cheilitis) and spoon-shaped nails (koilonychia).
● Dysphagia due to oesophageal webs and atrophy of
circulating polymorphonuclear neutrophilic leukocytes
as a result of bone marrow maturation arrest. filiform papillae.
● Treatment consists of oral and parenteral iron therapy.
Clinical features
● It occurs at any age commonly seen in infants and Q.9. Polycythaemia rubra vera.
young children. Ans.
● Patients manifest fever, malaise, sore throat, stomatitis,
and regional lymphadenopathy. ● Polycythaemia vera is a chronic stem cell disorder with
● Headache, arthritis, cutaneous infection and conjunc- an insidious onset characterized as a panhyperplastic,
tivitis. malignant and neoplastic marrow disorder.
● Prominent feature is an absolute increase in the total
● Oral manifestations include severe gingivitis, stomatitis
with ulcerations. number of circulating red blood cells and in the total
blood volume because of uncontrolled red blood cell
Radiographic features production.
Loss of alveolar bone may be seen on radiograph. ● Bone marrow of this patient shows normal and abnor-
Treatment mal stem cells.

No specific treatment is present. Oral manifestation
● Oral mucosa appears deep purplish red, gingiva and
Q.7. Schilling test.
tongue are most commonly affected of them.
Ans. ● Cyanosis can be seen due to presence of reduced hae-
moglobin in amount exceeding 5 g/dL.

● Shilling test is a measure of patient’s ability to absorb
● Gingiva engorged and swollen and bleeds upon slight
orally administered radioactive vitamin B12 labelled
provocation.
with 60Co.
● Submucosal petechiae, ecchymosis and haematomas are
● Following oral administration of radioactive vitamin
commonly seen and intercurrent infection may be seen.
B12, unlabelled vitamin is given intramuscularly, as a
flushing dose to induce urinary excretion of labelled Treatment
vitamin, which is measured in a 24 h urine specimen. ● No specific treatment is required.
Topic 16
Diagnostic Laboratory Procedures
SHORT ESSAYS:
1 . Enumerate the importance of intravital staining.
2. What are the indications of following investigations in dentistry: (a) biopsy, (b) sialography and (c) exfoliative
cytology?
3. ESR.
4. Discuss: (a) Toluidine blue vital staining, (b) peripheral blood picture in oral medicine and (c) role of immuno-
globulin in oral medicine. [Same as SE Q.1]
SHORT NOTES:
1. Brush biopsy.
2. Schirmer test.
3. Paul–Bunnell test.
4. Oral exfoliative cytology.
5. State purpose of Toluidine blue staining. [Ref SE Q.1]
6. How do direct and indirect immunofluorescence differ from each other?
7. Vitality tests.
8. Age in examination.
9. Patch test.
10. Paget test.
11. Rose–Waaler test.
12. Describe the role of peripheral blood smear in oral medicine. [Ref SE Q.1]
13. ESR. [Ref SE Q.3]
14. Tzanck test.
15. Indications of Tzanck smear.
16. Nikolsky sign.
17. Acid phosphatase.
18. Alkaline phosphatase.
19. Antinuclear antibody (ANA) test.
20. Postprandial blood glucose technique.
21. Diagnostic tests of bleeding disorders.
22. Diagnostic test for HIV.
23. Biopsy. Types and indications of biopsy in oral medicine.
24. Lab investigations for anaemias.
25. Fine needle aspiration cytology.
26. Significance of haemogram.
27. Bence Jones proteins.
28. Schilling test.
29. Bleeding time.
30. Write in brief about toluidine blue test. [Same as SN Q.5]
31. Role of intravital staining in oral medicine. [Same as SN Q.5]
32. Two differences between direct and indirect immunofluorescence. [Same as SN Q.6]
33. Age estimation methods. [Same as SN Q.8]
34. Elevation of serum calcium. [Same as SN Q.17]
35. Serum alkaline phosphatase. [Same as SN Q.18]
36. Name two conditions that show elevated serum alkaline phosphatase levels. [Same as SN Q.18]
37. Western blot test. [Same as SN Q.22]
38. Aspiration biopsy. [Same as SN Q.25]
SOLVED ANSWERS
SHORT ESSAYS:
Q.1. Enumerate the importance of intravital staining.
Ans.
II. Peripheral blood picture in oral medicine
I. Toluidine blue vital staining
{SN Q.12}
{SN Q.5}
● Examination of a Wright’s stained smear of blood is
● Toluidine blue is a basophilic vital nuclear dye,
a long-established component of the complete blood
which can guide biopsy by localizing small foci of
count that provides information about morphologic
tumour cells within the larger area of inflammation
abnormalities of RBCs and platelets in addition to
in the evaluation of early asymptomatic oral cancers.
the differential WBC count.
● For evaluation of early asymptomatic oral cancers,
● The differential WBC count actually is the morpho-
areas of redness that persist beyond the observation
logic description of abnormal cells that constitutes
period must be biopsied.
the important diagnostic information that can be ob-
tained from the stained blood smear. It has little di-
● Obtaining multiple random samples from the entire agnostic validity unless the figure lies well outside
area is not a reliable diagnostic procedure because the normal range.
small foci of tumour cells can still be missed. ● The stained blood smear is usually examined only if
Toluidine blue vital staining procedure abnormalities are detected in the total RBC, total
● Topical application of the staining medium to the WBC or differential WBC counts. Automated optical
oral mucosa is followed by a rinse of 1.0% acetic scanning techniques provide information on abnor-
acid in order to remove dye retained by debris or mal RBCs and a platelet estimate, in addition to a
within irregularities of the mucosal surface. WBC differential, but abnormal smears detected in
● The dye, retained predominantly in the abnormal this way are also usually examined manually.
nuclei of tumour cells, produces areas of uptake ● The stained blood smear provides a variety of infor-
seen as discretely blue-stained tissue. mation about the RBC: size (macrocytes and micro-
● Positive areas of uptake do not represent ulcer- cytes), shape (anisocytosis, poikilocytosis and sphe-
ation or disruption of the mucosa; they represent rocytosis) and haemoglobin content (hyperchromia
retention of dye by the increased nuclear DNA and hypochromia).
content of tumour cells in the intact mucosa. ● Immature RBC, WBC and other abnormal cells that
● Biopsy of dye retention areas is most likely to appear in the bloodstream in some disease states may
demonstrate foci of invasive cancer on micros- also be observed and are recorded on the report of
copy. the stained smear. For example, patients with leukae-
● Routine use of this technique without due consid- mia, a leukaemoid reaction or severe anaemia.
eration of all other factors essential to diagnosis
should be discouraged.
III. Role of immunoglobulin in oral medicine
● The function of the immune system is to distinguish
{SN Q.5} self from nonself and eliminate potentially destruc-
tive foreign substances from the body. This function
● Casual overreliance on an apparently effective, yet
has direct clinical application in the fields of infec-
simple, screening modality encourages the examiner
tious and neoplastic diseases and in transplant im-
to become complacent regarding the comprehensive
munology.
integration of history and clinical examination, which
● Current concepts of human immunology support
are essential to the reliable detection of early cancer.
the theory that the cells responsible for the immune
● Toluidine blue staining is remarkably reliable. False-
response are derived from an undifferentiated stem
negative and false-positive rates are low. Although
cell precursor that originates in the bone marrow.
highly suggestive of malignancy, a positive toluidine
● These stem cells differentiate into two distinct
blue reaction is not conclusive in establishing the
populations of lymphocytes that form the two com-
diagnosis of cancer. Biopsy and histologic evaluation
ponents of the immune system.
are required for a definitive diagnosis.
● One population of lymphoid stem cells contacts
● Toluidine blue could be used as a general intraoral
the thymus and forms the thymus-dependent or the
rinse for gross screening purposes.
T-cell system.
Other cells contact the human equivalent of the bursa

● basement membrane and to search for nests of inva-
of Fabricius of birds, possibly the intestinal lym- sive tumour cells.
phoid tissue of Peyer’s patches or the appendix, to ● Most pathologists request that the specimen include a
differentiate into the bursa or B-cell system. zone of adjacent, clinically normal tissue in order to
● The T-cell system is responsible for cell-mediated recognize malignant changes; however, when ulcer-
immunity, which serves as the body’s primary de- ation is present, specimens obtained from the ulcer-
fence against viruses and fungi. ated areas may reveal only nondiagnostic necrosis.
● The T-cell system is also responsible for delayed ● Inclusion of some clinically uninvolved tissue in the
hypersensitivity reactions and graft rejection and specimen when ulceration is present, usually en-
helps to regulate the B-cell system. sures a representative sample of active non-necrotic
● T-lymphocytes perform many of their functions by tumour.
releasing mediators: cytotoxic mediators destroy ● Intentional excisional biopsy that is total removal of
grafts and tumour cells, while migration inhibition all abnormal tissue for diagnostic purposes has abso-
factor (MIF) attracts phagocytic macrophages to the lutely no role in the diagnosis of oral cancer.
site of bacterial infection. ● Planned excisional biopsy of a lesion clinically sus-
● T-cells populate the paracortical areas of lymph pected to be malignant cannot be justified by any
nodes and the white pulp of the spleen, and consti- rationale and should be condemned.
tute 60%–80% of lymphocytes in the peripheral ● Adequate excision of a malignant lesion usually re-
blood. quires at least a 1.5 cm margin of clinically unin-

● The B-cells populate the follicles around germinal volved tissue along each periphery; if the diagnosis
centres of lymph nodes, spleen and tonsils. is benign, it is impossible to justify removal of such
● B-lymphocytes have immunoglobulin receptors on a large block of tissue.
their surface. When these receptors combine with ● If the diagnosis is malignant, any specimen with less
antigen, they differentiate into plasma cells and pro- than 1.5 cm of clinically normal tissue along each
duce antibody. margin is inadequate, and retreatment of the lesion
● Antibodies are the body’s primary defence against would be mandated.
bacterial infection. ● Excision of a lesion for diagnosis is justifiable only
Five major classes of antibodies or immunoglobulins when the lesion is almost certainly benign or when
(lg) are now recognized: IgM, IgG, IgA, IgD and IgE. Each the lesion is so minute that total removal is required
of these immunoglobulins has different chemical as well as to ensure an adequate volume of tissue for micro-
distinct biological properties. scopic evaluation.
● In most cases, every reasonable attempt should be
Q.2. What are the indications of following investigations
made to obtain an incisional specimen that is re-
in dentistry: (a) biopsy, (b) sialography and (c) exfolia-
moval of small representative portion of the lesion.
tive cytology?
Sialography
Ans.
● Sialography is a specialized radiographic view taken by
Biopsy introduction of the radiopaque dye into the ductal sys-
● Biopsy is the removal of tissue from living individual tem of the major salivary glands, mainly parotid and
for microscopic examination and precise diagnosis of submandibular.
the lesion. ● This technique is used to examine the ductal and acinar
systems of the major salivary glands.

Various types of biopsy are as follows:
● Sialography will aid in the diagnosis in cases where the
i. Excisional biopsy
radiographs are negative and will demonstrate a filling
ii. Incisional biopsy
defects, narrowing of ducts at the site of the stone, and
iii. Aspiration biopsy
dilation of the duct proximal to the stone.
iv. Punch biopsy
● This technique is no longer considered as desirable,
v. Frozen section biopsy, etc.
since there is some danger of glandular damage by the
● Biopsy in diagnosis of malignant lesions is an abso-
injected dye, and in patients with severe Sjögren the dye
lute requirement before ablative cancer therapy can
will remain in the gland interfering with future tests.
be initiated.
● The biopsy specimen obtained should be representa- Exfoliative cytology
tive of the lesion under investigation. Adequate ● Intraoral exfoliative cytologic study, although eliminat-
depth that is through the epithelium into connective ing many of the disadvantages of the biopsy, by no
tissue is necessary to determine the integrity of the means supplants the usual biopsy study.
● Over the last 25 years, considerable experience has been ● In general, the preparation of the smear is similar to that
gained with the exfoliative cytologic techniques in oral used to obtain oral smears for other purposes with the
diagnosis that were originally developed by Silverman exception that firm pressure with a wooden or steel
and Sandler. scraper must be used to ensure that adequate numbers of
● A variety of oral diseases have been studied with this cells are obtained, and the smear must be fixed immedi-
technique, but the procedure is of most value in the ately. For this purpose, an aerosol fixative such as
evaluation of suspected malignancies, especially when Spraycyte or 95% alcohol may be used.
these present as ulcerated or red nonkeratinized lesions. ● Oral exfoliative cytology has been used for the study of
● Oral cytology should never be relied on for diagnosis of other nonmalignant changes in the oral cavity, for ex-
an oral lesion simply because it may be easier to obtain ample, studies of buccal mucosa in various anaemias
than a biopsy. and of the maturation of the buccal mucosa with the
● Once a lesion is suspected to have a slightest chance of menstrual cycle.
being malignant, the lesion should be biopsied ade- ● Oral cytology is generally most helpful in evaluation of
quately at the earliest opportunity. nonkeratinized ‘red patches’ or ulcerative lesions of the
● With these considerations in mind, Papanicolaou- oral mucosa. Specimens obtained from heavily keratin-
stained smears of oral mucosal lesions are indicated in ized ‘white patches’ are composed mainly of superficial
the following circumstances in clinical dentistry: squames, and the more immature basal cells are not
i. For rapid laboratory evaluation of an oral lesion represented on the smear.
on clinical grounds is thought to be malignant. For
The standard classification used in oral cytology reports is
example, in the case of advanced malignancies
as follows:
where delay or preliminary incision of the lesion is
● Class I, normal cells.
not warranted, laboratory confirmation of the clini-
● Class II, some atypical cells, but no evidence of malig-
cal impression often can be obtained by a Papanico-
nancy.
laou-stained smear in 1–2 days.
● Class III, changes in nuclear pattern of indeterminate
ii. For laboratory evaluation of an oral lesion that on
nature; no definite evidence of malignancy, but clearly
clinical grounds is thought to be premalignant and
aberrant cells are present.
for which the dentist is unable to obtain permission
● Class IV, suggestive of malignancy.
for a biopsy.
● Class V, obvious malignant changes.
iii. In patients with multiple premalignant lesions, bi-
A report of class III, IV or V changes should always be
opsy of multiple lesions or entire removal of exten-
followed by a biopsy of the lesion.
sive lesions may not be feasible, and cytology may
be a very practical adjunct to biopsy. Q.3. ESR.
iv. For sequential laboratory evaluation of an area of
Ans.
mucosa that has previously been treated by excision
or radiation to remove a malignancy. Successive
biopsies are often not possible, and cytology pro-
{SN Q.13}
vides something better than simple clinical observa-
tion, especially where previous treatment has led to ● The erythrocyte sedimentation rate (ESR) measures
scarring or other tissue change. the rate at which RBCs sediment in a tube of plasma.
v. For evaluation of vesicular lesions (herpes simplex, ● The rate is accelerated when changes in plasma pro-
pemphigus and pemphigoid) where facilities for teins cause the RBCs to aggregate or when there are
rapid evaluation of a Tzanck smear are not available changes in the physicochemical properties of plasma
or where more detailed cytology is required. or the red cell surface.
● The test is helpful in following the progress of some
Procedure chronic infections (tuberculosis and osteomyelitis)
● The clinical value of exfoliative cytology is directly reas well as diseases characterized by altered globulins
lated to the skill of the cytologist and his experience such as the collagen diseases, nephritis, rheumatic
with oral smears. fever and the dysproteinaemias.
● A dentist who proposes to use this laboratory procedure ● It is claimed to be more sensitive than temperature,
should first determine, which laboratories are available WBC count, weight and subjective symptoms as an
to him to routinely handle oral smears. indication of progress of some diseases.
● The laboratory will frequently provide a kit (slides, cy- ● Marked elevations usually indicate the presence of dis-
toscraper and mailing tube) with instructions for obtain- ease, the exact nature of which should be investigated.
ing, fixing and transporting the specimen.
Q.3. Paul–Bunnell test.

● In the Westergren method, a graduated sedimentation
tube is filled with oxalated blood and placed in an Ans.
absolutely vertical position.
● Patients with infectious mononucleosis develop an in-
● The erythrocyte level is read at 10 min intervals and
creased serum titre of an antibody that cross-reacts with
at the end of the hour.
red blood cells from other species (heterophil or Forss-
The generally accepted normal sedimentation rates in man antibody).
60 min for this method are males, 0–15 mm, and females, ● Whenever a patient is suspected of having infectious
0–20 mm. mononucleosis because of symptoms, examination find-

● The sedimentation rate may be increased in women ings, or haematologic abnormalities, ‘the titre of hetero-
with intrauterine contraceptive devices (IUDs) and phil antibody’ is used to confirm the diagnosis.
women taking an ovulatory steroids (oral contra- ● The traditional test for heterophil antibody is based on
ceptives). agglutination of sheep red cells and is known as the

Paul–Bunnell test.
● The (Davidsohn) differential test is a modification of
● This test is also of considerable importance in the diag- the Paul–Bunnell test, in which the serum titre of sheep
nosis of giant cell arteritis (temporal arteritis) and a agglutinins is measured before and after absorption of
closely related disease, polymyalgia rheumatica, which the patient’s serum with beef or guinea pig red cells to
are uncommon but clearly defined causes of recurrent make the test more specific for detecting infectious
facial pain. mononucleosis.
Q.4 . Discuss: (a) Toluidine blue vital staining, (b) periph- Q.4. Oral exfoliative cytology.
eral blood picture in oral medicine and (c) role of immu-
Ans.
noglobulin in oral medicine.
● Intraoral exfoliative cytology, originally developed by
Ans.
Silverman and Sandler, although eliminates many of the
[Same as SE Q.1] disadvantages of the biopsy, by no means supplants the
usual biopsy study.
● A variety of oral diseases have been studied with this
SHORT NOTES: technique, but the procedure is of most value in the
Q.1. Brush biopsy. evaluation of suspected malignancies, especially
when these present as ulcerated or red nonkeratinized
Ans.
lesions.
i. Brush biopsy technique is only a screening tool, which ● The clinical value of exfoliative cytology is directly re-
enables a transepithelial capture of cells. lated to the skill of the cytologist and his experience
ii. In this technique, a brush is rotated against the tissue with oral smears.
until slight bleeding is observed, indicating that the ● The laboratory will frequently provide a kit (slides, cy-
brush has reached the basement membrane. toscraper and mailing tube) with instructions for obtain-
iii. The cellular aggregate on the brush is transferred to ing, fixing and transporting the specimen.
a glass slide, fixed and then analysed by computer ● Oral cytology is generally most helpful in evaluation of
scans and pathologists trained specifically in oral brush nonkeratinized ‘red patches’ or ulcerative lesions of the
biopsy interpretation. oral mucosa.
iv. The technique can be applied to a wider segment of the ● Specimens obtained from heavily keratinized ‘white
population. patches’ are composed mainly of superficial squames,
and the more immature basal cells are not represented
Q.2. Schirmer test.
on the smear.
Ans.
Q.5. State purpose of Toluidine blue staining.
i. Schirmer test is one of the tests to evaluate lacrimal
Ans.
gland function in suspected Sjögren patients.
ii. The Schirmer test consists of placing a strip of filter [Ref SE Q.1]
paper in the lower conjunctival sac.
Q.6. How do direct and indirect immunofluorescence
iii. Normal patients will wet 15 mm of filter paper in 5 min.
differ from each other?
Patients with Sjögren syndrome will wet less than
5 mm of filter paper. Ans.
Fluorescent antibody procedures are carried out in one of Q.8. Age in examination.
three ways:
Ans.
i. Direct immunofluorescence
ii. Indirect immunofluorescence Age is one of the important parameter in estimation of
iii. The sandwich technique diseased.
There are various methods for the estimation of growth:
Direct immunofluorescence
i. Clinical methods of age estimation.
● Fluorescent-labelled antiserum directed against a
ii. Radiographic methods of age estimation.
particular tissue component is applied directly to a
iii. Estimating age in children and adolescents.
thin, unfixed smear or tissue section mounted on
● Moorrees’ method
slide, and the slide is incubated at 37°C to allow the
● Demirjian’s method
antigen and labelled antibody to react.
● Open apices method
● Nonspecific reactions are common with this tech-
iv. Third molars in age estimation.
nique, which requires a separate labelled antibody
v. A combined clinical and radiographic method.
preparation for each component to be located. It has
vi. Estimating age in adults, using Kvaal’s radiographic
largely been superseded by either the indirect or
method.
sandwich techniques.
Indirect immunofluorescence Q.9. Patch test.
● Unlabelled specific antiserum directed against a
Ans.
particular tissue component is applied directly to the
smear or tissue section, allowed to react and fol- ● The patch test is the only test that can be used to distin-
lowed by an FITC-conjugated antiglobulin antise- guish contact allergy from other lesions.
rum. Following incubation and washing to remove ● In this test, the suspected allergen is placed on normal
unreacted reagents, the slide is examined in the ul- nonhairy skin. The best test site is the upper portion of
traviolet microscope. the back.
● Similar staining reactions to those observed with the ● The test substance is covered in most instances and
direct technique are obtained, but the technique has allowed to remain in contact with the skin for 48 h. The
several advantages. patch is removed, and 2–4 h later the area examined
● In general, the fluorescence is brighter because sev- for persistent erythema.
eral fluorescent antiglobulin molecules bind onto ● Patch testing of the skin may not be reliable in diagno-
each of the antibody molecules in the specific antise- sis of hypersensitivity reactions confined to the oral
rum. Because the process of conjugation is lengthy, mucosa.
there is considerable cost saving and versatility to the ● Patch testing directly on the oral mucosa has been at-
indirect technique, which requires only one labelled tempted by incorporating the test substance in Orabase,
antiserum (antiglobulin antiserum). by use of a prosthetic appliance to hold the substance in
● Staining of more than one tissue component per slide place, or by use of a rubber cup attached to the teeth.
can also be accomplished, but usually with some loss
of specificity. Q.10. Paget test.
● A variation of this technique uses complement as an
Ans.
additional reagent that binds the specific antigen–
antibody complex and an FITC-labelled anticomple- ● Paget test is used to determine whether a mass is a solid
ment antiserum to locate the complex. tumour or a cyst.
● When a swelling is smaller than 2 cm in size, Paget test
Q.7. Vitality tests. is done.
Ans. ● Cystic swellings feel soft in the centre and firm at the
periphery.
● The tooth is said to be vital when it is capable of re- ● Solid swellings feel firm at the centre than periphery.
sponding to stimuli.
● To check the vitality of teeth, there are three basic Q.11. Rose–Waaler test.
stimuli in the form of thermal, electrical or mechanical.
Ans.
● Thermal: Heat/cold application.
● Electric pulp testing: Direct electric stimulation of sen- ● A special type of passive haemagglutination test is the
sory nerves in the pulp. Rose2Waaler test.
● Mechanical stimulation: Blowing air to the exposed ● In rheumatoid arthritis, an autoantibody (RA factor) ap-
dentine and test cavity preparation. pears in the serum, which acts as an antibody to g-globulin.
● The RA factor is able to agglutinate red cells coated Q.17. Acid phosphatase.
with globulins.
Ans.
● The antigen used for the test is a suspension of sheep
erythrocytes sensitized with a subagglutinating dose of ● Acid phosphatase occurs in large quantities in the pros-
rabbit antisheep erythrocyte antibody. tate and erythrocytes.
● Elevated serum levels are found in about three-fourths
Q.12. Describe the role of peripheral blood smear in
of patients with metastatic prostatic carcinoma and in
oral medicine.
about one fourth of these before metastasis occurs.
Ans. ● The serum level also rises as a result of prostatic mas-
sage or biopsy and may also be increased in metastatic

[Ref SE Q.1]
breast carcinoma as a result of production of this en-
Q.13. ESR. zyme by the neoplastic tissue.
Ans. Q.18. Alkaline phosphatase.
[Ref SE Q.3] Ans.
Q.14. Tzanck test. ● The causes of raised serum alkaline phosphatase are as
follows:
Ans. i. Rickets
● Tzanck test is considered as a rapid supplemental test ii. Osteomalacia
for pemphigus. iii. Hyperparathyroidism
● It involves taking of cytological smears from freshly iv. Paget disease
opened vesicles. These smears characteristically display ● In the presence of increased serum alkaline phospha-
Tzanck cells that are diagnostic of pemphigus. tase, determination of serum 5-nucleotidase, which is
● Tzanck cells are clumps of large hyperchromatic epithe- elevated in obstructive biliary disease but not in bone
lial cells lying free within the vesicular fluid. These cells disease, can be helpful in identifying the site of origin
are also characterized by swollen nucleus and hyper- of the alkaline phosphatase.
chromatic staining. Q.19. Antinuclear antibody (ANA) test.
Q.15. Indications of Tzanck smear. Ans.
Ans. ● Antinuclear antibody test (ANA): Four types of antinu-
clear antibodies that produce characteristic patterns of
Indications of Tzanck smear
immunofluorescence can be identified by this technique.
● These smears are used for identification of the giant
● Both the titre of the serum (or joint fluid) and the mag-
cells that accompany vesicular virus infections (herpes
nitude of fluorescence are taken into consideration in
simplex, varicella and herpes zoster) and are commonly
reporting positive results.
known as viral giant cells.
● Tests that are scored as only 11 or 21 (on a 11 to 41 scale)
● For identification of acantholysis, a characteristic tissue
on undiluted serum are usually not reported as positive.
change occurring in pemphigus.
● The four patterns of nuclear fluorescence detected by
● In both diseases, the smear is made from the cells mak-
this technique are caused by differences in the distribu-
ing up the floor of the lesion. The technique of obtaining
tion of antigens in the cell nucleus as follows:
a smear from this location and staining it is known as
i. Diffuse:
the Tzanck smear.
Homogenous distribution of specific fluorescence
Q.16. Nikolsky sign. throughout the nucleus. It is not only characteristic
of Systemic lupous Erythematosis (SLE) but also
Ans.
seen in rheumatoid arthritis, Sjögren syndrome and
● The Nikolsky sign is most frequently associated with scleroderma.
pemphigus, but may also occur in epidermolysis bullosa ii. Shaggy:
and Ritter disease. Peripheral distribution of fluorescence, usually seen
● The characteristic sign of these diseases is that pressure only in SLE, especially with active nephritis.
to an apparently normal area will result in formation iii. Speckled:
of a new lesion. This phenomenon, is called as the Discrete particulate staining of the nucleus. Seen
Nikolsky sign, it results from the upper layer of the skin most commonly in rheumatoid arthritis, liver disease,
pulling away from the basal layer. ulcerative colitis, Sjögren syndrome and scleroderma.
iv. Nucleolar: Indirect immunofluorescence test

●
A relatively rare pattern seen most often in sclero- RIA

●
derma and Sjögren syndrome. Confirmatory tests

● Western blot test
Q.20. Postprandial blood glucose technique.
Western blot test
Ans. The most widely used confirmatory test for HIV is
Western blot test.
● Two-hour postprandial blood glucose can be done with
● In this test, HIV proteins are separated according to
Dextrostix, Visidex or Chemstrip bG techniques.
their electrophoretic mobility and molecular weight
● The 2 h blood glucose test should ideally be pro-
by polyacrylamide gel electrophoresis.
grammed for a particular appointment and the patient
● These separated proteins are bloated on the strips of
prepared with an explanation of the test and the diet
nitrocellulose paper. These strips are reacted with
instructions.
test sera and then with enzyme conjugated antihu-
● However, the test can be performed immediately, if pa-
man globulin.
tient has ingested approximately 75 g of carbohydrate.
● Antibodies to HIV proteins present in test serum
● A sample of urine should also be collected and checked
combine with all or any fragment of HIV. The strips
for glucose whenever the test is performed.
are washed and treated with enzyme conjugated
Indications antihuman g-globulin. Then a suitable substrate is
i. For evaluation of a patient suspected of having diabetes added that produces colour bands.
mellitus. ● The position of the band on the strip indicates the an-
ii. As a screening test for diabetes mellitus. tigen with which the antibody has reacted. In a posi-
iii. As a measure of the degree of control of the disease in tive serum, bands will be seen with multiple proteins
a patient who is known to be a diabetic, but who is not typically with p24, p31 and gp41, gp120 or gp160.
under regular medical care and is unwilling to accept
Q.23. Biopsy. Types and indications of biopsy in oral
referral to a physician for re-evaluation of this disease.
medicine.
Q.21. Diagnostic tests of bleeding disorders.
Ans.
Ans.
● Biopsy is a surgical procedure to obtain tissue from
● In most cases of bleeding and clotting disorders, first a living organism for its microscopic examination, usu-
consultation would include a medical history and physi- ally to perform a diagnosis.
cal examination. Types of biopsy
● The following is the laboratory work-up for bleeding i. Aspiration or Fine Needle Aspiration (FNA) biopsy
abnormalities: ii. Cone biopsy
i. Complete blood count iii. Core needle biopsy
ii. Measurement of bleeding time iv. Suction-assisted core biopsy
iii. Prothrombin time and partial thromboplastin time v. Endoscopic biopsy
iv. A platelet count vi. Punch biopsy
● With the exception of the haematocrit and bleeding vii. Surface biopsy
time, these procedures require specialized equipment viii. Surgical biopsy or excisional biopsy, etc.
and a trained technician. Indications of biopsy
● When blood tests are performed outside the office, the i. For the assessment of any unexplained oral muco-
bleeding time and capillary fragility test must be persal abnormality that persists despite of treatment or
formed as office/chairside procedures by the clinician the removal of local irritants.
unless the patient goes in person to the laboratory to ii. Malignancy is suspected when persistent oral mu-
have blood drawn. cosal lesions are ulcerated, indurated or fixed to
deeper tissues.
Q.22. Diagnostic test for HIV.
iii. Persistent lesions that bleed easily or grow rapidly
Ans. with possibility to transform into malignancy.
There are two types of serological tests for Anti-HIV Q.24. Lab investigations for anaemias.
antibodies:
Ans.
Screening tests
● Enzyme linked immunosorbent assay (ELISA) ● Anaemia is defined as a decrease in the amount of oxygen-
● Karpas test carrying substance per unit volume of blood and may
result from a reduction in the number of red cells per Q.27. Bence Jones proteins.
cubic millimetre of blood, a reduction in haemoglobin Ans.
concentration or both.
● Anaemia may, therefore, be detected by several labora- ● Bence Jones proteins can be demonstrated in the urine
tory procedures: of patients who have multiple myeloma and is an excre-
i. Total red cell count tory product of the abnormal serum globulins.
ii. Haemoglobin concentration ● 60%285% of myeloma patients exhibit Bence Jones
iii. Haematocrit proteins in the urine.

● Of these procedures, only the haematocrit can be per- ● This is an unusual protein that coagulates when urine is
formed accurately without special training and with heated to 40260°C and disappears when urine is boiled.
simple equipment. It reappears as urine is cooled.
● When performed on capillary blood obtained from a ● Occasionally, Bence Jones proteins are found in urine of
finger prick, this procedure is known as the microhae- patients with other diseases such as leukaemia and poly-
matocrit and measures the percentage volume occupied cythaemia.
by the red cells in relation to the total volume of blood Q.28. Schilling test.
in a centrifuged capillary tube.
● The microhaematocrit is a rapid and accurate means of Ans.
detecting anaemia in the office or clinic setting when ● Of fundamental importance in the differentiation of
the services of a diagnostic laboratory are not readily megaloblastic macrocytic anaemias is the Schilling test,
available. a measure of the patient’s ability to absorb orally admin-
istered radioactive vitamin B12 labelled with Co.
Q.25. Fine needle aspiration cytology.
● Following oral administration of the radioactive vitamin
Ans. B12 unlabelled vitamin is given intramuscularly as a

flushing dose to induce urinary excretion of the labelled
● Fine needle aspiration cytology is performed with a fine vitamin, which is measured in a 24 h urine specimen.
needle attached to a syringe. Aspiration biopsy is often ● The flushing dose is the essence of the Schilling test,
referred to as fine needle aspiration. It is a percutaneous which allows vitamin B12 absorption measurements to
biopsy. be made with acceptable doses of radioactivity.
● FNA is typically accomplished with a fine gauge needle
● Patients with pernicious anaemia (who are unable to
(22 or 25 gauge). absorb orally administered vitamin B12) excrete less
Advantages than 5% of the orally administered dose in comparison
i. Excellent patient complaint with excretion of 8%225% by normal individuals.
ii. Can be readily repeated ● In patients with pernicious anaemia, repetition of the test
iii. Minimum/no complication such as pain or bleeding 3 days later together with administration of gastric intrin-
Disadvantages sic factor will result in normal levels of urinary excretion
i. Inadequate sample with little or no cells of the orally administered radioactive vitamin B12.
ii. False positive or negative results
Q.29. Bleeding time.
Q.26. Significance of haemogram. Ans.
Ans. ● The time taken for the arrest of bleeding is known
● Haemogram is used in the measurement of haemoglo- as bleeding time. The arrest of bleeding is due to the
bin concentration. formation of platelet plug.
● Bleeding time normally ranges from 2 to 5 min.
● The haemoglobin concentration, expressed as grams of
● This can be determined by pricking the ear lobe or the
haemoglobin per decilitre of blood, is commonly mea-
sured to obtain information about circulating RBCs fingertip.
● Bleeding time is prolonged in purpura due to platelet
and the amount of oxygen-carrying substance they
contain. deficiency.
● The bleeding time is a useful screening test in a patient
● The haemoglobin concentration is also used for the cal-
culation of MCHC and MCH, which are used in deter- with a history of prolonged bleeding following previous
mining the nature of a patient’s anaemia. surgery.
● The most satisfactory techniques for which stable stan- Q.30. Write in brief about toluidine blue test.
dards are commercially available. For example, the
Drabkin technique, Sahli’s method and oxyhaemoglo- Ans.
bin method. [Same as SN Q.5]
Q.31. Role of intravital staining in oral medicine. Q.35. Serum alkaline phosphatase.
Ans. Ans.
Q.32. Two differences between direct and indirect Q.36. Name two conditions that show elevated serum
immunofluorescence. alkaline phosphatase levels.
Ans. Ans.
Q.33. Age estimation methods. Q.37. Western blot test.
Ans. Ans.
Q.34. Elevation of serum calcium. Q.38. Aspiration biopsy.
Ans. Ans.
Topic 17
Miscellaneous
LONG ESSAYS:
1 . What are the oral causes of halitosis? How are you going to treat a case of ANUG?
2. Corticosteroids in dentistry.
3. Define halitosis. What are the various causes leading to halitosis? Discuss any two of them in detail. [Same as LE Q.1]
SHORT ESSAYS:
1. Metronidazole.
2. Oral penicillin.
3. Indications and contraindications of corticosteroid therapy in dentistry.
4. Anaphylactic shock.
5. Serum sickness.
6. Antifungal drugs in oral medicine.
7. Broad-spectrum antibiotics – side effects.
8. Classification and uses of oral penicillin. [Same as SE Q.2]
9. Uses and side effects of oral penicillin. [Same as SE Q.2]
10. Mention two oral conditions in which corticosteroids are drugs of choice and two oral conditions in which they
are contraindications. [Same as SE Q.3]
11. How will you manage a case of anaphylactic shock due to local anaesthesia? [Same as SE Q.4]
1 2. Anaphylaxis. [Same as SE Q.4]
SHORT NOTES:
1 . Lipschutz bodies.
2. Melkersson–Rosenthal syndrome.
3. Ascher syndrome.
4. Albright syndrome.
5. Papillon–Lefevre syndrome.
6. Eagle syndrome.
7. Ramsay Hunt syndrome.
8. Ethics in dental profession.
9. Fixed drug eruption.
10. Halitosis – physiologic causes. [Ref LE Q.1]
11. Diazepam.
12. Classify antiviral drugs.
13. Classify nonsteroidal anti-inflammatory drugs?
14. Jarisch2Herxheimer reaction.
15. Lip prints.
16. Bite Marks.
17. Battered baby syndrome.
18. Bite marks analysis. [Same as SN Q.16]
SOLVED ANSWERS
LONG ESSAYS: ● As the periodontal pocket depth increases, it is
Q.1. What are the oral causes of halitosis? How are you seen that the concentration of the malodorous
going to treat a case of ANUG? chemicals increases. Deep pockets also cause
the formation of putrescine and cadaverine.
Ans. II. Tongue coating that harbours microorganisms
● The dorsum of the tongue is considered to be
● Halitosis means oral malodour or bad breath.
● Volatile sulphur compounds are the main cause of breath the primary aetiologic factor for oral malodour.
● Dorsum of the tongue is irregular and accom-
malodour. These mainly include hydrogen sulphide,
methyl mercaptan and dimethyl sulphide. Various other modates microorganisms and food debris.
● Desquamated cells and food remnants remain
compounds have also been implicated in the aetiology
such as putrescine, indole, skatole, butyric acid or propi- entrapped on the surface and are consequently
onic acid. decomposed and contribute to oral malodour.
● There are several causes for halitosis, unpleasant breath
III. Stomatitis, xerostomia
● Dry mouth can cause the volatile sulphur
can be due to intraoral or extraoral causes. They are as
follows: compounds to escape.
● The number of microorganisms that produce
volatile sulphur compounds are increased in

{SN Q.10} absence of saliva.
Physiologic causes IV. Faulty restorations retaining food and bacteria
a. Mouth breathing V. Unclean dentures
b. Medications VI. Oral pathologic lesions
c. Ageing and poor dental hygiene ● Carious cavities, infected extraction wounds,
d. Fasting/starvation dental abscesses and purulent discharge all can

e. Tobacco contribute to oral malodour.
f. Foods (onion, garlic, etc.) and alcohol VII. Aphthous ulcers
● Certain conditions such as pericoronitis,
ANUG and oral ulcers can also contribute to
Pathologic causes oral malodour.
Intraoral and other contributing factors such as: VIII. Crowding of teeth
I. Periodontal infections/periodontal pathology ● The crowded teeth cause accumulation of
● Actinobacillus actinomycetemcomitans, Porphy- food debris, which can result in halitosis.
romonas gingalis, Campylobacter rectus and Systemic and extraoral factors include:
Tannerella forsythia are responsible for patho- I. Nasal infections
genesis of periodontitis and production of vola- ● For example, rhinitis, sinusitis, postnasal drip,
tile sulphur compounds. tumours and foreign bodies.
II. Diseases of gastrointestinal tract (GIT) ● Halita 1M is a new solution containing 0.05%
● For example, various conditions that contrib- chlorhexidine, 0.05% cetyl pyridium chloride (CPC)
ute to oral malodour are Zenker diverticu- and 0.14% zinc lactate with no alcohol has been
lum, hiatus hernia, carcinomas, gastroesoph- more efficient than 0.2% chlorhexidine formulation
ageal reflux disorder (GERD) and intestinal in reducing the VSC levels.
gas production.
Q.2. Corticosteroids in dentistry.
III. Pulmonary infections
● For example, chronic bronchitis, pneumonia, Ans.
tuberculosis and carcinomas are also extra-
Corticosteroids are the hormones produced by the cortex of
oral causes of oral malodour.
the adrenal gland. They are as follows:
IV. Hormonal changes
● Glucocorticoids–cortisol.
● Certain hormonal changes that occur during
● Mineralocorticoids–aldosterone.
ovulation, menstruation, pregnancy and
● A small amount of androgens.
menopause.
V. Systemic diseases The secretion of adrenal cortex is under the control of
● Other extraoral causes that contribute to ACTH secreted by the anterior pituitary, which in turn is
halitosis are liver insufficiency, kidney in- regulated by corticotropin releasing factor (CRF). This is
sufficiency, diabetes mellitus, renal failure, termed as hypothalamic–pituitary–adrenal axis.
blood dyscrasias, rheumatologic diseases, Classification of corticosteroids
dehydration and fever and cirrhosis of liver. A. Short acting (8212 h)
Treatment aspects of oral malodour i. Hydrocortisone
Tongue cleaning ii. Cortisone
● In patients with thick coatings on their tongue, B. Intermediate acting (18236 h)
cleansing of tongue has been recommended. i. Prednisolone
Toothpastes ii. Methylprednisolone
● Cleaning the dentition and the tongue with a den- iii. Triamcinolone
tifrice has shown to reduce the levels of volatile C. Long acting (36254 h)
sulphur compounds. i. Paramethasone
Mouth rinses ii. Dexamethasone
● In addition to above procedures, the use of different iii. Betamethasone
mouth rinses containing cetylpyridinium chloride, Mechanism of action
triclosan, chlorhexidine, essential oils, chlorine diox- Corticosteroids bind to specific receptors in the cyto-
ide, metal ions, etc. has been shown to be effective in plasm, the drug–receptor complex is transported into the
controlling oral malodour. nucleus where it binds to specific sites on DNA and regu-
● Chemical reduction of oral microbial load in- lates the synthesis of new proteins that bring about the
cludes rinsing or gargling with an effective mouth- hormone effects.
wash.
Chewing gum Steroid hormone enters the cells of target organ
● Chewing gum containing metal salts such as fluo-
g
rides or chlorhexidine helps in reducing the bacte-
rial load and the levels of malodorous chemicals In the cytoplasm it binds to specific receptors
from the oral cavity. g
● Drinking water at frequent intervals and chewing
of gum can keep the volatile sulphur compounds Steroid receptor complex becomes activated
in solution and prevent them from producing oral g
malodour.
Oral malodour associated with periodontitis Enters the nucleus
● One way to treat oral malodour associated with peri-
g
odontitis is to combine regular periodontal treatment
and a chlorhexidine mouth rinse. Binds to specific site on the DNA
● Another treatment strategy for oral malodour is
g
conversion of volatile sulphur compounds by using
various metal ions. Zinc (Zn21) is an ion, which Protein synthesis regulation
bonds to the twice negatively charged sulphur radi- g
cals to reduce the expression of volatile sulphur
compounds. Shows response
● Synthetic corticosteroids are more selective corti- and the relative potency of additional miner-
costeroids. They do not have mineralocorticoid alocorticoid effects.
action. i. Cushing syndrome: Abnormal fat distri-
● They are more potent than the natural corticoids. bution causes moon face, buffalo hump,
They generally have intermediate to long duration of truncal obesity, muscle wasting, thin-
action. ning of limbs and skin, easy brushing,
● Synthetic glucocorticoids include: purple striae and acne.
I. Prednisolone ii. Hyperglycaemia: Precipitation of dia-
● It is more selective glucocorticoid and is four betes mellitus or aggravation of pre-
times more potent than hydrocortisone. existing diabetes.
● Used for allergic, inflammatory, autoimmune iii. Susceptibility of infection: Long-term
diseases and in malignancies. therapy with steroids leads to immuno-
● For example, available as DELTACORTRIL, suppression, which makes the patient
HOSTACORTIN-H, 5, 10 mg tab, 20 mg/mL more vulnerable to various opportunis-
for i.m., intra-articular injection, WYSO- tic infections like fungal, viral and bac-
LONE, NUCORT, 5, 10 and 20 mg tab. terial, etc.
II. Methylprednisolone iv. Osteoporosis: Especially of the verte-
● Slightly more potent and more selective than brae is more common in the elderly.
prednisolone; 4232 mg/day oral. v. Avascular necrosis: Avascular necrosis
● For example, available as SOLU-MEDROL of the bone due to restriction of blood
methylprednisolone (as sodium succinate) flow through bone capillaries may cause
0.5 g (8 mL) and 1.0 g (16 mL) injection for pain and restriction of movement.
i.m., slow i.v. injection. Growth in children may be suppressed.
III. Triamcinolone vi. Peptic ulceration: This may sometimes
● Slightly more potent but highly selective occur on prolonged therapy especially
glucocorticoid than prednisolone: 4232 mg/ when other ulcerogenic drugs are (e.g.
day oral, 5240 mg i.m., intra-articular injec- NSAIDs) used concurrently.
tion. Also used topically. vii. Mental disturbance: Include euphoria,
● For example, available as KENACORT, TRI- psychosis and depression.
CORT 1, 4 and 8 mg tab., 10 mg/mL, 40 mg/mL viii. Eye: Cataract and glaucoma may occur
(as acetonide) for i.m., intra-articular injec- on prolonged therapy.
tion LEDERCORT 4 mg tab. ix. Delayed wound healing.
IV. Dexamethasone x. Other effects: Raised intracranial pres-
● Very potent and highly selective glucocorti- sure, convulsions, hypercoagulability of
coid than prednisolone. It is used for inflam- the blood and menstrual disorders.
matory and allergic conditions in a dose of xi. Mineralocorticoid effects: This includes
0.5–5 mg/day oral. In shock, cerebral oe- salt and water retention, oedema, hypo-
dema, etc. 4220 mg/day i.v., i.m., injection. kalaemia and hypertension are rare with
Also used topically. selective glucocorticoids.
● For example, available as DECADRON, xii. Thinning of muscles: Steroid treatment
DEXONA 0.5 mg tab, 4 mg/mL (as sodium can cause hypokalaemia leading to
phosphate) for i.v., i.m., injection, 0.5 mL muscle weakness and fatigability. Long-
oral drops, etc. term steroid therapy leads to steroid
V. Betamethasone myopathy.
● Same as that of dexamethasone: 0.5–5 mg/ xiii. HPA axis suppression: The most unde-
day oral, 4220 mg/day i.v., i.m., injection or sirable and dangerous outcome of long-
infusion, also topical. term steroid therapy leads HPA axis
● For example, available as BETNESOL, BE- suppression.
TACORTRIL and CELESTONE 0.5 mg, 1 mg
tab and 4 mg/mL (as sodium phosphate) for Q.3. Define halitosis. What are the various causes lead-
i.v., i.m., injection, 0.5 mL oral drops, etc. ing to halitosis? Discuss any two of them in detail.
● Most of the adverse effects of glucocorticoids
Ans.
are extension pharmacological actions and
are dependent on dose, duration of therapy [Same as LE Q.1]
SHORT ESSAYS: ● Metronidazole also inhibits warfarin metabolism.

Patients undergoing anticoagulant therapy should
Q.1. Metronidazole. avoid metronidazole because it prolongs prothrom-
Ans. bin time.
● It also should be avoided in patients who are taking
● Metronidazole is a potential agent for local antimicro- lithium.
bial therapy due to its selective antimicrobial features
against the obligate anaerobes. Q.2. Oral penicillin.
● The most extensively tested and used device for metro-
Ans.
nidazole application is a gel consisting of a semisolid
suspension of 25% metronidazole benzoate in a mixture ● Antibiotic is a chemical substance produced by a micro-
of glyceryl monooleate and sesame oil (Elyzol Dental organism, which has the capacity to inhibit the growth
Gel, Dumex, Copenhagen, Denmark). Applied with a or kill other organism in dilute solution.
syringe inserted into the pocket, the gel increases in ● Penicillin is the most important and the first antibiotic to
viscosity after placement. be used, obtained from a fungus of penicillium notatum,

● Metronidazole is a nitroimidazole compound used to but the yield was very low. The present source of peni-
treat protozoal infections. It is bactericidal to anaerobic cillin is the high-yielding P. chrysogenum.
organisms. Classification
Clinical uses Natural penicillin
● Although metronidazole is not the drug of choice for ● Benzyl penicillin (penicillin G)
treating A. actinomycetemcomitans infections, it may Semisynthetic penicillin

be effective at therapeutic levels because of its hy- i. Acid-resistant penicillin
droxy metabolite. When used in combination with ● Phenoxymethyl penicillin (penicillin V)
other antibiotics metronidazole is effective against ii. Penicillinase-resistant penicillin

A. actinomycetemcomitans. ● Methicillin
● Metronidazole is also effective against anaerobes ● Oxacillin
such as Porphyromonas gingivalis and Prevotella ● Cloxacillin
intermedia. ● Dicloxacillin
● Metronidazole has been used clinically to treat gingi- iii. Extended-spectrum penicillin
vitis, acute necrotizing ulcerative gingivitis (ANUG), ● Aminopenicillins
chronic periodontitis and aggressive periodontitis. ● Ampicillin
● A single dose of metronidazole (250 mg orally) ap- ● Bacampicillin
pears in both serum and GCF in sufficient quantities ● Amoxicillin
to inhibit a wide range of suspected periodontal iv. Carboxypenicillins

pathogens. ● Carbenicillin
● Administered systemically (75021000 mg/day for ● Carbenicillin indanyl
2 weeks), metronidazole reduces the growth of an- ● Carbenicillin phenyl (carfecillin)
aerobic flora, including spirochetes, and decreases the ● Ticarcillin
clinical and histopathologic signs of periodontitis. v. Ureidopenicillins

● The most common regimen is 250 mg three times ● Piperacillin
daily (t.i.d.) for 7 days. ● Mezlocillin
Subgingival metronidazole ● Mecillinam (Amdinocillin)
● A topical medication containing an oil-based metro- vi. b-lactamase inhibitors

nidazole 25% dental gel (glyceryl monooleate and ● Clavulanic acid
sesame oil) has been tested in a number of studies. ● Sulbactam
● As a precursor, the preparation contains metronida- Therapeutic uses

zole-benzoate, which is converted into the active i. Penicillin G or benzyl penicillin is the drug of choice
substance by esterases in GCF. for infection caused by bacteria susceptible to it that
Side effects is streptococci, pneumococci, Bacillus anthracis,
● Metronidazole has an antiabuse effect when alcohol Corynebacterium diphtheriae, Clostridia, Listeria,
is ingested, resulting in severe cramps, nausea and spirochaetes and Neisseria species.
vomiting. Hence, products containing alcohol should a. Streptococcal infections:
be avoided during therapy and for at least 1 day after i. Pharyngitis, otitis media, scarlet fever, rheumatic
therapy is discontinued. fever. 0.525 MU i.v. 8 hourly for 7210 days.
ii. Subacute bacterial endocarditic caused by ● The most convenient regimen of benzathine pen-
S. viridans or faecalis. 10220 MU i.v. daily icillin is 1.2 MU every 4 weeks till 18 years of
with streptomycin 0.5 g 1M BD for 226 weeks. age or 5 years after an attack whichever is more.
b. Pneumococcal infections: ii. Gonorrhoea and syphilis:
Though not recommended but can be given if or- ● 2.4 MU single dose of procaine penicillin or
ganisms are sensitive. 3–6 MU i.v. every 6 hourly. benzathine penicillin before or within 12 h of
c. Meningococcal infections: contact provides protection for both these sexu-
Respond well to high dose of penicillin. ally transmitted diseases.
d. Gonorrhoea: iii. Bacterial endocarditis:
i. Penicillin has been taken over by fluoroquino- ● Penicillin is used before dental extraction, endos-
lones/ceftriaxones as the first-line drugs. How- copies, catheterization and other surgical proce-
ever, it can be used in NPPG infection as 4.8 dures to prevent bacteraemia in patients with
MU i.m. single dose divided and given in both valvular heart disease.
buttocks or procaine penicillin with Ig proben- iv. Agranulocytosis:
ecid orally. ● Penicillin alone or in combination with an ami-
ii. For ophthalmia neonatorum due to sensitive noglycoside.

N. gonorrhoeae. v. Surgical infection:
● Saline irrigation 1 1 drop containing ● 1 MU of procaine penicillin 1 an aminoglyco-
10,000220,000 U/mL of sodium penicillin side injected i.m. 1 h before and 8212 h after
G in each eye every 122 h for 1 week. surgery can reduce wound infection.
● In severe cases, give 50,000 U i.m. BD in
addition. Q.3. Indications and contraindications of corticosteroid

e. Syphilis: therapy in dentistry.
Penicillin G is the drug of choice for syphilis.
Ans.
i. Early and latent syphilis
1.2 MU of procaine penicillin daily for 10 days Corticosteroids are the hormones produced by the
●
(or) 2.4 MU of benzathine penicillin weekly cortex of the adrenal gland. They are
for 123 weeks. i. Glucocorticoids – cortisol
ii. Late syphilis ii. Mineralocorticoids – aldosterone
2.4 MU of benzathine penicillin weekly for iii. A small amount of androgens
4 weeks Classification of corticosteroids
or A. Short acting (8–12 h)
5 MU i.m. of sodium penicillin G 6 hourly for i. Hydrocortisone
2 weeks ii. Cortisone
f. Diphtheria: B. Intermediate acting (18–36 h)
Penicillin treatment is of adjuvant value to anti- i. Prednisolone
toxin therapy and prevents carrier state. ii. Methylprednisolone
122 MU of procaine penicillin daily for 10 days. iii. Triamcinolone
g. Tetanus and gas gangrene: C. Long acting (36–54 h)
Penicillin is used to kill the organism and has i. Paramethasone
adjuvant value to antitoxin. 6212 MU of penicil- ii. Dexamethasone
lin G daily. iii. Betamethasone
h. Actinomycosis: Indications of corticosteroids
224 MU i.v. of penicillin G 6 h for 4 weeks Lesions that usually respond well:
i. Trench mouth: i. Atopic eczema
Along with metronidazole, low doses of penicillin ii. Allergic contact
G for 7 days are effective. iii. Dermatitis
j. Penicillin G is the drug of choice for rare infec- iv. Seborrhoeic dermatitis
tions like anthrax, actinomycosis, rat bite fever v. Psoriasis of face, flexures
and those caused by Listeria monocytogenes and vi. Varicose eczema
Pasteurella multocida. Lesions requiring potent steroids, respond slowly:
Prophylactic uses i. Cystic acne
i. Rheumatic fever: ii. Alopecia areata
● Low concentration of penicillin prevents coloni- iii. Discoid LE
zation by streptococci responsible for rheumatic iv. Hypertrophied scars, keloids
fever. v. Lichen planus
vi. Nail disorders ● History of asthma.

vii. Psoriasis of palm, sole, elbow and knee ● Family history of allergy.
Contraindications of corticosteroids ● Parenteral administration of the drug.
i. Peptic ulcer ● Administration of high-risk allergens such as peni-
ii. Diabetes mellitus cillin.
iii. Hypertension ● Anaphylactic reactions may occur within seconds of
iv. Viral and fungal infections drug administration or may occur 30240 min later,
v. Tuberculosis and other infections complicating the diagnosis.
vi. Osteoporosis ● The symptoms of generalized anaphylaxis should be
vii. Herpes simplex keratitis known so that prompt treatment may be initiated.
viii. Psychosis ● The generalized anaphylactic reaction may involve
ix. Epilepsy the skin, the cardiovascular system, the intestines
x. Congestive Heart Failure (CHF) and the respiratory system.
xi. Renal failure ● The first signs often occur on the skin and are similar
to those seen in localized anaphylaxis (e.g. urticaria,
Q.4. Anaphylactic shock.
angioedema, erythema and pruritus). Pulmonary symp-
Ans. toms include dyspnoea, wheezing and asthma. GI tract
disease (e.g. vomiting, cramps and diarrhoea) often
● Anaphylactic shock after the administration of xylo-
follows skin symptoms. If these are untreated, symp-
caine is one of the uncommon systemic causes for acute
toms of hypotension appear as the result of the loss of
circulatory insufficiency.
intravascular fluid; if untreated, this leads to shock.
● But, when it occurs, it is accompanied by severe circula-
● Patients with generalized anaphylactic reactions may
tory and respiratory collapse, urticaria, laryngeal oe-
die from respiratory failure, hypotensive shock or
dema, steep fall in BP, weak pulse, bronchospasm and
laryngeal oedema.
loss of consciousness.
● The most important therapy for generalized anaphy-
Treatment of anaphylactic shock laxis is the administration of epinephrine. All clinicians
Immediate emergency treatment includes the following: who administer drugs should have a vial of aqueous
● The patient is kept in reclining position, adminis- epinephrine (at a 1:1000 dilution) and a sterile syringe
ter oxygen at high flow rate and perform cardio- easily accessible. For adults, 0.5 mL of epinephrine
pulmonary resuscitation if required. should be administered intramuscularly or subcutane-
● Resuscitation methods like cardiac massage, ously; smaller doses of from 0.1 to 0.3 mL should be
mouth to mouth breathing, if necessary. Without used for children, depending on their size. If the aller-
any delay, immediate medical consultation and gen was administered in an extremity, a tourniquet
hospitalization must be arranged to save the life of should be placed above the injection site to minimize
the patient. further absorption into the blood. The absorption can
● Inject adrenaline 0.320.5 mg (0.320.5 mL of 1 be further reduced by injecting 0.3 mL of epinephrine
in 1000 solution) i.m. and repeat every 5210 min (1:1000) directly into the injection site. The tourniquet
if patient does not improve. It is the only life- should be removed every 10 min.
saving measure. ● Epinephrine will usually reverse all severe signs of
● Maintenance of ventilation with oxygen under generalized anaphylaxis. If improvement is not ob-
pressure. If severe bronchospasm develops, served in 10 min, readminister epinephrine.
2502500 mg of aminophylline intravenously. ● If the patient continues to deteriorate, several
● Administer (H1 antihistaminic) diphenhydramine steps can be taken, depending on whether the pa-
502100 mg i.m. or slow i.v. inject hydrocortisone tient is experiencing bronchospasm or oedema.
sodium succinate 1002200 mg i.v. For bronchospasm, slowly inject 250 mg of ami-
Generalized anaphylaxis nophylline intravenously, over a period of 10 min.
● Generalized anaphylaxis is an allergic emergency. Too rapid an administration can lead to fatal car-
● The mechanism of generalized anaphylaxis is the diac arrhythmias.
reaction of IgE antibodies to an allergen that causes ● Do not give aminophylline if hypotensive shock is a
the release of histamine, bradykinin and SRS-A. part of the clinical picture.
These chemical mediators cause the contraction of ● Inhalation sympathomimetics may also be used to
smooth muscles of the respiratory and intestinal treat bronchospasm, and oxygen should be given to
tracts, as well as increased vascular permeability. prevent or manage hypoxia.
The following factors increase the patient’s risk for ana- ● For the patient’s with laryngeal oedema, establish an
phylaxis: airway. This may necessitate endotracheal intubation;
● History of allergy to other drugs or food. in some cases, a cricothyroidotomy may be necessary.
Q.5. Serum sickness. ii. Triazoles (systemic) – Fluconazole and itra-

conazole
Ans.
D. Allylamine
● Serum sickness is named for its frequent occurrence ● Terbinafine
after the administration of foreign serum, which was E. Other topical agents
given for the treatment of infectious diseases before the ● Tolnaftate, undecylenic acid, benzoic acid,
advent of antibiotics. salicylic acid, selenium sulphide, ciclopirox

● The reaction is presently less common but still occurs as olamine and sodium thiosulphate
a result of the susceptible patient’s being given tetanus Uses
antitoxin, rabies antiserum or drugs that combine with ● Broad-spectrum antifungal drugs are used against
body proteins to form allergens. a large variety of fungi and yeasts like Candida
● Penicillin, a drug commonly prescribed by dentists, oc- albicans, Histoplasma capsulatum, Cryptococcus
casionally causes serum sickness. The pathogenesis of neoformans, Blastomyces dermatitidis, Coccidi-
serum sickness differs from that of anaphylaxis. oides immitis, Torulopsis, Rhodotorula, Aspergil-
● Antibodies form immunocomplexes in blood vessels lus, Sporothrix, Deep mycoses, Epidermophyton,
with administered antigens. The complexes fix comple- Trichophyton and Microsporum.
ment, which attracts leukocytes to the area, causing di-
rect tissue injury. Q.10. Broad-spectrum antibiotics – side effects.
● Serum sickness and vasculitis usually begin 7210 days
after the administration of the allergen, but this period

Ans.
can vary from 3 days to as long as 1 month. Unlike other
allergic diseases, serum sickness may occur during the Classification of antibiotics
initial administration of the drug. Antibiotics are classified in the following way ac-
● Major symptoms consist of fever, swelling, lymphade- cording to type of action:
nopathy, joint and muscle pains and rash. Less common i. Bacteriostatic:
manifestations include peripheral neuritis, kidney dis- For example, tetracyclines, sulphonamides,
ease and myocardial ischaemia. erythromycin, etc.
● Serum sickness is usually self-limiting, with spontane- ii. Bactericidal:
ous recovery in 123 weeks. For example, penicillin, cephalosporins, etc.
● Treatment is symptomatic. Aspirin is given for arthral- ● The broad-spectrum antibiotics are tetracy-
gia and antihistamines are given for the skin rash. clines and chloramphenicol. They are so
● Severe cases should be treated with a short course of termed as they are used against number of
systemic corticosteroids, which significantly shortens Gram-negative and Gram-positive infections.
the course of the disease. Although this reaction is rare, Adverse effects of broad-spectrum antibiotics
the dentist who is prescribing penicillin should be aware A. Irritative effects
of the possibility of serum sickness occurring weeks ● Epigastric pain, nausea, vomiting and diarrhoea.
after use of the drug. ● Pain at intramuscular (i.m.) injected site, throm-
bophlebitis of injected vein on repeated use.

Q.6. Antifungal drugs in oral medicine. B. Dose-related toxicity
i. Liver damage – Fatty infiltration of liver and
Ans.
jaundice.
● Fungal infections may be systemic or superficial. An- ii. Kidney damage – Prominent only in presence of
tifungal drugs are used in the treatment of fungal existing kidney disease.
infections. iii. Phototoxicity – Sunburn like or other severe skin
Classification of antifungal drugs reactions on exposed body parts especially with
A. Antifungal antibiotics demeclocyclines and doxycyclines.
i. Polyenes: Amphotericin-B, Nystatin, Hamy- iv. Teeth and bones – Tetracyclines have chelating
cin and Natamycin (Pimaricin) property and calcium tetracycline chelate get
ii. Heterocyclic benzofuran: Griseofulvin deposited in developing bone and teeth. Brown
B. Antimetabolites discolouration of ill-formed teeth.
● Flucytosine (5-FC) v. Antianabolic effect – Reduced protein synthesis
C. Azoles and overall catabolic effect.
i. Imidazoles (topical) – Ketoconazole, micon- vi. Increased intracranial pressure – Noted in some
azole, clotrimazole and econazole infants.
vii. Diabetes insipidus – Demeclocyclines antago- General features of Ascher syndrome

nizes Antidiuretic harmone (ADH) action and ● Blepharochalasis that is dropping of the tissue be-
reduces urine concentrating ability of kidney. tween the eyebrow and the edge of upper eyelid so
viii. Vestibular toxicity – Minocyclines produce that it hangs loosely over the margin of the lid
ataxia, vertigo and nystagmus which subsides on ● Nontoxic thyroid enlargement
discontinuation of drug. Oral manifestations

ix. Hypersensitivity reactions – Skin rashes, urti- ● Double lip.
caria, glossitis, pruritus and even exfoliative der-

Q.4. Albright syndrome.
matitis occurs but not common.
x. Superinfections – Tetracyclines are most com- Ans.
mon antibiotics responsible for superinfections
● Albright syndrome is also called as ‘McCune–Albright
by causing marked suppression of the resident
syndrome’.
flora.
● It includes:
xi. Adverse effects especially associated with chlor-
● Polyostotic fibrous dysplasia involving nearly all
amphenicol are bone marrow depression, agranu-
bones of the skeleton
locytosis, grey baby syndrome, aplastic anaemia
● Pigmented lesions of skin (café-au-lait spots)
and hypersensitivity reactions.
● Precocious sexual development
Q.11. How will you manage a case of anaphylactic shock ● Hyperfunction of one or more endocrine glands
due to local anaesthesia?
Q.5. Papillon–Lefevre syndrome.
Ans.
Ans.
[Same as SE Q.4]
General features of Papillon–Lefevre syndrome
Q.12. Anaphylaxis. ● Keratotic lesion of palmar plantar surface; general-
Ans. ized hyperhydrosis; very fine body hairs, calcifica-

tion of falx cerebri or dura, contralateral Jacksonian
[Same as SE Q.4] epilepsy, mental retardation, ocular and aural
changes
SHORT NOTES: Oral manifestation
● Severe destruction of alveolar bone involving both
Q.1. Lipschutz bodies. the dentitions; leading to premature exfoliation of
Ans. teeth; inflammatory gingival enlargement, gingival
ulceration and formation of deep pockets; hemifacial
● The herpetic vesicle is an intraepithelial blister filled atrophy and trigeminal neuralgia
with fluid. The infected cells are swollen and have pale
eosinophilic cytoplasm and large vesicular nuclei, de- Q.6. Eagle syndrome.
scribed as ballooning degeneration, whereas others Ans.
characteristically contain intranuclear inclusions known
as Lipschutz bodies. Eagle syndrome is characterized by:
● Lipschutz bodies are eosinophilic, ovoid, homogenous ● Elongation of styloid process or ossification of the
structures within the nucleus, which tend to displace the stylohyoid ligament causing dysphasia, sore throat,
nucleus and nuclear chromatin peripherally. otalgia, glossodynia, headache and vague orofacial
● The displacement of chromatin often produces a peri- pain
inclusion halo. ● Pain along the distribution of the internal and exter-
nal carotid arteries

Q.2. Melkersson–Rosenthal syndrome. ● Pharyngeal pain
Ans. ● Calcification of sternocleidomastoid muscle, etc
Melkersson–Rosenthal syndrome is a triad of: Q.7. Ramsay Hunt syndrome.

● Cheilitis granulomatosa.
Ans.
● Facial paralysis.
● Fissured tongue. ● Ramsay Hunt syndrome is a zoster infection of genicu-

late ganglion with involvement of external ear and oral
Q.3. Ascher syndrome.
mucosa, Bell palsy and unilateral vesicles of the exter-
Ans. nal ear and vesicles of the oral mucosa.
Q.8. Ethics in dental profession ● Antiviral drugs interfere with the steps of viral repro-
duction cycle with in host cell.
Ans.
Classification of antiviral agents
● Ethics is defined as the part of philosophy that deals
i. Drugs used against herpetic infection (antiherpes
with moral conduct and judgement.
agents) – Acyclovir, valacyclovir, ganciclovir, idoxu-
Major principles are:
ridine, vidarabine and foscarnet
i. Do no harm (nonmaleficence).
ii. Drugs used against HIV infection (antiretroviral
ii. Do good (beneficence).
agents):
iii. Autonomy.
a. Nucleoside reverse transcriptase inhibitors – Zid-
iv. Justice.
ovudine, didanosine, zalcitabine, stavudine and
v. Truthfulness.
lamivudine
vi. Confidentiality.
b. Nonnucleoside reverse transcriptase inhibitors –
Q.9. Fixed drug eruption. Nevirapine, delaviridine and efavirenz
c. Protease inhibitors – Saquinovir indinavir, ritona-
Ans.
vir and lopinavir
● Intraoral fixed drug eruptions may occur in patients who d. Fusion inhibitor – Enfuvirtide
are administered on repeated occasions a drug to which e. Anti-influenza virus agents – Amantadine, riman-
they are sensitive. tadine and oseltamivir
● This fixed eruption is characterized in the appearance of l Other antiviral agents – Ribavirin and interferons
a skin reaction at the same sites each time and is appar-

Q.13. Classify nonsteroidal anti-inflammatory drugs?
ently due to local sensitization of the tissues.
● Drugs commonly implicated in such allergic reactions Ans.
include barbiturates, salicylates, phenazone derivatives,
● Analgesics are the drugs that are prescribed to relieve
sulphonamides and tetracycline.
patient from pain. Analgesics are basically two types:
● The oral lesions appear as localized areas of erythema
i. Narcotic analgesics (opioids)
and oedema, commonly seen on the labial mucosa and
ii. Nonsteroidal anti-inflammatory drugs (NSAIDs;
can later develop into vesiculoulcerative lesions.
nonopioids)
Q.10. Halitosis – physiologic causes. Classification of NSAIDs
Nonselective COX inhibitors:
Ans.
i. Aspirin
[Ref LE Q.1] ii. Piroxicam
iii. Ketorolac
Q.11. Diazepam.
iv. Ibuprofen
Ans. v. Diclofenac
vi. Indomethacin
● Diazepam is a popular anticonvulsant drug. It is rela-
vii. Phenylbutazone
tively safe if given intramuscularly or intravenously for
viii. Mephenamic acid
conscious or deep sedation.
Preferential COX inhibitors
● Of the many available agents, it is found that diazepam
i. Nimesulide
with or without nitrous oxide and xylocaine meet the
Selective COX inhibitors
requirements for a safe, effective, versatile technique of
ii. Rofecoxib
conscious sedation.
Analgesics – Antipyretics with poor anti-inflammatory
● Diazepam when given orally is one of the readily ac-
action
ceptable tranquillizing drugs.
i. Nefopam
● It provides muscle relaxation and a degree of amnesia.
ii. Metamizol
● Minimum dosage: for normal adults, 10 mg; for children
iii. Paracetamol
5–7.5 mg depending on the age group.
● Rapid injection of diazepam may cause apnoea and fall Q.14. Jarisch–Herxheimer reaction.
in BP.
Ans.
Q.12. Classify antiviral drugs.
● Jarisch2Herxheimer reaction is an acute exacerbation
Ans.
of signs and symptoms of syphilis during penicillin
● Viruses are intracellular parasites and depend on host therapy.
cells for food, growth and multiplication. ● It is due to release of endotoxins from the dead organisms.
● The manifestations are fever, chills, myalgia, hypoten- followed by the analysis of life-sized or enlarged photo-
sion, circulatory collapse, etc. graphs.
● It is treated with aspirin and corticosteroids. ● A separate qualitative and quantitative analysis of the
models and occlusal registrations of the suspect’s denti-

Q.15. Lip prints.
tion can be performed at this stage.
Ans. ● Rather than relying on the number of teeth depicted in
the mark, analyse uncommon characteristics such as

● The study of lip print is called cheiloscopy. It is impor-
presence or absence of a particular tooth, mesiodistal
tant in crime investigation.
dimension of the teeth and dental arch, rotation, fracture
● According to Ehara and Marumo (1998), lipstick smears
and diastema.
are frequently encountered in forensic investigations as
● According to Sweet (1995), the protocol for bite mark
an important form of transfer evidence.
comparison is made up of two broad categories:
● Snyder (1950) is believed to have first pointed out that
i. Metric analysis
the lines and fissures on the lips have individual varia-
ii. Pattern association
tions like fingerprints.
● These researchers and a few others studied lip prints Q.17. Battered baby syndrome.
using similar classification, a composite of which are:
i. Vertical grooves Ans.
ii. Branched grooves
● Battered child syndrome refers to injuries sustained by
iii. Bifurcated grooves
a child as a result of physical abuse, usually inflicted by
iv. Intersected grooves
an adult caregiver.
v. Reticular grooves
● It is also known as shaken baby syndrome, child abuse
vi. Other grooves (comma, ellipse, triangle, horizontal,
and nonaccidental trauma (NAT).
etc.)
● Internal injuries, cuts, burns, bruises and broken or frac-
Q.16. Bite marks. tured bones are all possible signs of battered child syn-
drome.
Ans.
● Emotional damage to a child is also often the byproduct
Analysing and comparing bite mark evidence: of child abuse, which can result in serious behavioural
● Ideally, bite mark analysis should begin with a qualita- problems such as substance abuse or the physical abuse
tive and quantitative analysis in situ. This should be of others.
Section I

of Previous Years
PART II: ORAL RADIOLOGY

Topic 1 Radiation Physics 429
Topic 2 Radiation Biology, Hazards of Radiation
and Radiation Protection 441
Topic 3 X-Ray Films and Accessories 455
Topic 4 Processing of X-Ray Films 463
Topic 5 Image Principles: X-Rays Quality Control 472
Topic 6 Intraoral Radiographic Techniques 483
Topic 7 Extraoral Radiographic Techniques 492
Topic 8 Specialized Imaging Techniques 507
Topic 9 Radiographic Interpretations 516
Section I

of Previous Years
Part II
Oral Radiology
Topic 1
Radiation Physics
LONG ESSAYS:
1. With a neatly labelled diagram explain the principle, construction and working of an X-ray tube, with the
significance of each component.
2. Define ideal radiograph and discuss the factors affecting the X-ray beam.
3. Describe the parts of an X-ray tube and add a note on the properties of X-rays.
4. What are the parts of an X-ray tube? Describe the working of an X-ray tube and add a note on Bremsstrahlung
radiation. [Same as LE Q.1]
5. Describe the construction and working of the X-ray tube. Also describe the production of X-rays. [Same as LE Q.1]
6. Describe with a neat and labelled diagram on the production of X-rays. [Same as LE Q.1]
7. Describe in detail the factors controlling X-ray beam. [Same as LE Q.2]
8. Write an essay on the properties of X-rays. [Same as LE Q.3]
SHORT ESSAYS:
1 . Production of X-rays. [Ref LE Q.1]
2. Electromagnetic spectrum.
3. What are the properties of X-rays? [Ref LE Q.3]
4. Collimation and filtration. [Ref LE Q.2]
5. Ideal requirements of target material.
429
6 . Role of grid in diagnostic radiography.

7. Bremsstrahlung radiation. [Same as SE Q.1]
8. Name any four properties of X-rays. [Same as SE Q.3]
9. Types and uses of filtration. [Same as SE Q.4]
SHORT NOTES:
1. Basic principles of shadow casting.
2. Heel effect.
3. Position indicating device (PID).
4. Inverse square law. [Ref LE Q.2]
5. Filtration. [Ref LE Q.2]
6. Electromagnetic spectrum. [Ref SE Q.2]
7. Collimation. [Ref LE Q.2]
8. Anode in X-ray machine. [Ref LE Q.3]
9. Resolution.
10. Why is tungsten used as a target material in an X-ray tube?
11. Define frequency.
12. What represents the particulate radiations?
13. Compton effect.
14. What is line focus principle?
15. Gray.
16. Ionization.
17. Kilovoltage peak (kVp). [Ref LE Q.2]
18. Radiology and roentgenology.
19. Explain generation of X-rays.
20. Characteristic radiation.
21. Definition of roentgen.
22. Coolidge tube.
23. X-ray timer.
24. Uses of X-rays.
25. Factors controlling X-ray beam.
26. Filtration of X-ray beam. [Same as SN Q.5]
27. Collimation of X-ray beam. [Same as SN Q.7]
28. Tungsten application in an X-ray machine. [Same as SN Q.10]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. With a neatly labelled diagram explain the princi- ● The component parts of the X-ray tube are
ple, construction and working of an X-ray tube, with the i. Leaded-glass housing
significance of each component. ii. Negatively charged cathode
iii. Positively charged anode
Ans.
Leaded-glass housing
Principle ● The leaded-glass housing is a leaded-glass vac-
The fundamental principle of X-ray production is that uum tube that prevents escape of X-rays in all
X-rays are produced by the sudden deceleration or directions.
stoppage of rapidly moving stream of electrons at a ● One central area of the leaded-glass tube has a
positively charged metal target in a high vacuum tube. ‘window’ that permits the X-ray beam to exit
Construction of X-ray tube the tube and directs it towards the aluminium
● The X-ray tube is like the heart of the X-ray generating discs, lead collimator and PID. It is also used for
system and is critical to the production of X-rays. earthing.
Negatively charged cathode ● Step-up transformer: It increases voltage from the

● The cathode, or negative electrode, consists of two incoming 110–220 line voltage to 65,000–100,000 V
components: as required by a high-voltage circuit.
a. Filament: Filament is a coiled wire made of tung- ● Autotransformer: It serves as a voltage compen-
sten, which produces electrons when heated. sator that corrects the minor fluctuations in the
b. Focusing cup: It is a cup-shaped holder made of current.
molybdenum and houses the filament. It focuses Timer
the electrons into a narrow beam and directs the A timer completes the circuit with the high-voltage
beam across the tube towards the tungsten target transformer and helps to control the time for which high
of the anode. voltage is applied to the tube.
● The purpose of the cathode is to supply the electrons Tube rating
necessary to generate X-rays. In the X-ray tube, the The maximum safe intervals (seconds) the tube
electrons produced in the negative cathode are acceler- may be energized at a given range of voltage (kVp)
ated towards the positive anode. and the tube current (mA) values is known as tube
Positively charged anode rating.
● Anodes are of two types: Duty cycle
a. Stationary/fixed Duty cycle is related to the frequency with which suc-
b. Rotating cessive exposures can be made.
The rotating anode helps to dissipate heat and is Working of X-ray tube and production of X-rays
mainly used in extraoral or cephalometric ma- A series of steps involved in the production of X-rays
chines. are as follows:
● The purpose of the anode is to convert electrons into ● When the X-ray machine is turned on, the electric
X-ray photons and it consists of: current enters the control panel from the wall out-
a. Tungsten target let and travels to the tube head through the electri-
i. It is a wafer thin tungsten plate embedded in cal wires in the extension arm.
a copper stem. It serves as a focal spot and ● In the tube head, the current is directed to the fila-
converts bombarding electrons into X-ray ment circuit and the step-down transformer, which
photons. reduces the 110 or 220 entering-line voltage to
ii. The target is inclined at an angle of 20° to the 3–5 volts.
central ray of electron to cause effective focal ● The filament circuit uses the 3–5 volts to heat
spot to be smaller in size (1 3 1 mm) in con- the tungsten filament in the cathode portion of the
trast to actual focal size (1 3 3 mm). This is X-ray tube.
known as ‘Line-Focus Principle’. a. When the tungsten filament in the cathode is
Sharpness of image increases by reducing the heated to incandescence or red hot, thermionic
effective focal spot size. emission occurs.
b. Copper stem: The copper stem dissipates the heat b. Thermionic emission is defined as the re-
away from the tungsten target through conduc- lease of electrons from the tungsten filament
tion. when the electrical current passes through it
Circuits used in the production of X-rays and heats the filament. The outer-shell elec-
● Filament circuit: Low voltage (3–5 V) trons of the tungsten atom acquire enough
a. Controlled by mA setting in control panel. energy to move away from the filament sur-
● Regulates flow of current to filament. face, and an electron cloud forms around the
● High-voltage circuit: Uses 65,000–100,000 V. filament.
a. Controlled by kVp setting in control panel. a. The electrons stay in an electron cloud until
b. Accelerates electrons. the high-voltage circuit is activated.
Transformers ● The high-voltage circuit is activated when the
Transformer is a device used to control voltage in the exposure button is pushed. The electrons pro-
electrical circuit. Various transformers used in the produced at the cathode are accelerated across the
duction of X-rays are as follows: X-ray tube to the anode. The molybdenum cup in
● Step-down transformer: It has more turns in pri- the cathode directs the electrons to the tungsten
mary coil and reduces voltage from the incoming target in the anode.
110–220 line voltage to 3–4 V as required for fila- ● The electrons travel from the cathode towards the
ment circuit. anode. When the electrons strike the tungsten target,
their kinetic energy is converted to X-ray energy It is defined as X-ray radiation produced when high-
●
and heat. speed electrons are suddenly stopped at the target. This
a. Less than 1% of energy of electrons is con- process of rapidly decelerating the high-speed electron
verted to X-rays at anode and other 99% is lost gives rise to Bremsstrahlung or braking radiation.
as heat. ● Bremsstrahlung radiation is produced by either:
b. The heat build-up at the anode is calculated as: a. The electron directly hitting the nucleus of an
Heat unit (HU) 5 kVp 3 mA 3 s (watts) atom of the target material or
● The heat produced during the production of b. Passage of the electron by the side or near the
X-rays is carried away from the copper stem nucleus due to which the electron will be de-
and absorbed by the insulating oil in the tube flected or decelerated.
head. i. Electron directly hitting the nucleus. When the
● The X-rays produced are emitted from the target electron directly hits the nucleus of the tung-
in all directions. The leaded-glass housing pre- sten atom in target material, the entire kinetic
vents the X-rays from escaping from the X-ray energy of it is transformed into a single X-ray
tube. A small number of X-rays are able to exit photon.
from the X-ray tube through the unleaded glass ii. Numerically the energy of the resultant photon
window portion of the tube. is equal to the energy of the electron, which
● The X-rays travel through the unleaded glass win- is in turn equal to the kVp applied across the
dow, the tubehead seal and the aluminium discs. X-ray tube.
The aluminium discs remove or filter the longer a. When the electron comes closer to the nucleus
wavelength X-rays from the beam. i. If the electron misses the hitting of nucleus and
● The size of the X-ray beam is restricted by passes by the side of it, then the negatively
the lead collimator. The X-ray beam then travels charged high-speed electron is attracted to-
down the lead-lined PID and exits the tube wards the positively charged nucleus and de-
head. celerates thereby losing some kinetic energy,
● The exposure time is the duration of time when which is converted into X-ray photon.
X-rays are produced; it is about 0.8–0.9 s. ii. The electron that misses the nucleus continues
● The X-ray tube does not emit a continuous to penetrate many such tungsten atoms before
stream of radiation, but a series of impulses of it imparts all its kinetic energy thus producing
radiation. The number of impulses depends on many low-energy X-ray photons. As a result
the number of cycles per second in the electric Bremsstrahlung radiation consists of X-rays of
current used. In a 60-s-cycle alternating cur- many different energies and wavelengths and
rent, there are 60 pulses of X-rays per second. hence it is also called continuous spectrum.
Each impulse lasts only l/120 s as no X-rays Characteristic radiation
are emitted in the negative half of the cycle ● When a high-speed electron dislodges the inner shell
when the polarity of the tube is reversed. A electron from the tungsten atom, it results in ioniza-
full-wave rectified X-ray machine produces tion of the atom. Once the electron is dislodged, the
120 bursts of X-ray photons per second. remaining orbiting electrons rearrange to fill the
vacancy; this produces a loss of energy that results in
X-ray photon, with energy equal to the difference
[SE Q.1]
in the two orbital energy states. The X-ray thus
{Production of X-rays is achieved by following two produced is called characteristic radiation.
processes that are described as follows: ● The radiation emitted constitutes the ‘Line Spectrum’.}
1. Bremsstrahlung radiation
2. Characteristic radiation Q.2. Define ideal radiograph and discuss the factors
The Bremsstrahlung radiation accounts for most of the affecting the X-ray beam.
X-rays produced in dental machines, while characteris- Ans.
tic radiation accounts for a very small part of X-rays
produced. According to HM Worth word’s, ‘An ideal radiograph is
Bremsstrahlung radiation one that has desired density and overall blackness and
● Bremsstrahlung is a German word for braking which shows the part completely without distortion with
radiation. It is also called general radiation, white maximum details and has the right amount of contrast to
radiation or Brems radiation or breaking radiation. make the details fully apparent’.
Factors controlling the X-ray beam Exposure time

The quality and quantity of the X-rays are controlled by ● Keeping mA and kVp constant, when the exposure
various factors as described below: time is doubled, the number of X-ray photons gener-
1. Tube current ated also doubles.
2. Tube voltage ● The changes in the exposure time influence the quan-
3. Exposure time tity of X-rays produced.

4. Filtration ● The effect of increasing or decreasing exposure time
5. Collimation will control the quantity of X-ray photons.

6. Inverse square law ● To compensate for the increased penetrating power
7. Quality of the X-ray beam of X-ray beam, when kVp is increased, an adjust-
8. Quantity of the X-ray beam ment in exposure time is necessary.
9. Half-value layer (HVL)
[SE Q.4]
Tube current {Filtration
● The number of X-ray photons generated is deter- An X-ray beam is composed of a spectrum of X-ray
●
mined by the tube current (mA). photons with different wavelengths and penetrating
● As the mA is increased, more number of electrons powers. Only those photons with sufficient energy
are generated at the cathode, which strikes the target and definite penetrating power contribute to image
to produce more number of X-ray photons. formation, whereas X-ray photons with less penetrat-
● The number of X-rays produced depends directly on ing power will be absorbed by the soft tissues and
the number of electrons that strikes the target. The cause unnecessary radiation exposure to the patient.}
number of electrons is directly proportional to the
tube current. (SE Q.4 and SN Q.5)
● Practically, the quantity of X-ray photons generated
depends on both the mA and the duration of time the ● {(Filtration is the process of removing X-ray pho-
X-ray machine is operated. tons of less penetrating power by placing a filter in
a. The quantity of radiation produced by an X-ray the path of the primary beam, which allows only X-
tube is directly related to the tube current and the ray photons with sufficient energy to pass through.
time the tube is operated. ● A filter is a device made up of an aluminium disc
b. There is a linear relationship between mA and placed in the path of the primary X-ray beam to ab-
tube output. Doubling the tube current should sorb X-ray photons of less penetrating power.
double the number of photons produced at each ● Filtration is of three types:
energy value. Inherent filtration:
Tube voltage a. Inherent filtration is produced by materials which
the X-ray beam encounters as it leaves from the
target, e.g. the glass wall of the X-ray tube, insu-
{SN Q.17} lating oil present around the tube and the barrier
● Voltage is a measurement of force that refers to the material, which prevents the oil from leaking out.
potential difference between two electric charges. In The inherent filtration usually provides 0.5–2.0
simple terms, voltage is a measurement of electrical mm aluminium equivalent of filtration.
force that causes electrons to move from negative b. Added filtration: Added filtration refers to any
cathode to positive anode. additional aluminium disc placed in the path of
● Tube voltage controls the energy of electrons. As the the primary beam.
kVp is increased, the energy of each electron striking c. Total filtration: Total filtration means the sum
the target increases resulting in increase in the of inherent and added filtration. The total filtra-
number of X-ray photons generated. tion should be equivalent to 1.5 mm of alu-
● As kVp increases, there is an increase in minium up to 70 kVp and 2.5 mm of alumin-
a. The number of photons generated ium above 70 kVp.)}
b. The mean energy of the photons
c. The maximum energy of the photons ● With the use of filters, the contrast and quality of film is
● As the kVp increases, the contrast of the resultant increased, while the density is affected; therefore, when
radiographic image decreases. filtration is increased, a slight increase in exposure time
is required.
(SN Q.7 and SE Q.4) have less penetrating power and get absorbed by the
patient’s soft tissues.
● The quality of an X-ray beam is governed by the
{(Collimation
● Collimation is the process of restricting the size of kVp. When the kVp increases, it results in X-ray
the X-ray beam and thus the volume of the irradi- photons with high energy and better penetrating
ated tissue of the patient from which the scattered power.
photons originate. Quantity of the X-ray beam
● Quantity of the X-ray beam refers to the number of
● Collimator is a device that is used to shape or re-
strict the size of the X-ray beam striking the pa- X-ray photons produced.
● The amperage determines the electrons passing
tient’s tissues.
● The collimator is made up of a material, which is
through the filament. When mA is increased, more
capable of absorbing the radiation, e.g. lead. number of electrons are released in the cathode
● Various collimators used in dental radiography
and they strike the target to produce more number of
are the diaphragm, tubular and rectangular colli- X-ray photons.
● The quantity depends on the product of mA and ex-
mators. Among them, the rectangular collimators
help in defining the X-ray beam to a size slightly posure time in seconds (mAs).
larger than the size of the film. HVL
● HVL refers to the thickness of a specified material
Uses of collimation
● It decreases the size of the X-ray beam and the
such as aluminium required to reduce the intensity of
amount of scattered photons. an X-ray beam by one-half. Usually 2.0 mm filter is
● It decreases the volume of the irradiated tis-
required in dentistry.
● Quality of X-ray beam can be determined by deter-
sues, thereby decreasing the radiation exposure
to the patient. mining its HVL. HVL is the useful way to designate
● It minimizes the film fog and enhances the im-
the penetrating power of X-ray beam.
● HVL is the thickness of an absorber, usually alu-
age quality.)}
minium, required to reduce the number of X-ray
photons passing through it by one-half.
● Contrast and the quality of film are increased with
{SN Q.4}
the use of filters, while density is affected because
Inverse square law increased filtration may result in absorption of some
● Inverse square law states that the intensity of an of the useful penetrating X-rays.
X-ray beam at a given point is inversely propor- ● When filtration is increased, a slight increase in
tional to the square of the distance from the exposure time is required.
source of radiation.
● The mathematical formula used to calculate
Q.3. Describe the parts of an X-ray tube and add a note
inverse square law is given by on the properties of X-rays.
Ans.
Original intensity (I1 ) New distance 2 (D 2 ) 2

New intensity (I 2 ) Original distance 2 (D1 ) 2 The parts of the X-ray tube are
1. Leaded-glass housing
● The reason for this decrease in intensity of the 2. Negatively charged cathode
X-ray beam is due to the divergent nature of the 3. Positively charged anode
X-rays. If the distance from the source to the ob- Leaded-glass housing
ject is increased, the intensity of the X-ray beam ● The leaded-glass housing is a leaded-glass vacuum
decreases, thereby changing the image quality. tube that prevents escape of X-rays in all directions.
For example, if the distance from the source to the ● One central area of the leaded-glass tube has a ‘win-
film is doubled, say from 8 inches to 16 inches, it dow’ that permits the X-ray beam to exit the tube and
results in a beam that is one-fourth as intense. directs the X-ray beam towards the aluminium discs,
lead collimator and PID.
Quality of the X-ray beam Cathode
● The quality of the X-ray beam refers to its mean en- ● The cathode or negative electrode consists of two
ergy or penetrating ability. components:
● X-rays with shorter wavelengths have more penetrat- a. Filament: The filament is a coiled wire made of
ing power, whereas those with longer wavelengths tungsten, which produces electrons when heated.
b. Focusing cup: It is a cup-shaped holder made of ● X-rays affect photographic plate in the similar
molybdenum and houses the filament. It focuses manner as light. They can produce image on
the electrons into a narrow beam and directs the a photographic film.
beam across the tube towards the tungsten target ● X-rays can cause biological changes in living
of the anode. cells. The cells can either be damaged or killed

Anode due to X-ray exposure.
● Electrical and magnetic fields fluctuate perpen-
{SN Q.8} dicular to direction of X-rays and at right angles

to each other.
● Anodes are of two types: ● X-rays have selective attenuation.
a. Stationary/fixed and rotating anode. ● They produce different types of scattered and
b. Rotating anode helps to dissipate heat and is mainly secondary radiations. It is undesirable both for
used in extraoral or cephalometric machines. operator and the patient.
● The purpose of the anode is to convert electrons in to ● They cause the air through which they pass to
X-ray photons and consists of: become electrically conductive.}
a. Tungsten target: It is a wafer-thin tungsten plate ● They are not deviated by the influence of electric
embedded in a copper stem that serves as a focal or magnetic field.
spot and converts bombarding electrons into
X-ray photons. Q.4. What are the parts of an X-ray tube? Describe the
b. Copper stem: The copper stem dissipates the heat working of an X-ray tube and add a note on Brems-
away from the tungsten target through conduction. strahlung radiation.
Ans.
Properties of X-rays are as follows: [Same as LE Q.1]
[SE Q.3] Q.5. Describe the construction and working of the X-ray
tube. Also describe the production of X-rays.
● {X-rays are wave packets of energy of electro-
magnetic radiation that originate at the atomic Ans.
level. Each wave packet is equivalent to a quan-
[Same as LE Q.1]
tum of energy and is called a photon.
● X-rays are invisible and carry no charge and mass. Q.6. Describe with a neat and labelled diagram on the
● X-rays exhibit dualistic behaviour, i.e. wave and production of X-rays.
particle. They are electromagnetic waves.
● X-rays travel in straight line as waves and at the Ans.
same speed as that of light in free space. [Same as LE Q.1]
● No medium is required for its propagation.
● X-rays have penetrating power. Q.7. Describe in detail the factors controlling X-ray
● Wavelength of X-rays is 0.1–0.5 Angstrom. X-rays beam.
of shorter wavelength possess greater energy and Ans.
can therefore penetrate to a greater distance.
● X-rays have high frequency. Their frequency [Same as LE Q.2]
ranges from 2 3 1016 s–1 to 3 3 1019 s–1.
Q.8. Write an essay on the properties of X-rays.
● Intensity of X-ray beam obeys inverse square law.
● X-rays cannot be focused to a point as they di- Ans.
verge from the source.
● X-rays are absorbed by matter. [Same as LE Q.13]
● X-rays cause ionization of matter which they
penetrate. SHORT ESSAYS:
● X-rays cause certain substance to fluoresce or
emit radiation in longer wavelength. Q.1. Production of X-rays.
● X-rays produce phosphorescence, i.e. delayed Ans.
emission of light after exposure to radiation in
various inorganic salts. [Ref LE Q.1]
Q.2. Electromagnetic spectrum. straight line carrying ‘energy’ or ‘electromagnetic

radiation’.
Ans.
Q.3. What are the properties of X-rays?
{SN Q.6} Ans.
● When the electromagnetic radiations are grouped [Ref LE Q.3]
according to their energies, it is called as electromag- Q.4. Collimation and filtration.
netic spectrum. Electromagnetic radiations are either
man-made or natural. Ans.
● The electromagnetic spectrum actually goes far
[Ref LE Q.2]
below infrared and far above ultraviolet radiation.
● These radiations are cosmic rays, gamma rays, Q.5. Ideal requirements of target material.
X-rays, ultraviolet rays, visible light, infrared light, Ans.
radar waves and microwaves.
Properties of electromagnetic radiation Properties or ideal requisites of target metal
● They travel through space in a wave-like motion ● The target material should have higher atomic num-
along a straight line. ber. Higher the atomic number, denser is the metal.
● They do not carry mass, weight or electrical Sufficiently dense metal is required to stop the high-
charge. speed electrons.
● They travel at a speed of light, in a vacuum, i.e. ● It should have low vapour pressure at high tempera-
186,000/s. ture. Since electron beam is directed to a very small

● As they travel through space, they give off an area, some of the atoms may reach the vapour state,
electric field at right angle to the path of propaga- so water droplets may be found.
tion and a magnetic field at right angles to both. ● It should have high melting point. Since most of the
● They transfer energy from place to place in quanta energy is converted into heat, the melting point of the
(photons). target metal must be high, e.g. tungsten has MP of
● All electromagnetic radiations have measurable 3370°C, which is quite higher than others.
but different temperature, energy, frequency and ● It should have a high degree of thermal conductivity,
wave length. since most of the heat generated is passed to the ra-
● All electromagnetic radiations are invisible to the diator or other cooling device, e.g. as the thermal
naked eye, except those falling within the range of conductivity of tungsten is low, the tungsten target is
the visible spectrum. therefore fitted in a copper stem, which is a very
good thermal conductor.
Q.6. Role of grid in diagnostic radiography.
Theories of electromagnetic spectrum
Ans.
● Electromagnetic radiations move through spaces
as both a particle and a wave; hence, a dualistic ● A grid consists of a series of large number of long parallel
theory explains the characteristics of electromagnetic strips of radiopaque material, e.g. lead separated by radio-
radiation. lucent/transparent inter-space material such as plastic.
1. Wave theory – wave ● It was invented by Dr Gustave Bucky in 1913.
2. Quantum theory – particle ● It is the most effective way of removing scattered radia-
Wave theory tion from reaching the film. They are placed between
This theory states that all electromagnetic radia- the object and the film.
tions travel in the form of waves at the speed of ● Grids having 80 or more line pairs per inch do not show
light in vacuum (186,000 miles/s) and exhibit the grid lines in the image.
properties of velocity, wavelength, frequency and ● The scattered radiation usually travels obliquely. Hence,
amplitude. most of these scattered radiations get absorbed by the

Quantum theory lead strips of the grid, while some of the scattered pho-
According to this theory, particle concept character- tons travel in the same plane as the primary beam con-
izes electromagnetic radiations as discrete bundles of tributes to the formation of image.
energy called photons or quanta that travel as waves ● An ideal grid should be capable of removing 80%–90%
at the speed of light and move through space in a of the scattered radiation. The resultant image thus has
a better contrast. This improvement in the quality is Q.7. Bremsstrahlung radiation.

referred to as the ‘contrast improvement factor’ (K).
Ans.
X-ray contrast with grid
[Same as SE Q.1]
X-ray contrass t without grid
Q.8. Name any four properties of X-rays.
An ideal grid should have a high K value, around 1.5–3.5.
Ans.
● Grid ratio is defined as the ratio between the height of the
lead strip and the distance between them. The lead strips [Same as SE Q.3]
are 0.05 mm thick. Inter spaces are much thicker than the
Q.9. Types and uses of filtration.
lead strips. Grid ratio usually ranges from 4.1 to 16.1.
Types of grid Ans.
● Stationary grid
[Same as SE Q.4]
● Moving grid
Stationary grid: Stationary grid is built in the tube side

of cassette. Its disadvantage is that there are grid lines SHORT NOTES:
in which absorption of primary beam occurs. There
are two basic patterns of grid – linear and crossed. Q.1. Basic principles of shadow casting.
Linear grid: In this grid, the lead strips are placed
Ans.
parallel to each other in longitudinal axis. This
grid allows the angle of the X-ray tube along the The basic principles of shadow casting are as follows:
length of the grid without loss of primary radia- ● The focal spot (source of radiation) should be as small
tion from grid cut-off. These grids can only be as possible.
used effectively with very small X-ray fields or ● The focal spot–object distance should be as long as
long target grid distance. possible.
Crossed grid: A crossed grid is made up of two ● The object–film distance should be as small as possible.
linear grids having same focusing distance superim- ● The long axis of the object and the film planes should
posed at right angle to each other. This minimizes be parallel to each other.
the scattered radiation traversing in the same line as ● The beam of X-ray should strike the object and the film
the primary beam. The disadvantage of crossed grid planes at right angles.
is that it cannot be used with oblique technique, ● There should be no movement of the tube, film or pa-
requiring angulation of the X-ray tube. tient during exposure.
Stationary grids are of two types:
Q.2. Heel effect.
a. Parallel grid: In this the secondary radiation is
absorbed by the parallelly placed radiopaque lead Ans.
strips.
The intensity of X-ray beam is not uniform throughout. The
b. Focused grid: Here, the lead strips are angled from
intensity of X-ray beam on anode side of the X-ray tube is
the centre to the edge and are directed towards the
significantly less than that of the cathode side. It is called
direction of the paths of the diverging secondary
heel effect.
radiation, thereby eliminating the absorption of
The reasons for this effect to occur are
more secondary radiation than parallel grid.
● Self-absorption: The X-ray photons that are emitted on
Moving grid: It was invented by Dr Hollis E. Potter
the anode side of the field passes through thickness of
in 1920 and is known as Potter-Bucky grid.
anode than those towards cathode side. As most of the
Grids are moved to blur out the shadow caused
photons are produced inside the surface of the target,
by the lead strips. Mostly they move 3–5 cm
they are absorbed by the target before they reach the
back and forth throughout the exposure. They
surface. It results in reduced intensity on the anode side.
start moving when the anode begins to rotate.
On cathode side there is short path within the target.
Advantage
The use of moving grid reduces/eliminates the grid, Q.3. Position indicating device.
i.e. white lead lines in the radiographic image. This is
Ans.
achieved by moving the grid sideways during exposure.
Disadvantages ● There are mainly three types of PIDs:
They are costly; they put a limit on the minimum expo- a. Rectangular PID
sure time because they move slowly, and increase the b. Cone PID
patient’s radiation dose. c. Round PID
● Compared to round PID, the use of rectangular PID ● It has low vapour pressure at high temperature.
having an exit orifice of 3.58 3 40.4 cm will reduce the ● It does not have a high degree of thermal conductivity;
area of patient skin surface exposed by 60%. this problem can be overcome by embedding a small
● As PIDs are used, there is no specific head position or piece in a copper stem to form the anode.
vertical angulation for orienting the X-ray tube. ● The mechanical properties of tungsten are favourable
for moulding, machining and other processes involved

Q.4. Inverse square law.
in the manufacture of the target.
Ans.
Q.11. Define frequency.
[Ref LE Q.2]
Ans.
Q.5. Filtration.
● Frequency may be defined as the number of times wave
Ans. repeats itself each second, it is represented by ‘v’.
● Frequency and wavelength are inversely proportional to
[Ref LE Q.2]
each other.
Q.6. Electromagnetic spectrum. ● The unit of frequency is measured in Hertz, 1 Hertz 5
1 cycles/s.
Ans.
Q.12. What represents the particulate radiations?
[Ref SE Q.2]
Ans.
Q.7. Collimation.
● According to one of the theories of electromagnetic
Ans.
radiation, the transfer of energy is not in the form of
[Ref LE Q.2] waves but as a flux of quanta or photons.
● The quantum is small packet or bundle of energy with
Q.8. Anode in X-ray machine.
its size proportional to the frequency of radiation.
Ans. ● Every quantum is associated with a definite amount of
energy. Usually packet of energy is called quanta but in

[Ref LE Q.3]
case of electromagnetic radiation, it is called photons.
Q.9. Resolution. ● The unit of photon energy is electrons volt (eV), and the
photons and X-rays have energies greater than 1000 eV

Ans.
or 1 kiloelectron unit (1 keV).
● It is the measurement of a radiographic visualization to ● Energy of a quantum is directly proportional to the fre-
differentiate between different structures that are close quency of radiation and inversely proportional to the
together. wavelength. So, photons of shorter wavelength have
● According to photographic physics, resolution is measured higher energy. Photons used in dental radiography have
in terms of test pattern consisting of a series of black lines wavelength of 0.1–0.5 A.
on a white background, where width of lines is equal to the
Q.13. Compton effect.
width of spaces between them. Resolution is then expressed
in terms of the maximum number of lines per millimetre, Ans.
which the photographic material is capable of recording.
● Compton effect is also called inelastic scattering, modi-
● It is determined mainly by the type of film, speed and
fied scattering or incoherent scattering. It occurs when
silver halide crystal size, penumbra effect and contrast.
a photon interacts with a free or loosely bound outer
● Type of film: As compared to direct exposure, film
electron.
resolving power of intensifying screen is less.
● In dental X-ray beam, approximately 62% of the pho-
● Speed of film: It also affects the resolution of the
tons undergo Compton interaction.
film. High speed has less resolving power compared to
● It is accomplished by:
low-speed films.
a. Collision of incident photons
Q.10. Why is tungsten used as a target material in an b. Recoil electron
X-ray tube? c. Scattering
Influencing factors
Ans.
● Electron density: The probability of Compton inter-
Tungsten is used as target material due to the following action is directly proportional to the electron density.
reasons: The number of electron in bone is greater than in
● It has a high atomic number, i.e. 74. water, thus the probability of Compton interaction is
● It has high melting point, i.e. 3370°C. greater in bone than in tissues.
● Photon energy: The photon energy and Compton used in ionization chamber, proportional counters,
effect are inversely proportional to each other. When Geiger–Muller counters and semiconductor detectors.
compared to low-energy radiations, high-energy
Q.17. kVp.
radiations are less scattered.
● Unlike elastic scattering, Compton process results in Ans.
both scattering and absorption.
[Ref LE Q.2]
Q.14. What is line focus principle?
Q.18. Radiology and roentgenology.
Ans.
Ans.
● Line focus principle is also called as Benson line focus
The science or study of radiation as used in medicine; a
principle.
branch of medical science that deals with use of X-rays’
● The X-ray beam travels at approximately right angles to
radioactive substances and other forms of radiant energy in
the long axis of the X-ray tube. The sharpness of the
the diagnosis and treatment of disease is called Radiology
radiographic images increase as the size of the radiation
or roentgenology.
source, i.e. the focal spot size decreases.
The production of radiographs of teeth and adjacent
● Briefly, the line focus principle is the use of an anode
structures by the exposure of film to X-rays is known as
with the target material angulated such that effective
dental radiography.
focal spot is smaller than actual focal spot.
● The use of line focus principle allows the X-rays to be Q.19. Explain generation of X-rays.
generated over a large area on the target, thus less heat
Ans.
per unit area is produced. Therefore, greater number of
electrons can be used and great number of X-ray ● When the X-ray machine is turned on, the electric cur-
photons results. rent from wall outlet enters the control panel, and in the
● Effective focal spot size should be decreased to increase X-ray tube head, the current is then directed to the fila-
the sharpness of image. ment circuit.
● When the tungsten filament in the cathode is heated to
Q.15. Gray.
incandescence or red hot, thermionic emission occurs.
Ans. ● The electrons stay in an electron cloud until the high-
voltage circuit is activated, then electrons produced at

● If an ionizing radiation imparts 1 joules (J) of energy
the cathode are accelerated across the X-ray tube to the
per kg mass to a body, then absorbed dose is said to be
anode. The molybdenum cup in the cathode directs the
1 Gray.
electrons to the tungsten target in the anode.
● 1 Gy 5 100 rad.
● The electrons travel from the cathode towards the an-
● The term ‘Gray’ was coined after Dr L.H. Gray who
ode. When the electrons strike the tungsten target, their
made fundamental contribution to radiation dosimetry.
kinetic energy is converted to X-ray energy and heat.
● SI unit: Gray (Gy) measured in J/kg.
● Less than 1% of energy of electrons is converted to
● Subunit: Milligray (mGy).
X-rays at anode and other 99% is lost as heat.
Q.16. Ionization.
Q.20. Characteristic radiation.
Ans.
Ans.
● The ionization is a process of converting atom into
● When a high-speed electron dislodges inner shell electron
the ion.
from the tungsten atom, it results in ionization of the atom.
● An atom that is not electrically balanced is called ion.
Once electron is dislodged, the remaining orbiting elec-
When an atom loses the electron, it is called positive ion
trons rearrange to fill the vacancy. This produces a loss of
and when an atom gains the electron, it is called nega-
energy that results in X-ray photon, with energy equal to
tive ion.
the difference in the two orbital energy states. The X-ray
● Electrons can be removed from an atom by various
thus produced is called characteristic radiation.
means like heating or interaction with high-energy
● The radiation emitted constitutes the ‘line spectrum’.
X-rays or particles such as protons.
● In ionizing type of radiation, there are various products Q.21. Definition of roentgen.
like a-rays, b-rays, g rays or neutrons or X-rays.
Ans.
● In any ionization process, ion pairs are formed and this
is the process, which elicits chemical changes in matter. ● Roentgen is the traditional unit of exposure for X-rays. It
● These ion pairs can be collected by applying an electri- is defined as the quantity of X-radiation or gamma radia-
cal field, to give rise to current or pulses. This system is tion that produces an electrical charge of 2.58 3 1024
Coulombs in a kilogram of air at standard temperature Uses of X-rays are as follows:

and pressure (STP). ● Diagnostic use in dentistry and medicine.
● It measures only the amount of energy that reaches the ● Radiotherapy–the treatment may be curative or palliative.
surface of an organism, but it does not describe the ● In industries to check uniformity of insulating materials,
amount of radiation absorbed. quality of oil paintings etc.

● For examination of gross engineering works.
Q.22. Coolidge tube.
● Spectroscopy.
Ans. ● Crystallography.
● Sterilization.
● Coolidge tube was invented by William Coolidge in
1913. Q.25. Factors controlling X-ray beam.
● It is the basis of all dental X-ray machines.
● The basic shape of original Coolidge tube consisted of Ans.

a spherical bulb with two cylindrical arms extending on
The factors controlling the quality and quantity of X-ray
opposite sides.
beam are as follows:
● Advantages of Coolidge tube are as follows:
i. Tube current: The quantity of radiation produced by
a. Quantity and hardness of X-ray beam could be inde-
an X-ray tube is directly related to the tube current and
pendently controlled.
the time the tube is operated.
b. Even voltage and tube current could be controlled
ii. Tube voltage: As kVp increases, there is an increase in
separately.
the number, mean energy and maximum energy of
c. Output of Coolidge tube was easily duplicated from
photons.
one time to another.
iii. Exposure time: Keeping mA and kVp constant, when
d. In Coolidge tube with only adjustment of voltage
the exposure time is doubled, the number of X-ray
and current, the X-ray beam could be hardened or
photons generated also doubles.
softened.
iv. Filtration: With the use of filters, the contrast and
Q.23. X-ray timer. the quality of film are increased while density is
affected.
Ans.
v. Collimation:
● An X-ray timer completes the circuit with the high- l It decreases the volume of the irradiated tissues and
voltage transformer and helps to control the time for radiation exposure to the patient.
which high voltage is applied to the tube. l It minimizes the film fog and enhances the image
● Exposure timers control the length of X-ray exposure. It quality.

is included in primary circuit of high-voltage supply. vi. Inverse square law
● Most of the timer machines automatically reset them- l Inverse square law states that the intensity of an
selves. X-ray beam at a given point is inversely propor-

● There are four types of exposure timers: tional to the square of the distance from the source
a. Mechanical timers of radiation.
b. Electronic timers vii. Quality of the X-ray beam
c. Photo timers l When the kVp increases, it results in X-ray photons
d. Pulse counting timers with high energy and better penetrating power.
viii. Quantity of the X-ray beam
Q.24. Uses of X-rays.
l The quantity of X-rays depends on the product of
Ans. mA and exposure time in seconds (mAs).

X-ray
tube
Stepup Leaded Stepdown

transformer glass transformer
housing Metal housing
Focal of X-ray
spot Vacuum
Tungsten Copper tubehead
filament stem
Cathode
Anode Insulating oil
Focusing
cup
Tungsten
Electron target
stream Tube
window
Aluminium Lead collimator

discs PID (position
indicating device)
Tubehead seal
X-ray tube.
Q.26. Filtration of X-ray beam. Q.28. Tungsten application in an X-ray machine.

Ans. Ans.
Q.27. Collimation of X-ray beam.
Ans.
[Same as SN Q.7]
Topic 2
Radiation Biology, Hazards of Radiation
and Radiation Protection
LONG ESSAYS:
1. What are the effects of radiation in the oral cavity? Write in detail about osteoradionecrosis.
2. Describe radiation protection measures.
3. Discuss types of biologic effect of X-rays.
4. Write in detail about harmful effects of radiation on whole body.
5. Write an essay on the effects of ionizing radiation on the living cells and tissues.
6. What are the biologic effects of radiation in the oral cavity? [Same as LE Q.1]
7. Enumerate hazards of radiation or effects of radiation on oral tissues. [Same as LE Q.1]
8. Discuss radiation protection. [Same as LE Q.2]
9. Discuss the methods of radiation safety and protection of the operator, patient and public. [Same as LE Q.2]
10. Discuss the different methods of radiation protection of the patient and personnel (operator) in oral radiography.
[Same as LE Q.2]
11. Mention radiation hazards affecting whole body. How would you protect patients from these while taking
intraoral radiographs? [Same as LE Q.4]
12. What are the hazards of radiation seen on skin and bone? Discuss briefly protection of patient from radiation.
[Same as LE Q.4]
SHORT ESSAYS:
1. Radiation dosimetry.
3. Biological effects of radiation in oral cavity.
4. X-ray monitoring devices.
5. Radiation protection from X-rays.
6. Write briefly about postirradiation mucositis.
7. Types of the radiation caries.
8. Write briefly on radiation hazards in dentistry. [Ref LE Q.1]
9. Dosimetry. [Same as SE Q.1]
10. Write in brief about osteoradionecrosis. [Same as SE Q.2]
11. Clinical features and management of osteoradionecrosis. [Same as SE Q.2]
12. Thermoluminescent dosimeter (TLD). [Same as SE Q.4]
13. TLD. [Same as SE Q.4]
14.
Radiation protection for the operator. [Same as SE Q.5]
15.
Radiation protection of patient. [Same as SE Q.5]
16.
Enumerate the various means to reduce the exposure to the patient while taking radiograph for diagnosis.
[Same as SE Q.5]
17. Treatment of postirradiation mucositis. [Same as SE Q.6]
1 8. Write briefly on radiation caries. [Same as SE Q.7]
19. Describe radiation hazards in oral cavity. [Same as SE Q.8]
SHORT NOTES:
1. Radiation mucositis.
2. TLD.
3. Effects of radiation on developing tooth.
4. Dosimetry.
5. Enumerate four means to reduce the exposure to the patient while taking diagnostic radiographs.
6. Definition of erythema dose.
7. Film badge. [Ref SE Q.4]
8. Types of the radiation caries. [Ref SE Q.7]
9. Treatment of postirradiation mucositis. [Ref SE Q.6]
10. Write briefly on radiation hazards in dentistry/ oral cavity. [Ref LE Q.1]
12. Radiolysis of water.
13. Radiosensitive and radioprotective.
14. Definition of ‘roentgen’ and ‘erythema dose’.
15. ALARA principle.
16. Limitations of radiography.
17. Postirradiation mucositis. [Same as SN Q.1]
18. Measures to protect the patient from radiation hazards. [Same as SN Q.5]
19. Write briefly on radiation caries. [Same as SN Q.8]
20. Radiation hazards of jaws. [Same as SN Q.10]
21. Radiation hazards of teeth, oral mucosa and the jaws. [Same as SN Q.10]
22. Effects of radiation in the oral cavity. [Same as SN Q.10]
23. Clinical features and management of osteoradionecrosis. [Same as SN Q.11]
24. Radioresistant cells. [Same as SN Q.13]
25. ALARA. [Same as SN Q.15]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. What are the effects of radiation in the oral cavity? Radiation caries: The decrease in the salivary flow,
●
Write in detail about osteoradionecrosis. its pH and buffering capacity coupled with increased
viscosity are the complications of radiation exposure
Ans.
which lead to rampant type of carious lesions.
[SE Q.8] Bone
● The effects of radiation are more marked on man-
{The biological effects of radiation on oral cavity are dible; the initial changes are seen in the vasculature.
mainly the result of radiotherapy for malignant lesions. The ● Marked decrease in vascularity of bone because
effects of radiation on various structures of oral cavity are of irradiation decreases the capacity of bone to
as follows:} resist infection.
● The bone marrow becomes hypoxic and hypocellular.
(SE Q.8 and SN Q.10)
● These atrophic changes within the bone lead to
i. {(Oral mucous membrane osteoradionecrosis.)}
● ‘Radiation mucositis’ is seen by the end of second
week of radiotherapy, as the oral mucous membrane [SE Q.8]

contains radiosensitive vegetative and differentiating {Osteoradionecrosis
intermitotic coils in the basal layer. The term osteoradionecrosis implies an infection in
● Radiation mucositis is exhibited as marked redness bone rendered necrotic by ionizing radiation.
and inflammation. An inflammatory condition of bone (osteomyelitis) that oc-
● One of the most common complications of radiation curs often after the bone has been exposed to therapeutic
mucositis is candidiasis, a secondary infection caused doses of radiation usually given for the treatment of malig-
by Candida albicans. nancy of head and neck region is called osteoradionecrosis.}
Taste buds Precipitating factors
● By the end of second or third week of radiotherapy, Factors leading to osteoradionecrosis are as follows:
the changes occurring in the taste buds are exten- i. Irradiation of inadequately healed surgical site.
sive degeneration of normal histologic pattern and ii. Surgery in the irradiated areas in close proximity
loss of taste sensation. to bone.
● When the posterior two-third of tongue is irradi- iii. A high dose of irradiation with or without proper
ated, it affects the bitter and acidic flavours. fractioning.
● Anterior one-third of tongue when irradiated iv. Use of a combination of external radiation and
affects the sweet and salty flavours. intraoral implants with poor oral hygiene.
Salivary glands v. Indiscriminate use of prosthetic appliances
● Salivary glands are exposed to radiation during following radiation therapy.
radiotherapy of head and neck region. vi. Failure to prevent trauma to irradiated bony areas.
● The parenchymal cells are more radiosensitive. vii. Presence of numerous physical and nutritional
There can be inflammatory response involving factors prior to surgery.
serous acini, increase in serum amylase and pro- Pathogenesis
gressive fibrosis, adiposis, loss of fine vasculature The main factors involved in pathogenesis of osteora-
and parenchymal degeneration. dionecrosis are radiation, trauma and infection.
● Salivary flow becomes more viscous when flow is Osteoradionecrosis results from either of the following
decreased. The pH of saliva also decreases. or in combination:
Teeth ● Radiation in massive doses
● When teeth are irradiated during their develop- ● Partial necrosis of bone
ment, their growth is retarded. ● Trauma which causes infection
● If the radiation precedes calcification, the tooth The primary risk factor in the development of post ra-
may be destroyed. After calcification is com- diation osteoradionecrosis is radiation therapy in which
pleted, if irradiation continues, malformation can dose, fraction and number of fractions results in bio-
result and the root development is retarded. logical effect.
● Fully developed teeth are usually very resistant to There is increase in risk when greater volumes of bone
the X-radiations. are included in the field of irradiation.
Radiation induced damage to the vasculature be kept in mind when exposing dental films. This can be
g achieved by:
i. X-ray machines: Only use good machines by
Invasive doses destroy osteoblasts and to lesser extent
reputed manufacturing companies.
osteoclasts
ii. Only radiograph should be taken when required
g and avoid repeating the radiographic examination.
Subsequent irradiation to the tissues leads to partial iii. Film selection: Good quality, highly sensitive
necrosis of bone films like F and E-speed films should be used.
g In dental practice today only the type ‘E’ or the
Ektaspeed is recommended, since it reduces the
Hypovascular, hypotoxic and hypocellularity of the bone
exposure by at least 40% as compared to type D.
marrow
iv. Filtration: Filtration removes the low energy
g X-rays from the beam. These ‘soft’ X-rays are
Reduced mineralization of the bone absorbed by the patient and do not contribute to
g the image; removing them before they reach the
Brittleness or little alteration of the bone patient reduces the radiation exposure.
Units operating at 70 kVp or above should have
g filtration equivalent to 2.5 mm of aluminium
Bone death and those operating below 70 kVp should have
g the equivalent of 1.5 mm of aluminium.
Osteoradionecrosis v. X-ray collimation: Collimation should be used
to prevent scattering. The beam should be colli-
Clinical features mated so that it is no more than 7 cm in diameter
i. The posterior region of mandible is more commonly at the patient’s face. Rectangular collimators
affected than the maxilla due to the microanatomy and further reduce the amount of tissue irradiation.
reduced vasculature of the mandible. vi. Intensifying screens: Use of rare earth screens
ii. Intermittent swelling and drainage extraorally. reduces dosage for extraoral films like, lateral
iii. Intense pain may occur; pain is of severe, boring-type, cephalogram, Orthopantomogram (OPG) and
which may continue for weeks or months. lateral oblique, etc.
iv. Swelling of face results from secondary infection. vii. Grids: The use of grids reduces the fogginess of
v. Trismus, fetid odour and pyrexia can be noted. the film due to secondary radiation, thereby re-
vi. Soft-tissue abscesses. ducing the need for repeat films. Good consis-
vii. Persistently draining sinuses. tent processing technique also helps in prevent-
viii. Exposure of bone is the hallmark of osteoradionecrosis. ing unnecessary repetitions.
ix. The exposed bone becomes necrotic as a result of loss viii. Kilovoltage: X-ray units should be operated
of vascularity from periosteum and subsequently it using at least 60–90 kVp. Using an X-ray beam
sequestrates. with low kilovoltage results in higher patient
x. Pathological fractures of bone are common. doses, primarily to the skin.
xi. Osteoradionecrosis is treated by hyperbaric oxygen ix. Position-indicating devices (PIDs):
therapy. ● The cone-shaped devices should be replaced by
Q.2. Describe radiation protection measures. long, open-ended, lead-lined cylinders. Open-
ended, circular or rectangular lead-lined cylin-
Ans.
ders are preferred for directing the X-ray beam.
Various measures of radiation protection for patient, ● A long (12–16 inches) PID will reduce exposure
operator and associated personnel are as follows: to the patient better than a short (8 inch) PID,
Protective measures are employed for the operator of because there will be less divergence of the beam.
the X-ray equipment, patients and any associated personnel x. Lead aprons having lead content equivalent to
including individuals in adjacent office and occupants of 0.25 mm aluminium should be worn by the patient
doctor’s reception. while taking radiograph.
Protection of the patient xi. Use of thyroid collars will protect the thyroid
Mandatory steps during routine diagnostic radiographic gland from radiations.
examination are as follows: xii. Film-holding devices:
Despite the low risk to the patient from dental radiogra- ● Patient should not be asked to hold the film
phy, it is always best to keep exposure to ionizing radia- in the mouth to prevent additional exposure
tion to a minimum. Hence, the ALARA concept should of tissues.
● Film-holding devices usually result in a more Q.3. Discuss types of biologic effect of X-rays.
stable positioning of the film. In addition, the
Ans.
patient’s hands are not exposed to radiation.
xiii. Proper processing: Biological effects of radiation can be considered under
Well-designed darkroom will optimize the pro- the following headings:
cessing. Classification 1
xiv. Radiovisiography (RVG): A. Somatic: The effect of radiation, which occurs in ex-
● In the recent period, the use of RVG has posed individuals during their lifetime, is called somatic
further reduced the dose of the radiation re- effect.
quired in the Intra oral periapical radiograph Except reproductive cells, all the cells in the body are
(IOPA) with the Charged-coupled-device known as somatic cells.
sensors (CCD) sensors. a. Stochastic effect: It includes increase in probabil-
● Here the image appears directly on the com- ity of occurrence of biological effect with increas-
puter screen and can be saved as a picture ing absorbed dose rather than its severity. They
file on the hard disc. Printout on a regular occur as direct effect of dose.
paper is possible. b. Nonstochastic effects or deterministic effect: It is
Protection of the operator one in which severity increases with increase in
i. The operator should not: absorbed dose in affected individual.
● Hold the film in the patient’s mouth during exposure B. Genetic: The effect, which is manifested in the future
● Stabilize the X-ray machine during exposure generations of the exposed individuals, is known as ge-
● Stand near or directly in the path of the primary netic effect.
radiation The reproductive cells are termed genetic cells.
ii. The operator should: Classification 2
● Stand behind a lead barrier having 0.5 mm lead Acute or immediate effect: The effect appearing shortly
equivalent during exposure. after the exposure as a result of large dose.
● Stand 6 feet away from the primary X-ray beam Chronic or long-term effect: The changes become evi-
in an area called the zone of maximum safety, dent after long period of time.
which ranges from 90° to 135° with respect to Somatic effects
the primary X-ray beam. a. Somatic stochastic Effects
● Have radiation exposure periodically monitored by ● These are the effects in which probability of the
using personnel monitoring devices or film badges. occurrence of a change increases, rather than its
● Work on rotation of duties, so that continuous severity.
accidental exposure is avoided. ● These are effects that are likely to occur and are
iii. There are exposure limits for occupationally exposed dose dependent. There is as such no threshold
radiation workers. The maximum permissible dose dose for stochastic effect.
(MPD) is the dose of radiation to the whole body that ● When the body is exposed to any amount of radiation,
produces very little chance of somatic or genetic in- damaging effect may be induced. Lower the radiation
jury. The MPD for whole body exposure per year for dose, there is less possibility of cell damage.
occupationally exposed personnel is 0.05 Sv (5 rem). For example, radiation-induced cancer is a stochastic
Protection of other persons effect because greater exposure of a person or popu-
i. Only people whose presence is required should stay lation to radiation increases the probability of cancer
in the room. but not its severity.
ii. Plan and design maxillofacial radiology department. b. Somatic deterministic effects or nonstochastic effects
Conch shell design of the operatory area is recom- ● Effects that have increased probabilities of occur-
mended to protect people in surrounding areas from rence with increase in dose and have dose thresh-
radiation. old below which the response cannot be seen are
iii. An X-ray tube should be away from doorways to known as nonstochastic effects.
avoid accidental exposure. ● They result from specifically high doses of radia-
iv. Radiation exposure to the room and to adjacent tion, e.g. during radiotherapy.
office premises should be monitored. ● Ulceration and desquamation of skin resulting in
v. The walls of the room should be reinforced with reddening of skin, damage to connective tissue,
barium plaster or the thickness of the walls should blood vessels and glands, damage to alveolar
be increased by using an additional layer of bricks. bone and formation of cataract are all the exam-
vi. Caution or warning signs should be displayed. ples of this effect.
Genetic effects Dryness, erythema, thickening, desquamation

Genetic effects are not seen in the person irradiated but and cracking of hands may also occur.
are transferred to future generation. ii. Finger nails: Fingernails may become brittle,
Generic cells are germ cells of the reproductive organs. develop longitudinal fissures and ridges, and
Reproductive cells are prone to damage with compara- finally crumbled.
tively much smaller dose than amount needed to produce iii. Hair: Radiation causes epilation. It is often seen
radiation effect in somatic cells of the body. in association with dermatitis. Hair loss can be
Radiations cause fragmentation of chromosomes and permanent.
mutation of genes of sex cells and these mutant genes iv. Blood-forming tissue: The bone marrow and
with altered characteristics pass on to next generation. lymph nodes are susceptible to excessive expo-
Mutations are the changes in the information carried by sure, and it can manifest itself as change in blood
the chromosomes within the germ cells, i.e. sperm and count. The usual blood picture is leukopaenia.
egg cells. It is indicative of change in the DNA of the cells. v. Eyes: Radiation dose can cause cataract and
It may result in congenital abnormality in the offspring of the larger doses can cause detached retina.
person irradiated. There may be retardation of growth rate. Chronic or long-term effects
Doubling dose: This is the dose that causes complete Chronic effects are mainly due to low level of irradia-
doubling of all gene mutations. tion for longer period, or chronic irradiation.
Damage can be caused to either dominant or recessive Effect that appears after years, decades or generation is
genes. The dominant variety effect is seen in next gen- known as long-term effect.
eration, whereas recessive variety effect may be seen It depends on the extent of damage to the fine vasculature.
after several generations. Pathogenesis of long-term effect
Genetic damage follows nonthreshold type of response, Irradiation of capillaries causes swelling, degeneration
i.e. small amount of radiation has the potential to and necrosis.
produce lesser number of mutations in chromosomes. It increases the capillary permeability and initiates a
Genetic damage is cumulative and it cannot be repaired. slow progressive fibrosis around the vessels.
Human embryo is said to be most sensitive especially Due to this, deposition of fibrous scar tissue increases
during 15–42 days of its life, so radiation is avoided around the vessels, leading to premature narrowing and
during pregnancy. eventual obliteration of vascular lumen.
Sterility in human beings has been reported on exposure This impairs the transportation of oxygen, nutrients and
to heavy doses. waste products, and results in death of all cells.
No genetic effect is seen in individuals beyond the age This leads to loss of function and reduced resistance to
of reproduction. infection and trauma.
Acute or short-term effects Pathologic effects
Acute somatic effects will be manifested within few The long-term effects are associated with small amount
hours to few days of acute irradiation and the severity of of radiation absorbed over long period of time. The
the effect will depend on dose and dose rate. abnormalities induced by repeated low levels of radia-
Following the latent period, effects are seen within min- tion exposure are as follows:
utes, days or weeks. Carcinoma: The cancer of skin is the earliest form of
Acute radiation effect is a short-term effect. It occurs radiation-induced malignant tumour.
when large dose of radiation given in short period of time Leukaemia: It is one of the late effects and can be due to
as in atomic bomb explosion and in nuclear accidents. primary and secondary radiation. A higher incidence of
Short-term effect is not applicable to the dentistry as leukaemia is observed in radiologists as compared to others.
dental diagnostic radiographs use less than 5 rads. Necrosis: Due to heavy radiations, destruction of tissue
Factors modifying the acute effect are as follows: can occur. Necrosis can be seen in extraction socket
Sensitivity: It is determined by the sensitivity of paren- after radiation exposure.
chymal cells. If continuously proliferating tissues are Retardation of growth: Irradiation of developing teeth
irradiated with a moderate dose, cells are lost primarily results in disorganization of the odontoblasts. With
by mitosis-linked death. larger doses, retardation of bone and tooth development
Proliferative rate: The extent of cell loss depends on the is more obvious.
damage to the stem cell pools, and the proliferative rate Effect on the taste buds: Taste buds are very sensitive to
of cell population. radiation and soon degenerative changes begin. Loss of
Immediate effects of radiation are as follows: taste is very common.
i. Skin: Excessive exposure causes dermatitis. Effect on the salivary glands: The parenchymal compo-
Repeated exposures have a cumulative effect. nent of salivary gland is more radiosensitive. Exposure
to radiation leads to injury of these parenchymal cells Signs and symptoms include ulceration following
leading to following conditions: haemorrhage of the intestine. All these changes lead
● Loss of salivary secretion to diarrhoea, dehydration and loss of weight.
● Xerostomia Bone marrow depression
● Difficulty in swallowing Endogenous intestinal bacteria readily invade the
● Decrease in pH of saliva denuded surface producing septicaemia. By this
● Reduced buffering capacity of saliva time, the developing damage to the gastrointestinal
● Increase in bacterial count and radiation caries system reaches a maximum, the effect of bone
marrow depression begins to manifest.
Q.4. Write in detail about harmful effects of radiation Lowering of body defence
on whole body. By the end of 24 hours, the number of circulating
Ans. lymphocytes falls to a very low level. This is followed
by the decrease in the number of granulocytes and
When the whole body is exposed to low or moderate platelets. This hampers body defence mechanism
dose of radiation, characteristic changes called acute against bacterial infection and decreases the effective-
radiation syndrome develop. ness of the clotting mechanism.
Acute radiation syndrome Death
Prodromal period The combined effect on these stem cells causes death
After exposure of 1.5 Gy within the first few minute within 2 weeks due to fluid and electrolyte loss,
to few hours, symptoms characteristic of gastrointes- infection and possible nutritional impairment.
tinal tract (GIT) disturbance occur, such as anorexia, Cardiovascular and central nervous system syndrome
nausea, vomiting, diarrhoea, weakness and fatigue. Exposure in excess of 50 Gy can cause death in
They are dose-dependent; higher the dose, the more 1–2 days. Human beings show collapse of the circu-
rapid onset and greater is the severity of symptoms. latory system with precipitous fall in blood pressure
Latent period in the hours preceding death.
After the prodromal period, latent period occurs, Victims may show intermittent stupor, incoordina-
during which no signs and symptoms are present. tion, disorientation and convulsion suggestive of
This latent period is also dose-related. It varies from extensive damage to the nervous system.
hours or days at supralethal exposure (.5 Gy) to few This syndrome is irreversible and clinical course
weeks at sublethal exposures (,2 Gy). may run from only few minutes to about 48 h before
Haematopoietic syndrome death commences.
Whole body exposure of 2–7 Gy causes injury to Management of acute radiation syndrome
the haematopoietic stem cells of the bone marrow Antibiotics: Antibiotics should be started when infec-
and spleen. It causes rapid and profound fall in the tion threatens life or the granulocyte count falls.
number of circulating granulocytes, platelets and Fluid supplements: It is necessary to replace fluid
erythrocytes. and electrolytes.
Common signs: Infection, haemorrhage and anae- Blood transfusion: Whole blood transfusion is given
mia. Death can result from this syndrome usually to treat anaemia.
10–30 days after irradiation. Platelet: Administration of platelet to arrest thrombo-
As periodontitis may be the likely source of entry of cytopaenia.
microorganism in the bloodstream, the role of dentist Bone marrow grafts: Bone marrow grafts are indi-
is very important. The removal of source of infection cated for identical twins because there is no risk of
by administration of antibiotics should be attempted graft-versus-host response.
at the earliest. Protection of the patient
Gastrointestinal syndrome Mandatory steps during routine diagnostic radio-
Exposure of whole body in the range of 7–15 Gy graphic examination are as follows:
causes extensive damage to the gastrointestinal i. Use of good machines by reputed manufactur-
system. ing companies.
It causes considerable injury to the rapidly proliferat- ii. Radiograph should be taken only when re-
ing basal epithelial cells of the intestinal villi and quired and avoid repeating the radiographic
leads to loss of the epithelial layer of the intestinal examination.
mucosa. Due to this denuded mucosal surface, plasma iii. Good quality, highly sensitive films should be
and electrolytes are lost, and efficient intestinal abused.
sorption is impaired. iv. Collimation should be used to prevent scattering.
Q.5. Write an essay on the effects of ionizing radiation are required for the induction of deterministic
on the living cells and tissues. effects than when a rapidly dividing cell system
is involved.
Ans. b. Bystander effect
● Damaged cells release into immediate environ-
Radiation can induce structural and functional changes
in cellular organelles that culminate in cell death. ment certain molecules that kill nearby cells.
● This effect is demonstrated in both alpha particles
Radiation-induced changes in macromolecules results
in effects of radiation on intracellular structures. and X-rays. It causes chromosomal aberration,
Following are the effects of ionizing radiation on intra- cell killing, gene mutation and carcinogenesis.
cellular structures: c. Apoptosis or programmed cell death
● This occurs during normal embryogenesis.
i. Nucleus
● It is more radiosensitive than cytoplasma especially
Apoptosis is particularly common in haemato-
in dividing cells. poietic and lymphoid tissues.
● Cells round up, draw away from their neigh-
● The sensitive sight in the nucleus is DNA.
ii. Chromosome aberration: bours and condense nuclear chromatin.

● Chromosomes serve as a useful marker for radiation
This characteristic pattern can be induced by radia-
injury. tion in both normal tissues and tumours.
● Extent of chromosomal damage is related to cell
Recovery involves enzymatic repair of single-
survival. stranded breaks of DNA.
● Chromosomal aberrations are noted in irradiated
Radiosensitivity and cell type
cells at the time of mitosis when DNA condenses to Different cells of organs of the same individual may
form chromosome. respond to radiation differently. Radiosensitive cells
● The type of cell damage depends on stage of cell in
have the following characteristics:
cell cycle at the time of irradiation. i. High mitotic rate
● Radiation can cause breakage in the chromosomes. If
ii. Undergo many future mitosis
one arm of DNA is broken, it is called as chromatid iii. Are most primitive in differentiation
aberration. If both arms are broken, it is called as Mammalian cells may be divided into three broad cate-
chromosome aberration. gories of radiosensitivity as follows:
The frequency of aberration is generally proportional to a. High radiosensitivity, e.g. spermatogenic and eryth-
radiation dose received. roblastic stem cells, basal cells of oral mucosa.
Simple breaks can be repaired by biological process, b. Intermediate radiosensitivity, e.g. vascular endo-
but incorrect pair forming rings and dicentrics is le- thelial cells, fibroblasts, parenchymal cells of
thal as they cannot complete mitosis. liver, kidney and thyroid
Sometimes breakage occurs and union takes place at c. Low radiosensitivity, e.g. neurons and striated
different levels other than normal resulting in muta- muscles.
tions. Following are the deterministic effects of radiation on
Following are the effects on cell replication: the tissues:
l Short-term affects
Radiation is especially damaging to rapidly dividing
l Long-term effects
cell systems, e.g. skin and intestinal mucosa and
haematopoietic tissue are affected leading to de- Radiosensitivity of tissues or organ is measured by
crease in size of cell or cell death. its response to irradiations. If large number of cells
Reproductive death in a cell population is loss of the are affected, organisms display an observable result.
capacity for mitotic division. The severity of this change thus depends on dose
The three mechanisms of reproductive death are: amount of cell loss.
a. DNA damage Short-term effects
b. Bystander effect The effects seen in first days or weeks after exposure are
c. Apoptosis determined primarily by sensitivity of parenchymal
cells.
a. DNA damage When continuously proliferating tissues like bone mar-
● The chromosomal aberration due to DNA row and oral mucosa are irradiated with a moderate
damage causes cell to die in first few mitosis dose, loss of cells primarily occurs by reproductive
after irradiation. death, bystander effect and apoptosis. The extent of
● When population of slowly dividing cells is ir- cell loss depends on damage to the stem cell pools and
radiated, larger doses and longer time intervals proliferative rate of cell population.
The effects of irradiation on such tissues become appar- SHORT ESSAYS:

ent quickly as a reduction in the number of mature cell
Q.1. Radiation dosimetry.
in the series.
Tissues composed of cells that rarely or never divide, Ans.
e.g. neurons and muscles shows less or no hypoplasia.
Long-term effects The determination of the quantity of radiation exposure
These are seen after months or years of exposure, loss or dose is known as dosimetry.
of parenchymal cell and replacement of fibrous connec- Radiation dosimetry deals with the measurement of the
tive tissue caused by reproductive death of replicating absorbed dose or dose rate resulting from the interaction of
cell and by damage to fine vasculature. Damage to cap- ionizing radiation with matter and particularly in different
illaries leads to narrowing and eventually obliteration of tissues of the body.
vascular lumens. The various measures of dosimetry are as follows:
i. Absorbed dose
Q.6. What are the biologic effects of radiation in the oral ● The amount of radiation at a given point to the
cavity? amount of energy absorbed per unit mass at the site
Ans. of interest is known as dose.
[Same as LE Q.1] Or
Q.7. Enumerate hazards of radiation or effects of radia- Dose can be defined as the amount of energy absorbed
tion on oral tissues. by a tissue. The radiation absorbed dose or rad is the
traditional unit of dose.
Ans. ii. Erythema dose
[Same as LE Q.1] The dose which produces in one sitting a reversible
reddening of the skin (3–4 Gy) is known as erythema
Q.8. Discuss radiation protection. dose.
iii. Exposure
Ans.
● It is a measure of radiation quantity or the capacity
[Same as LE Q.2] of the radiation to ionize air.
● It is measured as the amount of charge per mass of
Q.9. Discuss the methods of radiation safety and protec-
air namely Coulombs/kg.
tion of the operator, patient and public.
iv. Equivalent dose(HT)
Ans. ● It is used to compare the biologic effects of different
types of radiation on a tissue or organ.

[Same as LE Q.2]
● It is the sum of absorbed dose and radiation weigh-
Q.10. Discuss the different methods of radiation protec- ing factor.
tion of the patient and personnel (operator) in oral ra- ● Effective dose.
diography. ● The dose used to estimate the risk in humans is
known as effective dose.

Ans.
● It is the sum of products of equivalent dose to each
[Same as LE Q.2] organ or tissue and the tissue weighing factor.
● The unit of effective dose is Sievert (Sv).
Q.11. Mention radiation hazards affecting whole body.
v. Radioactivity
How would you protect patients from these while taking
● The measurement of radioactivity (A) describes the
intraoral radiographs?
decay rate of a sample of a radioactive material.
Ans. vi. MPD:
It is the equivalent that a person or specified parts of
[Same as LE Q.4]
the person shall be allowed to receive in a stated period
Q.12. What are the hazards of radiation seen on skin of time.
and bone? Discuss briefly protection of patient from vii. Maximum accumulated dose:
radiation. It indicates that higher limits permitted for occupation-
ally exposed persons do not pertain to individual under
Ans.
the age of 18. They are limited to the same exposure as
[Same as LE Q.4] the general that is 0.005 Sv/year.
Q.2. Osteoradionecrosis. Acute effects are divided into those affecting large
●
and small area of the body.

Ans.
● Chronic somatic effects are mainly due to low
i. An inflammatory condition of bone (osteomyelitis) that level of irradiation for longer period, or chronic
occurs often after the bone has been exposed to thera- irradiation.
peutic doses of radiation usually given for the treatment ● Chronic somatic effects are also of two types:
of malignancy of head and neck region is called osteo- those affecting large area of the body and those
radionecrosis. affecting small area of the body.
ii. Predisposing factors to osteoradionecrosis are as follows: ● Bombardment
● Irradiation of inadequately healed surgical site. ● Acute radiation affecting small area of the
● Surgery in the irradiated areas in close proximity to bone. body is seen in cases of treatment of malignant
● Improperly fractioned high dose of irradiation. tumours.
● Indiscriminate use of prosthetic appliances follow- ● Acute reactions do occur over skin and other
ing radiation therapy. parts resulting in skin erythema.

● Failure to prevent trauma to irradiated bony areas. Chronic radiation affecting large area of the body
iii. The main factors involved in pathogenesis of osteora- Usually seen in the workers (occupational hazard) or
dionecrosis are radiation, trauma and infection. exposure received by a group of population.
iv. Clinical features: Patients feel nervous, apprehensive and tired. Nausea,
● The posterior region of mandible is more commonly vomiting and other GIT disturbances are likely to follow.
affected than the maxilla. Chronic radiation affecting small area of the body
● Intense pain may occur along with intermittent It may result in radiation burns, dry skin, burning sensa-
swelling and drainage extraorally. tions on skin and mucous membrane, friable nails, loss
Pain is of severe, boring type which may continue for of hair (alopecia), cataract, radiation mucositis, loss of
weeks or months. taste, xerostomia and radiation caries.
Trismus, foetid odour and pyrexia can be noted. Marked decrease in vascularity of bones because of
Exposure of bone is the hallmark of osteoradionecrosis. irradiation results in osteoradionecrosis.
Pathological fracture of bone is common. Genetic effects
Radiations cause fragmentation of chromosomes and
Q.3. Biological effects of radiation in oral cavity.
mutation of genes of sex cells and these mutant genes
Ans. with altered characteristics pass on to next generation.
Human embryo is said to be the most sensitive, espe-
Acute radiation affecting large area of the body: cially during 15–42 days of its life, hence avoided in
These are rare in dentistry but are only possible in pregnancy.
nuclear accidents and atomic explosions. Sterility in human beings has been reported on exposure
I. Biological effects of radiation can be considered in two to heavy doses.
aspects:
A. Somatic: The effect which occurs in exposed indi- Q.4. X-ray monitoring devices.
viduals is called somatic effect. Ans.
B. Genetic: The effect which is manifested in the future
generation of the exposed individuals is known as
{SN Q.7}
genetic effect.
II. Biological effects can also be categorized into: X-ray monitoring devices are used for physical measure-
A. Stochastic effects: The effects for which the proba- ment of X-radiations. Commonly used devices are film
bility of an effect occurring rather than its severity badges and thermoluminescent badges.
is regarded as a function of the dose without thresh- A. Film badges.
old, e.g. leukaemia and carcinoma. B. Thermoluminescent badge or dosimeter (TLD).
B. Nonstochastic effects: For this type of nonstochastic
. Film badges
A
effects, the severity of the effect varies with the dose
i. Film badges are worn on chest, and under nor-
for which a threshold may matter, e.g. cataract,
mal conditions they give whole body radiation.
shortening of life span and infertility.
ii. Wide range of doses from 10 mR to 1000 R of
Somatic effects
various types of radiations like X-rays, beta rays
Somatic effects can be classified into:
and gamma rays are measured with film badges.
a. Acute
iii. Advantages:
b. Chronic
● Permanent record can be kept.
● Acute somatic effects will be manifested within
● Differentiation of radiation is possible.
few hours to few days of acute irradiation.
Protection of the operator

iv. Disadvantages:
The operator should not:
● Not very accurate
l Hold the film in the patient’s mouth during
● Cannot read immediately and accidental
exposure.
exposures cannot be recorded.
l Stabilize the X-ray machine during exposure.
l Stand near or directly in the path of the primary

B. Thermoluminescent badge or dosimeter (TLD) radiation.
i. TLD is used for the measurement of the actual l Use personnel monitoring devices or film badges
dose received by the operator/patient as a result of for monitoring radiation and rotation of duties of
radiography or radiotherapy exposures. the operator so that continuous accidental expo-
ii. They are most common type of personnel monitor- sure is avoided.
ing devices used for personal monitoring of the The operator should preferably stand behind a lead
whole body and/or the extremities, as well as mea- barrier having 0.5 mm lead equivalent during expo-
suring the skin dose from particular investigations. sure or should stand 6 feet away from the primary
iii. Features X-ray beam.
● They contain materials, such as lithium fluoride, Protection of other persons
which absorb radiation and then release the en- i. Only people whose presence is required should stay
ergy in the form of light when heated. in room.
● TLD badge consists of a nickel plated aluminium ii. An X-ray tube should be away from doorways to
plate having three symmetrical holes, each of avoid accidental exposure.
diameter 12 mm, over which three identical iii. Radiation exposure to the room and to adjacent
CaSO4 Teflon discs are embedded. office premises should be monitored.
● Personal monitors consist of a yellow or orange
Q.6. Write briefly about postirradiation mucositis.
plastic holder, worn like the film badge for about
1–3 months. Ans.
iv. Uses:
● Radiotherapy
{SN Q.9}
● Radiodiagnosis
● Personal monitoring Postirradiation mucositis has an effect on oral mucous

v. Advantages: membrane following radiation therapy.
They are chemically inert, reusable and suitable for
a wide variety of dose measurements. As a part of the treatment of malignancy, patients, who re-
vi. Disadvantages: ceive radiotherapy to the head and neck, invariably develop
● Relatively expensive, only limited information is
widespread and painful oral mucosal erosion or ulceration
provided on the type and energy of the radiation. known as radiation mucositis.
● Read-out is destructive, giving no permanent
Once the irradiation is over, usually the mucous membrane
record; results cannot be checked or reassessed. heals rapidly, otherwise after few months, the mucous mem-
Q.5. Radiation protection from X-rays. brane will tend to become atrophic and relatively avascular.
Aetiology
Ans.
Protective measures are employed for the operator of the {SN Q.9}
X-ray equipment, patients and any associated personnel,
It is secondary to therapeutic radiation (doses in excess
including individuals in adjacent office and occupants of
of 3500–4000 rads).
doctor’s reception.
Protection of the patient
Mandatory steps during routine diagnostic radiographic Superinfection by Candida and staphylococci may also play
examination are as follows: a role in the development of radiation-induced mucositis.
i. Use of good machines by reputed manufacturing Clinical features
companies. The symptoms typically begin 1–2 weeks after the com-
ii. Radiograph should only be taken when required mencement of radiation therapy.
and avoid repeating the radiographic examination. The mucous membrane shows areas of redness and in-
iii. Good quality, highly sensitive films should be flammation known as mucositis.
used. With repeated exposures, pseudomembranes are formed
iv. Collimation should be used to prevent scattering. because of breakdown of the mucous membrane, and
secondary infection by Candida albicans is a common

Treatment
complication.
i. Daily application of viscous topical 1% neutral so-
l Sloughing of the mucosa
dium fluoride gel in custom-made trays causes de-
l Oral ulcerations
lay in growth of Streptococcus mutans.
l Unable to tolerate prosthesis
ii. Avoid dietary sucrose and restricted intake of
l Fibrosis of connective tissue
cariogenic foods.
Diagnosis
iii. Restorative dental procedures and good oral hy-
giene maintenance.
{SN Q.9}
It is usually diagnosed by straightforward history of
radiotherapy that encompassed the orofacial tissues. Q.8. Write briefly on radiation hazards in dentistry.
Treatment
Maintaining good oral hygiene is the most important Ans.
aspect of management. [Ref LONG ESSAY Q.1]
Topical anaesthetics may be required at meal times.
A soothing mouth rinse such as an antihistaminic Q.9. Dosimetry.
with Kaopectate will offer pain relief. [Same as SE Q.1]
Q.10. Write in brief about osteoradionecrosis.
Q.7. Types of the radiation caries.
Ans. [Same as SE Q.2]
Q.11. Clinical features and management of osteoradio-
necrosis.
{SN Q.8}
Radiation caries is a rampant type of dental caries that [Same as SE Q.2]
occurs due to radiotherapy. Q.12. Thermoluminescent dosimeter (TLD).
Patients who have received therapeutic radiation to
the head and neck may suffer loss of salivary gland func- [Same as SE Q.4]
tion leading to xerostomia.
Q.13. TLD.
Radiation caries develops secondary to changes seen
in the salivary glands and saliva-like reduced flow rate, [Same as SE Q.4]
decrease in pH, lack of buffering capacity and increased
viscosity etc. Q.14. Radiation protection for the operator.
In postirradiation period, due to lack of normal [Same as SE Q.5]
cleansing action of saliva, accumulation of local irritants
results in increased incidence of dental caries. Q.15. Radiation protection of patient.
The destruction begins at the cervical region and may
aggressively encircle the entire tooth resulting in loss of [Same as SE Q.5]
the entire crown with only root fragments remaining in Q.16. Enumerate the various means to reduce the expo-
the jaws. sure to the patient while taking radiograph for diagnosis.
The radiographic appearance of radiation caries is
characteristic dark radiolucent shadows appearing at [Same as SE Q.5]
the neck of the teeth, most obvious on mesial and distal
aspect.
Clinically there are three types of radiation caries: [Same as SE Q.6]
i. Widespread superficial lesion – it attacks buccal,
occlusal, incisal and palatal surfaces. Q.18. Write briefly on radiation caries.
ii. Circumferential caries – it usually occurs in cemen- [Same as SE Q.7]
tum and dentine in cervical region. It may result in
loss of irradiation of the crown. Q.19. Describe radiation hazards in oral cavity.
iii. Pigmentation of crown – it is usually dark in colour.
[Same as SE Q.8]
SHORT NOTES: Radiation dosimetry deals with the measurement of the

absorbed dose or dose rate resulting from the interaction of
Q.1. Radiation mucositis. ionizing radiation with matter and particularly in different
Ans. tissues of the body.
The various measures of dosimetry are as follows:
Postirradiation mucositis is an effect on oral mucous mem- i. Absorbed dose
brane following radiation therapy. ii. Erythema dose
The mucous membrane shows areas of redness and inflam- iii. Exposure dose
mation. iv. Equivalent dose
With repeated exposures, pseudomembranes are formed be- v. Effective dose
cause of breakdown of the mucous membrane, and secondary vi. Radioactivity
infection by Candida albicans is a common complication.
Once the irradiation is over, usually the mucous membrane Q.5. Enumerate four means to reduce the exposure to
heals rapidly, otherwise after few months, the mucous mem- the patient while taking diagnostic radiographs.
brane will tend to become atrophic and relatively avascular. Ans.
Q.2. Thermoluminescent dosimeter. Means of protection of the patient during routine diag-
Ans. nostic radiographic examination are as follows:
i. Use of good machines by reputed manufacturing
TLD is used for the measurements of the actual dose received companies.
by the operator/patient as a result of radiography or radio- ii. Radiograph should only be taken when required and
therapy exposures. avoid repeating the radiographic examination.
These are most common type of personnel monitoring de- iii. Good quality highly sensitive films should be used.
vices used for personal monitoring of the whole body or the iv. Collimation should be used to prevent scattering.
extremities. v. X-ray equipment is frequently tested.
These contain materials such as lithium fluoride, which vi. During X-ray exposure, use a thyroid collar and lead
absorbs radiation and then releases the energy in the form apron to protect body from X-ray radiation.
of light when heated.
TLD badge consists of a nickel-plated aluminium plate having Q.6. Definition of erythema dose.
three symmetrical holes, each of diameter 12 mm, over which Ans.
three identical CaSO4 Teflon discs are embedded.
These are chemically inert, reusable and suitable for a wide i. The dose that produces in one sitting a reversible
variety of dose measurements. reddening of the skin (3–4 Gy) is known as erythema
Relatively expensive, read-out is destructive, giving no per- dose.
manent record; results cannot be checked or reassessed. ii. In acute radiation affecting small area of the body, the
acute reactions resulting in skin erythema and even
Q.3. Effects of radiation on developing tooth. bone marrow depression are seen.
iii. However, skin reactions vary from individual to indi-
Ans.
vidual depending on the threshold.
i. Adult teeth are resistant to the effects of radiation. iv. Usually 250 roentgen is considered normal. In den-
ii. When the teeth are exposed to radiation in their devel- tistry, exposures are kept at 1/2 of the threshold dose
oping stage, their development may be retarded. (TED).
iii. Prior to calcification, the tooth buds gets destroyed, while
Q.7. Film badge.
after the initiation of calcification, there may be inhibition
of cellular differentiation causing malformation or arrest Ans.
of growth.
[Ref SE Q.4]
iv. Irradiation during developmental stages can result in
malformation of teeth. Q.8. Types of the radiation caries.
v. The pulp shows decreased vascularity, reduced cellularity
Ans.
and exhibits fibroatrophy.
[Ref SE Q.7]
Q.4. Dosimetry.
Ans.
Ans.
The determination of the quantity of radiation exposure or
dose is known as dosimetry. [Ref SE Q.6]
Q.10. Write briefly on radiation hazards in dentistry/ vii. They have a lifetime of about one microsecond and
oral cavity. attack most of the organic substances.
The free radicals can react with proteins, carbohy-
Ans.
drates, hormones and enzymes resulting in their
[Ref LE Q.1] breakdown.
Q.11. Osteoradionecrosis. Q.13. Radiosensitive and radioprotective.
Ans. Ans.
l Osteoradionecrosis implies infection of bone rendering i. Radio sensitivity of a tissue or organ is measured by its
necrosis by ionizing radiation. response to irradiation. (2500 R or less kills or seriously
l Occurs due to radiation in massive doses, partial necro- injures many cells, e.g.
sis of bone, trauma that causes infection. l Lymphocytes or lymphoblasts
l Cure of malignant conditions of tongue floor of oral l Bone marrow (myeloblastic and erythroblastic cells),
cavity, salivary glands, sinuses and neoplasms. epithelium of intestine or stomach

l Causes necrosis of maxillary and mandibular bones, l Germ cells (ovary and testis)
ulceration of soft tissues. ii. Radioprotective (over 5000 R necessary to kill or injure
l Strangulation of blood vessel. many cells, e.g. kidney, liver, thyroid, pancreas, pitu-
l Extractions are not indicated in such patients. itary adrenal and parathyroid glands, mature bone and
l Osteoporosis and atherosclerosis are there. cartilage, muscles, brain and other tissues).
l Poor oral hygiene, residual roots, periodontal diseases,
Q.14. Definition of ‘roentgen’ and ‘erythema dose’.
caries should be healed to prevent further osteoradione-
crosis. Ans.
Q.12. Radiolysis of water. i. The quantity of X-radiation or gamma radiation that
produces an electric charge of 2.58 3 1024 Coulombs
Ans.
in a kilogram of air at standard temperature and
i. Human tissues consist of 85% of water, on irradiation pressure is called roentgen.
most of the energy will initially get deposited in ii. The dose that produces in one sitting a reversible red-
water; only small proportion will be taken up by bone, dening of the skin (3–4 Gy) is known as erythema
skin, etc. dose.
ii. When water molecules are irradiated, ionization takes iii. In acute radiation affecting small area of the body, the
place as follows acute reactions resulting in skin erythema and even
H2O loses an electron and becomes H2O1 bone marrow depression are seen.
● Ionizing radiation
Q.15. ALARA principle.
H O → H O e Ans.
2 2
i. The ALARA concept states that all exposure to radia-
iii. The electron can be captured by another H2O molecule tion must be kept to a minimum, or ‘as low as reason-
to give a negative molecule. ably achievable’ to provide protection for both patients
and operators.
H O e → H O ii. It is one of the possible methods of reducing exposure
2 2 to radiation employed to minimize risk.
This completes the formation of an ion pair. iii. This principle can be used to minimize patient and
iv. The stability of molecule is maintained till now, and operator exposure, thus keeping radiation exposure ‘as
this comes under physical changes. low as reasonably achievable’.
v. The chemical change follows as shown: Q.16. Limitations of radiography.
H O → H OH
Ans.
2
The limitations of radiography are as follows:
H O → H OH i. Initial bone changes may not be apparent in the radio-
2
graph.
vi. Free radicals have an odd electron (surplus or deficient), ii. Soft-tissue and hard-tissue relationship cannot be deter-
which are highly reactive entities. mined.
iii. Radiographically, it may not be possible to differen- Q.21. Radiation hazards of teeth, oral mucosa and the jaws.
tiate between a diseased state and successfully
Ans.
treated case.
iv. The actual extent of bone destruction may be more than [Same as SN Q.10]
what has been visualized in the radiograph.
Q.22. Effects of radiation in the oral cavity.
Q.17. Postirradiation mucositis.
Ans.
Ans.
[Same as SN Q.10]
[Same as SN Q.1]
Q.23. Clinical features and management of osteoradio-
Q.18. Measures to protect the patient from radiation necrosis.
hazards.
Ans.
Ans.
[Same as SN Q.11]
[Same as SN Q.5]
Q.24. Radioresistant cells.
Q.19. Write briefly on radiation caries.
Ans. Ans.
Q.20. Radiation hazards of jaws. Q.25. ALARA.
Ans. Ans.
Topic 3
X-Ray Films and Accessories
LONG ESSAYS:
1. What is the composition of the radiographic film? Describe the mechanism of image formation. Add a note on
the constituents of developing and fixing solutions.
2. Packaging of intraoral periapical films.
3. Composition of intraoral periapical films. [Same as LE Q.1]
SHORT ESSAYS:
1 . Radiographic film composition (or) dental X-ray film. [Ref LE Q.1]
2. Intensifying screens.
3. Grid functions and grids in radiography.
4. Composition, ideal requirements and uses of intensifying screen.
5. Speed of intraoral film.
6. Moving grid.
7. Enumerate various types of intraoral films.
SHORT NOTES:
1 . Storage of X-ray films.
2. Composition of intensifying screen. [Ref SE Q.4]
3 . Advantages of bitewing radiographs. [Ref SE Q.7]

4. Intraoral X-ray film packet. [Ref LE Q.2]
5. Occlusal film. [Ref SE Q.7]
6. State the functions of lead foil in the X-ray film packet.
7. Intraoral periapical film.
8. Speed of intraoral film. [Ref SE Q.5]
9. Potter–Bucky diaphragm. [Ref SE Q.6]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. What is the composition of the radiographic ● The emulsion is a homogenous mixture having two
film? Describe the mechanism of image formation. principal components:
Add a note on the constituents of developing and fix- a. Silver halide crystals
ing solutions. b. Gelatin matrix}
Ans. a. Silver halide crystals
● A halide is a chemical compound that is
[SE Q.1]
sensitive to radiation or light. The halides
{The dental X-ray film serves as a recording medium used in dental X-ray film are made up of the
or image receptor. A latent image is recorded in the X-ray element silver plus a halogen (bromine or
film when it is exposed to information carrying X-ray iodine).
photons. ● Silver bromide (AgBr) and silver iodide (AgI)
Composition of the radiographic film are two types of silver halide crystals found in
The X-ray film used in dentistry has four basic components: the film emulsion. The typical emulsion is
i. Film base 80%–99% silver bromide and 1%–10% silver
ii. Adhesive layer iodide.
iii. Film emulsion ● It is composed primarily of silver bromide and
iv. Protective layer to lesser extent silver iodide.
i. Film base The presence of silver iodide adds greatly to the
● The film base is a flexible piece of polyester plastic
sensitivity to the film emulsion, thereby reducing
(polyethylene terephthalate) 0.2 mm in thickness radiation dose required to produce an adequate
that is constructed to withstand heat, moisture and diagnostic image.
● The silver halide crystals absorb radiation dur-
chemical exposure.
● It is transparent and exhibits a slight blue tint that is
ing X-ray exposure and store energy from the
used to emphasize contrast and enhance image qual- radiation.
ity and also to provide optimal viewing conditions. b. Gelatin matrix
● The gelatin is derived from ‘cattle bone’.
● The primary purpose of the film base is to provide a
● It is used to support silver halide crystals sus-
stable support for the delicate emulsion. The base also
provides strength. pended in gelatin framework over the film base.
● During film processing, the gelatin absorbs the
ii. Adhesive layer
● The adhesive layer is a substratum or subcoating
processing solutions and allows the chemicals
consisting of a thin layer of adhesive material that to react with the silver halide crystals.
covers both sides of the film base. [SE Q.1]
● This layer is added to the film base before the emul-
sion is applied and it serves to attach the emulsion to iv. {Protective layer
the base. ● The protective layer is a thin, nonabrasive, transparent
iii. Film emulsion super coat placed over the emulsion.
● The film emulsion is a coating on both sides of the ● It serves to protect the emulsion surface from ma-
film base to give the film greater sensitivity to X-ray nipulation as well as mechanical and processing
radiation. damage.}
Image formation Ingredient Chemical Function

Latent image formation
iii. Activator Sodium or ● Activates developer
● Silver halide crystals absorb X-ray radiation dur-
potassium agents by providing
ing X-ray exposure and store the energy from the hydroxide, necessary alkaline en-
radiation. sodium vironment for develop-
● Depending on the density of the objects in the carbonate ing agents
● Softens gelatin of the
area exposed, silver halide crystals contain vari-
film emulsion so that
ous levels of stored energy. developing agents can
● The stored energy within the silver halide crystals diffuse more rapidly in
forms a pattern and creates an invisible image the emulsion
within the emulsion on the exposed film. This pat- iv. Restrainer Potassium ● Depresses the reduc-
tern of stored energy on the exposed film cannot bromide tion of unexposed
be seen and is referred to as a latent image. silver halide crystals
● When the X-ray photons hit the surface of the film ● Acts as antifog agent
emulsion, some silver bromide crystals are ex- and increases the
contrast
posed and energized, while other crystals are not
exposed. The silver bromide crystals exposed to
X-ray photons are ionized, and the silver and bro- Fixer solution
mine atoms are separated. The fixer solution contains four basic ingredients:
● Irregularities in the lattice structure of the exposed i. Fixing agent
crystal, known as sensitivity specks, attract the ii. Preservative
silver atoms. These aggregates of neutral silver iii. Hardening agent
atoms are known as latent image centres. iv. Acidifier
● Collectively, the crystals with aggregates of silver The functions of each ingredient in fixer solution are as
at the latent image centres become the latent im- follows:
age on the film.
● The latent image remains invisible within the Ingredient Chemical Function
emulsion until it undergoes chemical processing Clearing Sodium thio- Removes all unexposed
procedures. agent sulphate or undeveloped silver halide
Visible image formation ammonium grains from the emulsion
When the exposed film with latent image is pro- thiosulphate
(hypo)
cessed, a visible image results.
Developer solution Acidifier Acetic acid; Neutralizes or inactivates
The developer solution contains four basic ingredients: sulphuric acid any carryover developing
agents in film emulsion and
i. Developer stops further development
ii. Preservative
iii. Activator Preservative Sodium Prevents oxidation of the
sulphite thiosulphate clearing agent
iv. Restrainer
The functions of each ingredient in developer solution Hardener Aluminium Shrinks and hardens the
are as follows: sulphate or po- gelatin in the emulsion
tassium alum
Ingredient Chemical Function

i. Developer Hydroquinone ● Converts exposed sil- Q.2. Packaging of intraoral periapical films.
and Phenidone ver halide crystals to
and Elon metallic silver grains Ans.
● Quickly generates
the grey tones in the
image
{SN Q.4}
● Slowly generates the ● An intraoral film is a film that is placed inside the
black tones and con-
trast in the image
mouth during X-ray exposure and is used to examine
the teeth and supporting structures.
ii. Preserva- Sodium sulphite ● Prevents rapid oxida-
Intraoral film packaging
tive tion of the developing
● Each intraoral film is packaged to protect it from
agents
● Extends their useful life light and moisture.
● The outer wrapper of the film packet has two sides:

● The film and its surrounding packaging are
a. Tube side
referred to as a film packet.
b. Label side
● Intraoral X-ray film packets have four basic
components: a. Tube side:

i. The X-ray film ● The tube side is solid white and has a raised
ii. Paper film wrapper bump in one corner that corresponds to the
iii. Lead foil sheet identification dot on the X-ray film.
iv. Outer film wrapping ● When placed in the mouth, the white colour
side of the film packet must face the teeth and

the tube head.
i. X-ray film
b. Label side:
● The intraoral X-ray film is a double-emulsion film.
● The label side of the film packet has a flap
Double-emulsion film is used instead of single-
used to open the film packet.
emulsion film because it requires less radiation ex-
● This side is colour-coded to identify films
posure to produce an image.
outside of the plastic packaging container.
● A film packet may contain one film (one-film packet)
Colour codes are used to distinguish between
or two films (two-film packet).
one-film and two-film packets and between
A two-film packet produces two identical radiographs
film speeds.
with the same amount of exposure necessary to produce
● When placed in the mouth, the colour-coded
a single radiograph. This is used when a duplicate re-
side (label side) of the packet must face the
cord of a radiograph is needed either for insurance
tongue.
claims or patient referrals.
● The following information is printed on the
● A small, raised dot known as the identification dot
label side of the film packet:
is located in one corner of the intraoral X-ray film.
● A circle or dot that corresponds with the
This raised dot is used to distinguish between the
raised identification dot on the film
left and right sides of the patient after the film is
● The statement ‘opposite side toward tube’
processed; hence, it is significant in film orienta-
● The manufacturer’s name
tion, mounting and interpretation.
● The film speed
ii. Paper film wrapper
● The number of films enclosed
● The paper film wrapper within the film packet is a
● In dentistry, the terms ‘film packet’ and ‘film’
protective sheet of black paper that covers the film.
are often used interchangeably. Intraoral film
● It also shields the film from light leak.
packets are typically available in quantities of
iii. Lead foil sheet
25, 100 or 150 films per container.
● The lead foil sheet is a single thin piece of lead foil
● Film packets are packaged in convenient plastic
within the film packet that is located behind the film
trays or cardboard boxes that can be recycled.
wrapped in black protective paper.
● Boxes of intraoral film are labelled with the
● The thin lead foil sheet is positioned behind the film;
type of film, film speed, film size, number of
it absorbs most of the X-rays that pass through the film
films per individual packet, total number of
and prevent them from reaching the tongue and other
films enclosed and the film expiry date.
oral tissues. It also shields the film from back scattered
or secondary radiation, which results in film fog. Q.3. Composition of intraoral periapical films.
● It also gives sufficient strength to the whole film
Ans.
packet.
● If the film packet is inadvertently positioned reverse [Same as LE Q.1]
in the mouth, then the shadow of the foil is seen on
radiograph as ‘tyre track’ marks or ‘Herring bone’
appearance, which is the embossed pattern placed on
SHORT ESSAYS:
the lead foil by the manufacturer. Q.1. Radiographic film composition (or) dental X-ray film.
iv. Outer package wrapping
Ans.
● The outer package wrapping is a soft-vinyl or a pa-
per wrapper that hermetically seals the film packet, [Ref LE Q.1]
protective black paper and lead foil sheet.
Q.2. Intensifying screens.
● This outer wrapper serves to protect the film from
exposure to light and saliva. Ans.
● An intensifying screen is a device that transfers X-ray They may also be classified as:
energy into visible light, which in turn exposes the C. Focused grids
screen film. D. Nonfocused grids
● As they intensify, the effect of X-rays on the film and
A. Stationary grids
the use of intensifying screens reduce the radiation re-
i. Linear grid
quired to expose a screen film, thereby reducing the
● In the linear grid, the strips of lead are placed
patient’s exposure to radiation.
parallel to each other.
● In extraoral radiography, a screen film is sandwiched
● While using the linear grid, cut-off of the beam
between two intensifying screens of matching size and
can occur as some of the primary beam may
is secured in a cassette.
get absorbed by the lead in the peripheral re-
● An intensifying screen is a smooth plastic sheet coated
gion. If the grid is not perpendicular to the
with minute fluorescent crystals known as phosphors.
central axis of the beam, this can also take
When exposed to X-rays, the phosphors fluoresce and
place in the centre of the film.
emit visible light in the blue or green spectrum; the
● For all practical purposes, the central beam
emitted light then exposes the film.
should be in plane parallel with grid lines.
● Conventional calcium tungstate screens have phosphors
ii. Focused grid:
that emit blue light. The newer rare earth screens have
● In the focused grid, the lead strips are angled
phosphors that are not commonly found in the earth and
from the centre to the edge so that the inter-
emit green light.
spaces are directed at the focal spot.
● Rare earth intensifying screens are more efficient than
● The disadvantage of using a linear grid can be
calcium tungstate intensifying screens at converting
greatly minimized by using a focused grid.
X-rays into light. As a result, rare earth screens require
iii. Pseudofocused grid:
less X-ray exposure than calcium tungstate screens and
● The extra reduction of primary radiation away
are considered to be faster.
from the centre of the beam can be minimized
● The use of rare earth screens means less exposure to
by using a pseudofocused grid.
X-ray radiation for the patient. Rare earth intensifying
● In this grid, the height of the lead strips is
screens (Kodak Lanex Regular and Medium screens)
progressively reduced from the centre to the
are designed for use with green-sensitive films (Kodak
periphery.
Ortho and T-Mat films); whereas, conventional screens
iv. Crossed grid:
(Kodak X-somatic Regular screens) are used with blue-
● Another effective way of limiting the scattered
sensitive films (Kodak X-Omat and Ektamat films).
radiation further is by using a crossed grid.
Q.3. Grid functions and grids in radiography. ● In crossed grid, two grids are placed on top of
each other and at right angles. This minimizes

Ans.
the scattered radiation traversing in the same
● Grid is a radiographic accessory, which helps in reduc- line as the primary beam.
ing the scattered radiation when placed between the B. Moving grids
patient and the film, as close as possible to the latter. ● They are moved sideways across the film during
● It helps to reduce the film fog and improves the contrast. exposure.
● The grid is made up of alternate layers of radiolucent, ● The use of moving grid reduces the white lead
i.e. plastics and radiopaque, such as lead, which are lines in the radiographic image.
aligned in the direction of the primary beam either par-
Q.4. Composition, ideal requirements and uses of inten-
allel to each other or at an angle/focused. In general,
sifying screen.
grid has 80 line pairs per inch.
● Grid ratio – the ratio of the thickness of the grid to the Ans.
distance between the spacer is termed as the grid ratio.
● The moving grid is normally used to get rid of the radi- ● An intensifying screen is a device that transfers X-ray
opaque fine lines that may appear on the radiograph. It energy into visible light, which in turn exposes the
is also termed as the Potter–Bucky diaphragm. screen film.
● Intensifying screens make use of the principle of
● Most of the extraoral radiographic projections of the skull-
like Paranasal sinus view (PNS), Caldwell view, submento- fluorescence.

● An intensifying screen and film combination makes the
vertex view are best visualized using grids with screen films.
Various types of grids are classified as follows: image receptor system 10–60 times more sensitive than
A. Stationary grids when the film is used alone. Hence, their use consider-
B. Moving grids ably reduces the radiation exposure to the patient.
{SN Q.2} ● It is the surface layer of the intensifying screen which

protects phosphor layer from mechanical insult.
Composition of intensifying screens is as follows:
i. Base
ii. Reflecting layer ● This layer can be cleaned. The intensifying screen
iii. Phosphor layer should be kept clean without any debris, spots, or
iv. Coat scratches. Otherwise, these areas will result in underex-
posed or light areas in the image.
i. Base
The ideal requirements of a fluorescent material are:
● Base of an intensifying screen is usually made up
● The material should absorb a greater amount of X-rays,
of either stiff sheet of cardboard or polyester
i.e. it should have a high absorption coefficient.
plastic having a thickness of 0.25 mm.
● It should have moderately high atomic number (Z).
● It should emit a large amount of light of a suitable
● The base is the supporting component of the screen. energy and colour. There should not be any afterglow
which can adversely affect the image quality.
{SN Q.2} Q.5. Speed of intraoral film.
ii. Reflecting layer Ans.
● This layer is usually made of a white material
either magnesium oxide or titanium dioxide. {SN Q.8}

● It lies below the phosphor layer. It reflects the
● Film speed refers to the amount of radiation required
light emitted by the phosphor layer to the X-ray to produce a radiograph of standard density.
film. ● The speed of a film is clearly indicated on the label
iii. Phosphor layer side of the intraoral film packet as well as on the
This layer consists of a light sensitive phosphor outside of the film box or container.
crystal suspended in a plastic material. ● The factors determining film speed, or sensitivity, are
● The various phosphors used are as follows:
as follows:
● Calcium tungstate
i. Size of the silver halide crystals
● Zinc sulphide
ii. Thickness of the emulsion
● Zinc cadmium sulphide
iii. Presence of special radiosensitive dyes
● Barium lead sulphate
● Film speed determines how much radiation and how
● Terbium-activated gadolinium oxysulphide
much exposure time are necessary to produce an im-
(GdzOz:Tb). age on a film.
● For example, a fast film requires less radiation expo-
● Thallium-activated lanthanum oxybromide (LaOBr:Tm). sure because the film responds more quickly; a fast
● The last two phosphors in the list are rare earth materi- film responds more quickly because the silver halide
als. These phosphors are also called as ‘salts’; hence, crystals in the emulsion are larger. The larger the crys-
the intensifying screens are also called as salt screens. tals, the faster is the film speed.
● Calcium tungstate is the most commonly used phos- ● An alphabetical classification system is used to iden-
phor. When these crystals are struck by photons, they tify film speed:
fluoresce, i.e. emit visible light photons that expose the ● X-ray films are given speed ratings ranging from
X-ray film. A speed (the slowest) to F speed (the fastest). Only

● The rare earth intensifying screens are about four times D-speed film and F-speed film are used for intraoral
more efficient than calcium tungstate intensifying screens. radiography; E-speed film has been discontinued by
● Special X-ray films sensitive to green light are required Kodak.
while using rare earth intensifying screens. ● The American Dental Association (ADA) and the Amer-
ican Academy of Oral and Maxillofacial Radiology

(AAOMR) currently recommend the use of F-speed film.
{SN Q.2}
● F-speed film requires 60% of the exposure time of
iv. Coat D-speed film and has comparable image contrast and
● This acts as a protective coat and is made up of resolution.
plastic having a thickness of about 8 microns over ● The use of F-speed film results in less radiation ex-
the phosphor layer. posure for the patient. F-speed film is a faster film
than D-speed because of the larger crystals and the Disadvantages

increased amount of silver bromide in the emulsion. ● Costly
● Current F-speed films not only reduce radiation dose ● Subject to failure
to the patient but also provide stable contrast charac- ● Increases the minimum exposure time due to slow
teristics under various processing conditions. motion

● The Ekta speed films (E speed) have a marking EKT ● Increases patient dose
and only the E speed films must be used in the clinics

today since they allow good radiographic visualiza- Q.7. Enumerate various types of intraoral films.
tion with minimum radiation exposure.
Ans.
Q.6. Moving grid. ● Intraoral films are used inside the oral cavity. These
films are comparatively of smaller size. Intraoral films
Ans. are usually coated on both the sides, which allows fewer
radiations to make an image.
{SN Q.9} ● Single film packets or sometimes double film packets
are used. If two films are used, second film is used for
● Moving grid is also known as Potter–Bucky dia-
keeping the duplicating records.
phragm invented by Hollis E. Potter in 1920.
● Intraoral films are generally divided into three catego-
● Grid is a radiographic accessory, which helps in reduc-
ries. Categories are only on the basis of their clinical
ing the scattered radiation when placed between the
use. For sake of convenience, the intraoral films are
patient and the film, as close as possible to the latter.
designated by numbers, as periapical films (No. 1), bite
● Potter–Bucky grid is a moving type of a grid used in
wing films (No. 2) and occlusal films (No. 3).
radiography; it prevents scattered radiation from
A. Periapical films
reaching the film, thereby securing better contrast
● The periapical films are designated as No. 1. They
and definition.
are utilized where radiographs of crowns, roots
● The first models were built up from alternate strips of
and periapical areas are required. One such film is
lead and wood. The strips are built up on a radius
sufficient for three teeth.
which would have at its centre the X-ray tube anode.
● Periapical films are given number 1.0, 1.1, and so on.
● In this the grid is moved sideways across the film dur-
1.0 is periapical film for children (20 3 35 mm).
ing exposure. This leads to the blurring out of the shad-
This is also used in adults where the patient has the
ows of grid strips, thus they are not visible on the film.
problem of gagging. 1.1 is periapical film for routine
use and 1.2 is of little higher size.
● The image of the radiopaque grid lines on the film can ● The contrast and details are quite well with these
be deleted by mechanically moving the grid in a direc- films, whether the film may be single or double in
tion of 90° to the grid lines, during exposure. This re- one packet.
sults in blurring out the radiolucent lines and resulting B. Bitewing Films
in a more uniform exposure.
● When radiation encounters some form of matter, some {SN Q.3}
of the radiation is scattered in all directions and simply
● The bitewing films are designated as No. 2. Further
produces an overall fog level.
these are designated as 2.0, 2.1, and so on depending
● The Potter–Bucky diaphragm removes most of the scat-
upon the size. 2.3 is used in anterior teeth because
ter while allowing most of the primary radiation through.
the vertical height is greater than horizontal height.
● The lead slats would be expected to cast a shadow on
● These are available in three sizes suitable for anteri-
the image, but this is removed by moving the grid dur-
ors, premolars and molars.
ing the exposure.
● These films record the coronal portion of maxillary
● The modern version of the Potter–Bucky diaphragm is
and mandibular teeth in one image and are generally
flat instead of curved, but employs the same principle.
taken for periodic check-up to see early changes in
caries and periodontal tissues.
{SN Q.9}
● Bite wing films are used:
Advantages ● To detect early caries and periodontal lesions.
● It removes the scatter radiation effectively. ● To see the penetration of caries on the proximal
● Grid reduces the white lead lines effectively. side and extent of pulp chamber.
Q.3. Advantages of bitewing radiographs.

To see the permanent tooth bud in relation to the
●
deciduous tooth. Ans.

[Ref SE Q.7]
C. Occlusal films Q.4. Intraoral X-ray film packet.
Ans.
{SN Q.5}
[Ref LE Q.2]
● The occlusal films are designated as No. 3. The size
of the film is four times the routine periapical films Q.5. Occlusal film.
(60 3 75 mm). Ans.
● As the name derives, the occlusal film is held in posi-
tion by letting the patient bite lightly on the film to [Ref SE Q.7]
support it between the occlusal surface of each jaw. Q.6. State the functions of lead foil in the X-ray film packet.
● They are used:
● For gross examination of maxilla and mandible Ans.

and to have a broad view of deciduous teeth for ● The lead foil sheet is a single thin piece of lead foil
serial extractions. within the film packet that is located behind the film
● To view large areas with pathological involvement
wrapped in black protective paper.
and determine their buccolingual relationship. ● Functions of the lead foil sheet:
● To detect extent of fractures.
i. It absorbs most of the X-rays that pass through the
● To detect impacted or supernumerary teeth.
film and prevent them from reaching tongue and
● Localization of foreign bodies in glands.
other oral tissues.
ii. It also shields the film from backscattered or
secondary radiation, which results in film fog.
iii. It also gives sufficient strength to the whole film
SHORT NOTES: packet.
Q.1. Storage of X-ray films.
Q.7. Intraoral periapical film.
Ans.
Ans.
As the X-ray film is adversely affected by heat, humidity
● The term periapical is derived from the Greek word
and radiation, the following points should be considered
peri, meaning ‘around’, and the Latin word apex, mean-
while storing X-ray films:
ing the terminal end of a tooth root. This type of film
● To prevent film fog, unexposed, unprocessed film must
shows the tip of the tooth root and surrounding struc-
be kept in a cool, dry place.
tures as well as the crown.
● The optimum temperature for film storage ranges from
● The periapical film is used to examine the entire tooth
50° to 70° F, and the optimum relative humidity level
both crown and root and supporting bone.
ranges from 30% to 50%.
● Periapical films are available in three sizes:
● Film must be stored in areas that are adequately shielded
from sources of radiation and should not be stored in Size 0 Paediatric film – 22 3 35 mm
areas where patients are exposed to X-ray radiation.
Size 1 Adult anterior – 24 3 40 mm
● To prevent film fog, lead-lined or radiation-resistant
film dispensers and storage boxes are ideal. Size 2 Standard adult – 32 3 41 mm
● All dental X-ray films have a limited shelf life. They
must be used before the labelled expiration date. Q.8. Speed of intraoral film.
● The ‘first in, first out’ rule of thumb should be applied
Ans.
to film use; the oldest film in stock should always be
used before any new film. [Ref SE Q.5]
Q.2. Composition of intensifying screen. Q.9. Potter–Bucky diaphragm.
Ans. Ans.
[Ref SE Q.4] [Ref SE Q.6]
Topic 4
Processing of X-Ray Films
LONG ESSAYS:
1 . What is the composition of radiographic film? Describe the mechanism of image formation.
2. Describe the composition of developing and fixing solution and their functions.
3. Describe the processing of X-ray film.
4. Describe the darkroom chemistry.
5. Write in detail the composition and actions of developer and fixer used in dental radiography. [Same as LE Q.2]
SHORT ESSAYS:
1. Composition of developer solution. [Ref LE Q.2]
2. Fixing solution. [Ref LE Q.2]
3. Processing errors of radiographs.
4. Automatic film processing.
5. Processing of X-ray film.
6. Coin test.
7. Requirements of a darkroom. [Ref LE Q.4]
8. Composition and functions of developing solution. [Same as SE Q.1]
9. Composition and actions of developing solution. [Same as SE Q.1]
10. Composition and action of fixer solution. [Same as SE Q.2]
11. X-ray fixing solution. [Same as SE Q.2]
12. Types of X-ray film processing. [Same as SE Q.5]
13. Processing of an intraoral film. [Same as SE Q.5]
SHORT NOTES:
1 . Composition of developer solution. [Ref LE Q.2]
2. Resolution.
3. Replenisher.
4. Fixing solution.
5. Actions of developing solutions.
6. Automatic film processing.
7. Storage of X-rays films.
8. Requirements of darkroom. [Ref LE Q.4]
9. Coin test. [Ref SE Q.6]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. What is the composition of radiographic film? Composition of the radiographic film
Describe the mechanism of image formation. The X-ray film used in dentistry has four basic
components:
Ans.
i. Film base
The dental X-ray film serves as a recording medium or im- ii. Adhesive layer
age receptor. A latent image is recorded in the X-ray film iii. Film emulsion
when it is exposed to information carrying X-ray photons. iv. Protective layer
The mechanism of image formation in detail is as site, it is neutralized, with the result that an atom of
follows: metallic silver is deposited at the site.
● On exposure of the X-ray film to the information ● This process occurs many times at a single site
carrying beam of photons coming out of an ob- within a crystal whenever photons and recoil elec-
ject, there is a chemical change in the photosensi- tron strike bromide ions.
tive silver halide crystals in the film emulsion that ● After exposure of a film to radiation, the aggregate of
interact with these photons. These chemically al- silver atoms at the latent image sites comprises the
tered crystals are said to constitute the latent or latent image.
invisible image on the film. ● It is the metallic silver at each latent image site that
● The concept of the latent image implies that catalyses the development of the halide crystal in
chemical changes produced by the X-ray increase which it is formed, i.e. renders the crystal sensitive to
the ability of the altered crystals to the chemical development and image formation.
action of the ‘developing’ process that converts ● The larger the aggregate of silver atoms, the
the latent image to visible image. more sensitive the crystal is to the effects of the
Formation of latent image developer.
● The film emulsion is a suspension of tiny photosensi- ● The primary actions of the processing solution are to
tive silver bromide and silver iodide crystals that convert the crystals with the latent images to black
have been precipitated in gelatin and layered to a thin metallic silver grains that can be visualized and to
sheet of transparent plastic base. remove the unexposed silver bromide crystals.
● These silver halide crystals are imperfect in many
Q.2. Describe the composition of developing and fixing
ways and they contain a few free silver ions in the solution and their functions.
spaces between the crystalline lattice positions,
which are referred to as interstitial silver ions. Ans.
● There are physical distortions in the regular rectan-
(SE Q.1 and SN Q.1)
gular arrangement of the silver and bromide ions in
the crystals due to the presence of the iodine atoms {(Developer and fixer are two special chemical
occupying some of the bromide sites. solutions that are necessary for film processing.
● The silver halide crystals are chemically sensitized Developer solution
by the presence of added sulphur compounds that The developer solution contains the following five basic
play a critical role in image formation. The physical chemicals and other ingredients as follows:
irregularities in the crystal produced by the iodide i. Developing agent
ions are called the latent image sites. ii. Preservative
● There are many such latent image sites in each crys- iii. Activator
tal; their function is to begin the process of image iv. Restrainer
formation by trapping the electrons generated when v. Hardener
the emulsion is irradiated. vi. Fungicide, buffers and solvent)}
● When the silver halide crystals are irradiated, X-ray Developing agent
photons interact primarily with the bromide ions by ● The developing agent is also known as the reducing
Compton and photoelectric interactions. These result agent, which contains the following chemicals:
in the removal of an electron from the bromide ions a. Hydroquinone (paradihydroxybenzene)
with the production of high-speed electrons and scat- b. Elon or Metol (monomethyl-para-amino phenol
tered photons. sulphate)
● Due to the loss of the electrons, the bromide ions are c. Metol/phenindione (1-phenyl-3-pyrazolidinone)
converted into bromine atoms that are absorbed by ● The purpose of the developing agent is to reduce the
the gelatin of the emulsion. exposed silver halide crystals chemically to black
● The recoil electrons move through the crystal, gener- metallic silver.
ating additional bromine atoms, secondary recoil ● Hydroquinone is a benzene derivative and acts at
electrons and scattered photons until a major portion slow rate but generates the black tones and the sharp
of their energy has been expended and they encoun- contrast of the radiographic image. Hydroquinone is
ter a latent image site. Here they become ‘trapped’ temperature sensitive; it is inactive below 60°F and
and thereby impart a negative charge to the site. very active above 80°F. Films are best developed at
● The positively charged free interstitial silver ions are 70°F for 5 min.
attracted to the negatively charged latent image site. ● Elon is the product of aniline dyes and acts quickly
When the silver ion reaches the charged latent image to produce a visible radiographic image. It helps to
develop shadow areas or shades of grey on the film Solution should not be used for more than 10–14 days
and brings detail. It is less sensitive to temperature irrespective of the number of films processed during
changes and generates grey tones in the image. that time.
● Metal phenindione: It is a by-product of aniline dyes,
works at faster rate but gives a low contrast. It is an [SE Q.1]

efficient activator for hydroquinone at a very low {Composition of developer in brief
concentration and works at lower alkalinity. It is
more commonly used in automatic processor. Ingredient Chemical Function
● The image produced will have shades of grey if only Developing i. Hydroquinone i. Converts exposed silver ha-
Elon is used; if only hydroquinone is used, the image agent ii. Elon lide crystals to black metal-
will be black and white and if a combination is used, lic silver. Slowly generates
the black tones and contrast
image will have all black, white, and grey shades. in the image
Preservative ii. Converts exposed silver ha-
● Sodium sulphite is used as preservative. As it has lide crystals to black metal-
great affinity for oxygen, it prevents oxidation of lic silver. Quickly generates
developer solution and forms sulphonates, when the grey tones in the image
combined with oxygen. Preservative Sodium sulphite Prevents rapid oxidation of the
Activator developing agents
● Sodium carbonate is used as an activator. It provides Accelerator Sodium Activates developer agents
alkaline medium usually above a pH of 11, which is carbonate Provides alkaline environment
required for hydroquinone to act, and it also softens for developing agents; softens
gelatin of the film emulsion
the gelatin of the emulsion.
● It causes the emulsion to swell, makes the penetra- Restrainer Potassium Prevents the developer from
tion of developing agent, and diffusion of the reac- bromide developing the unexposed
silver halide crystals
tion product out, easier. This component of developer
makes it soapy to touch. Hardener Glutaraldehyde Used in automatic processing,
● Other activators used are sodium hydroxide, sodium
to prevent emulsion from soft-
ening and sticking to the rollers
metaborate and sodium tetraborate.
● Excessive alkalinity causes rapid reduction even of Antibacterial Fungicide Prevents bacterial growth
the unexposed silver bromide crystals and produces Solvent Water Dissolves chemicals }
fog.
Restrainer
● Potassium bromide or benzothiazole is used as the Composition of fixer
restrainer. It prevents chemical fog, which is also The function of fixer is to remove the undeveloped sil-
called developmental fog. ver halide crystals from the emulsion and harden the
● The added bromide serves to depress the reduction in emulsion.
the unexposed crystals and hence acts as an antifog The fixer solution contains four basic ingredients:
agent and it restricts the action of the developing i. Fixing agent
agent only to those silver halide crystals that are ii. Preservative
irradiated. iii. Hardening agent
Hardener iv. Acidifier
● Glutaraldehyde is added as a hardener, particularly in
[SE Q.2]
automatic processing to prevent emulsion from soft-
ening and sticking to the rollers. {Fixing agent
Fungicide ● The fixing agent is also known as the clearing agent
● It is added to prevent bacterial growth. and is made up of sodium thiosulphate (hypo) or am-
Buffers monium thiosulphate.
● These are added to maintain the pH of developer. ● Its purpose is to remove or clear all unexposed and unde-
Solvent veloped silver halide crystals from the film emulsion al-
● Distilled water is used as the solvent and as a me- lowing light to pass through the film image and permit-
dium in which the chemicals can react with the silver ting viewing of the radiographic image on a view box.
bromide of the emulsion. ● This chemical ‘clears’ the film so that the black
The alkaline developer solution should be concentrated image produced by the developer becomes readily
as recommended by the manufacturer’s instructions. distinguished.}
Preservative The purpose of processing is

● Sodium sulphite, the same preservative as in the de- ● Visible image formation
veloper solution, is also used in the fixer solution. ● Preservation of image permanently for later correspon-
● The purpose of the preservative is to prevent the dence

chemical deterioration of the fixing agent. Types of processing
● It also helps to clear the film by binding with any There are basically two types of processing methods. They are
oxidized developer, which is carried to the fixing i. Manual processing
solution. a. Visual method
Hardening agent b. Time–temperature method
● Potassium alum, aluminium chloride, etc. are used as ii. Automatic processing
the hardening agent in the fixer solution.
i. Manual processing
● It hardens and shrinks the gelatin in the film emul-
a. Visual method:
sion to prevent its oxidation and protects it against
● The visual method of manual processing is carried
the scratches.
out in a darkroom with safelighting conditions.
● It also shortens the drying time. It reduces the swell-
● In this method, an exposed X-ray film is im-
ing of the emulsion during the final wash resulting in
mersed in the developing solution and periodi-
less mechanical damage to the emulsion, hence lim-
cally viewed under the safelight for the emer-
iting water absorption.
gence of a clear image.
● It also neutralizes any contaminating alkali from the
● When the image appears, the film is washed
developer.
and immersed in the fixing solution.
Acidifier
b. Time–temperature method:
● The acidifier used in the fixer solution is acetic acid
● Time–temperature method is a type of manual
or sulphuric acid. Its purpose is to neutralize the al-
processing method in which effective stan-
kaline developer.
dardization may be achieved without any auto-
● It provides necessary acidic medium for diffusion of
matic aids.
thiosulphate into emulsion.
● It is a simple technique of immersing the film
● The acidifier also produces the necessary acidic en-
in the developer kept at a constant temperature
vironment required by the fixing agent.
for a fixed duration of time.
[SE Q.2] The time–temperature chart is as follows:
{Composition fixer Temperature Development Time

Ingredient Chemical Function 65°F 6 min
Fixing agent Sodium thiosul- Removes all unexposed 68°F 5 min
phate; ammonium undeveloped silver halide 70–72°F 4 min
thiosulphate crystals from the emulsion 76°F 3 min
Preservative Sodium sulphite Prevents deterioration of

fixing agent ● The advantage of manual processing is that the ac-
Hardening Potassium alum Shrinks and hardens the tion of development is under the direct control of the
agent gelatin in the emulsion operator.
● Disadvantages: Handling wet film, the requirement
Acidifier Acetic acid; Neutralizes the alkaline
sulphuric acid developer and stops further of a darkroom and time consuming.
development ii. Automatic processing
Solvent Water It dissolves chemicals} ● In automatic processing machines, the exposed
film is fed at one end and it passes successively

through the developer, fixer, water and drier.
● The roller system has a squeezing action; the de-
Q.3. Describe the processing of X-ray film. veloping solution absorbed by the gelatin of the
emulsion will be less as it is transported from the
Ans. developer to the fixer.
Processing is the term used to describe the sequence of ● The automatic processing machines make use of
events required to convert the invisible latent image con- roller system for the transport of film. The film
tained in the sensitized emulsion into the visible permanent comes out through the other end of the processor,
radiographic image. processed, dry and ready for viewing.
The steps involved in manual processing of X-ray film Darkroom equipment

consist of: ● The darkroom should contain the following infra-
i. Developing the film structure:

ii. Rinsing in water i. Safelights
iii. Fixing of film ii. Visible light source (tube lights)
iv. Washing film in running water iii. Working area to load extraoral cassettes
v. Drying and mounting of film iv. Processing tanks
v. Thermometer and stop clock
i. Developing the film vi. Dryer
● The exposed film is immersed in the developing
vii. Storage facility for unexposed films
solution until the image emerges. viii. Exhaust and appropriate ventilation
● Depending on the exposure time of film and
Requirements of a darkroom
concentration of the developing solution, the
time taken for development ranges from a few (SE Q.7 and SN Q.8)
seconds to a few minutes.
ii. Rinsing in water
● After developing the film, it is rinsed in water for
{(The darkroom must be properly designed and well
equipped. A well-planned darkroom makes processing
15–20 s before placing in the fixer. This slows down
easier. An ideal darkroom must have the following
the development process and removes any alkali of
characteristics:
the developing solution before placing in acidic fixer.
i. Convenient location
iii. Fixing of film
ii. Adequate size with ample working space
● Film is placed in the fixer for about 8–10 min.
iii. Correct lighting equipment
● The action of the fixing solution is to remove the
iv. Adequate storage
unexposed silver halide crystals and harden the
v. Temperature and humidity controlled
emulsion.
Other miscellaneous darkroom requirements include a
● Too long fixing time can cause film fog and loss
waste basket for the disposal of all film wrappings and
of proper contrast.
an X-ray view box.)}
iv. Washing of film
● The film should be washed thoroughly for suffi-
cient length of time in running water to remove [SE Q.7]

residual fixing solution.
● If the silver compounds are not removed, there i. {Convenient location
can be stains on the film. Discolouration of the ● The location of the darkroom must be convenient.
image can also result due to the presence of thio- Ideally, it should be located near the area where
sulphate and its products. X-ray units are installed.
v. Drying and mounting of film ii. Adequate size with ample working space
● The last step in the processing is drying the film ● The darkroom must be large enough to accommo-
and mounting for viewing. date film processing equipment and to allow ample
● The film should be dried in a relatively dust-free working space.
environment. ● The size of the darkroom is determined by the fol-
● Commercially, driers are available for drying the lowing factors:

film. a. Volume of radiographs processed
● Drying a film is very important as sometimes the b. Number of persons using the room
water marks can result in artefacts. The processed c. Type of processing equipment used
films should be properly identified, mounted and d. Space required for duplication of films and
then viewed under transillumination. storage
The dental darkrooms, since smaller developer and
Q.4. Describe the darkroom chemistry. fixer tanks can be utilized, may be of small sizes. The
Ans. average size required is 6 feet 3 8 feet. The ceiling
should not be less than 2.7 m high. The floor should
(SE Q.7 and SN Q.8) be made in such a way that it remains nonslippery
and resistant to staining. The ceiling and walls should
{(The main function of a darkroom is to provide a be well painted.
● For protection from the ionizing radiations, the walls
completely darkened environment where X-ray film can be
handled and processed to produce diagnostic radiographs should have 2.0 mm equivalency of lead. A 25-mm
in an efficient, precise and standardized procedure.)} thick barium plaster can also be used. The area where
films are stored should be covered well.
iii. Correct lighting equipment ● A relative humidity level of between 50% and 70%
● The main requirement of the darkroom is that it should be maintained. When humidity levels are too
should be light tight (light proof). The door should high, the film emulsion does not dry. When humidity
be light tight and with proper lock to avoid acciden- levels are too low, static electricity becomes a prob-
tal opening. lem and causes film artefacts.}
Two types of lightings essential in a darkroom are as ● The darkroom plumbing must include both hot and
follows: cold running water along with mixing valves to ad-

a. Room lighting just the water temperature in the processing tanks. A
● Incandescent room lighting is required for proce- utility sink with running water is also useful in the
dures not associated with the act of processing films. darkroom.
● An overhead white light that provides adequate il-
Q.5. Write in detail the composition and actions of
lumination for the size of the room is necessary to
developer and fixer used in dental radiography.
perform tasks such as cleaning, stocking materials
and mixing chemicals. Ans.
b. Safelighting
● The special type of lighting used to provide illu- [Same as LE Q.2]
mination in the darkroom is termed as safe-
lighting. SHORT ESSAYS:
● A safelight typically consists of a lamp equipped
with a low-wattage (15 watts) bulb and a safe- Q.1. Composition of developer solution.
light filter. A safelight filter removes the short Ans.
wavelengths in the blue-green portion of the vis-
ible light spectrum that are responsible for ex- [Ref LE Q.2]
posing and damaging X-ray film. Q.2. Fixing solution.
● Under safelight conditions, it is necessary to
maintain an adequate safelight illumination dis- Ans.

tance minimum of 4 feet (1.2 m) and to keep [Ref LE Q.2]
film handling times to a minimum otherwise
they appear fogged, and unwrapped films must Q.3. Processing errors of radiographs.
be processed immediately under safelight con-
Ans.
ditions.
● A good universal safelight filter recommended Processing errors of radiographs
for use in a darkroom in which both extraoral ● Poor image in an X-ray film results in loss of diagnostic
screen films and intraoral films are processed in information. Many defects are commonly encountered
the GBX-2 safelight filter by Kodak. in manual processors, though automatic processors also
iv. Adequate storage produce certain faults.
● The darkroom storage space must include ample Following errors are mainly encountered with manual pro-
room for chemical processing solutions, film cessing:
cassettes and other miscellaneous radiographic a. Light radiographs
supplies. The radiographs appear lighter due to:
● Storage of unopened boxes of film in the darkroom ● Underexposure and also may be due to insuffi-
is not recommended; a reaction between the fumes cient mA, kVp or time.
from chemical processing solutions and the film ● Excessive film–source distance.
emulsion may occur that will result in film fog. ● Underdeveloped, may be due to insufficient time,
● Boxes of opened extraoral film must be stored depleted developer or excessive fixation.
in the darkroom. A light tight storage drawer is ● Total white film is usually because of placing re-
necessary to protect opened boxes of unexposed verse side of the film during exposure.
extraoral film. b. Dark radiographs
v. Temperature and humidity controlled Dark radiographs are predicted because of the
● The temperature and humidity level of the darkroom following reasons:
must be controlled to prevent film damage. A room ● Overexposure or may be due to excessive mA,
temperature of 70°F is recommended; if the room kVp or excessive exposure time.

temperature exceeds 90°F, film fog results. ● Insufficient film–source distance.
● Overdevelopment or inadequate fixation. ● Automatic processing cycle is the same as for manual
● Accidental exposure to light. processing except that the rollers squeeze off any excess
c. Film fog developing solution before passing the film on to the
Fog on the film is due to: fixer, eliminating the need for the washing with water
● Leaking light in darkrooms. between these two solutions.
● Safelights not proper and/or excessive watt- Advantages
age. ● Time saving – dry films are produced in about five
● Contaminated solutions. minutes.

● Deteriorated films or films stored at the higher ● There is no need for a darkroom.
temperature and even outdated films. ● Controlled, standardized processing conditions are
● Overdevelopment. easy to maintain and chemicals can be replenished

d. Dark spots automatically.
The dark spots on the film are due to: Disadvantages
● Finger prints on the radiographs before ● Strict maintenance and regular cleaning are essential;
development. dirty rollers produce faulty radiographs.

● Excessive bending before development. ● Equipment is expensive.
● Film in contact with other films during fixation.

Q.5. Processing of X-ray film.
● Forceps touching the film during development.
e. Light spots/water spots Ans.

● Film contaminated with fixer before the pro-
Processing is the term used to describe the sequence of
cessing.
events required to convert the invisible latent image con-
● Film in contact with other film during developing.
tained in the sensitized emulsion into the visible permanent
● Scratches over the film.
radiographic image.
f. Yellow/brown stains
Various methods of processing are as follows:
The film shows yellow/brown stains due to:
i. Manual methods:
● Contaminated solutions and depleted devel-
a. Visual method
oper or fixer.
b. Rapid processing method
● Not thorough rinsing after fixing.
c. Time–temperature method
g. Blurred radiographs
ii. Automatic method
● Movement of the patient or X-ray tube and insta-
iii. Monobath method
bility of film during exposure.
iv. Daylight method
h. White lines
v. Digitalized processing method
● Manufacturing defects produce such type of
vi. Self-developing films
lines.
Various faults in case of automatic processor are as i. Manual method/time–temperature method
follows: The following steps are involved in manual method:
a. Pressure marks: Too tight roller springs. a. Replenish solutions and developing the film
b. Stripping of the emulsions: It may be because b. Rinsing in water
of the defective rollers or defective chemical c. Fixing of film
nature of the films. d. Washing film in running water
c. Streaks and mottles: They may result due to e. Drying and mounting of film
faulty position of air driers, squeezers and even a. Replenish solutions
too high temperature of the drier. ● The first step is to replenish the developer and fixer.
● Eight ounces (0.0284 L) per gallon (4.546 L)

Q.4. Automatic film processing.
of fresh developer and fixer are added to main-
Ans. tain the proper strength of each solution.
● Ensure that the level of developer and fixer in
● When the processing is carried out automatically by a tanks should cover the films on the top.
machine, it is known as automatic processing. ● The solutions are stirred to mix the chemicals and
● Several automatic processors are available, which are equalize the temperature throughout the tanks.
designed to carry the film through the complete cycle ● This prevents cross-contamination.
usually by a system of rollers. b. Developing
● Most have a daylight loading facility, eliminating the ● The timer mechanism is set and the hanger and
need for a darkroom. films are immersed immediately in the developer.
● The films are left in the developer for the pre- ● Results are not satisfactory as in conventional
determined time. processing.
The films are removed and the excess developer is
Q.6. Coin test
drained into the water bath. After developing, the
film hanger is placed in the running water bath for Ans.
30 s, agitating continuously to remove excess
developer and thus slow the development and {SN Q.9}
minimize contamination of the fixer.
c. Fixing ● Coin test is also known as Penny test.
● The hanger and film are then placed in the fixer ● The safelighting conditions in the darkroom can be
solution for a minute and agitated for 5 s every evaluated using a coin test.
30 s. The procedure of coin test is as follows:
d. Wash and dry i. Turn off all the lights in the darkroom, including
● After fixation of the films is complete, they are the safelight.
placed in running water for at least 10 min to ii. Unwrap the unexposed film. Place on a flat sur-
remove residual processing solutions. face at least 4 feet distance from the safelight.
● After the films have been washed, surface Place a coin on top of the film.
moisture is removed by gently shaking excess iii. Turn on the safelight. Allow the film and coin to
water from the films and hanger. be exposed to the safelight for 3–4 min and then
● The films are dried in circulating, moderately remove the coin and process the film.
warm air. The results of the safelighting test can be interpreted as
● After drying, the films are ready to mount. follows:
ii. Automatic method of processing ● If no visible image is seen on the processed radio-
This method uses equipment that automates all the graph, the safelighting is proper and proceed with
processing steps. film processing.
Types ● If the image of the coin and a fogged background
● Miniature roller-type that produces a dried film. appears on the processed radiograph, it indicates
● Automatic Dunking models that produces a washed improper safelighting and is not safe to use with
film that still has to be dried. processing of films.
Advantages
● Uniformity of results. Steps to avoid safelighting problems:
● Rapidity of the operation, the entire process may The dental radiographer must use the film manufactur-
take less than 4–7 min. er’s recommended safelight filters and bulb wattages. In
● Less floor space required and has daylight loading addition, the film must be unwrapped at least 4 feet away
capability. from the safelight. Safelighting problems must be corrected
● No reading of wet films. before proceeding with film processing.
Disadvantages Q.7. Requirements of a darkroom.
● High cost of the equipment and maintenance.
● Quality is not as high as that of a manually devel- Ans.

oped radiograph. [Ref LE Q.4]
iii. Monobath method
● In this method, the developer and fixer are combined
Q.8. Composition and functions of developing solution.
in one solution. Ans.
● This monobath is injected into special water proof-
[Same as SE Q.1]
ing film packet and the film is developed simply by
rubbing the film packet. Q.9. Composition and actions of developing solution.
Advantages Ans.
● There is no need of a darkroom.
● It is ideal and helpful in cases of quick spot diagno-

[Same as SE Q.1]
sis, e.g. RCT cases. Q.10. Composition and action of fixer solution.
Disadvantages
● The alkaline type of fixer very rapidly oxidizes
Ans.
under atmospheric conditions. [Same as SE Q.2]
Q.11. X-ray fixing solution. ● It removes the alkali activator, preventing neutraliza-
tion of the acid fixer.
Ans.
Q.4. Fixing solution.
[Same as SE Q.2]
Ans.
Q.12. Types of X-ray film processing.
Composition
Ans. ● Clearing agent–sodium thiosulphate
● Preservative–sodium sulphate
[Same as SE Q.5]
● Acidifier–acetic acid
Q.13. Processing of an intraoral film. ● Hardener–aluminium chloride
● Solvent–water
Ans.
Functions
[Same as SE Q.5] ● To help in removal of the undeveloped silver halide
grains from the emulsion.

SHORT NOTES: ● It also hardens the emulsion.
Q.5. Actions of developing solutions.

Q.1. Composition of developer solution.
Ans.
Ans.
Actions of developing solutions are as follows:
[Ref LE Q.2]
● When an exposed film is developed, initially the devel-
Q.2. Resolution. oper produces no visible effect, after which the density
increases very rapidly and then it slows down.
Ans.
● Eventually all the exposed crystals develop and become
● Sharpness of image is also known as detail, resolution reduced to black metallic silver. Slowly generates the
or definition. black tones and contrast in the image.
● Sharpness refers to how well the smallest details of an
Q.6. Automatic film processing.
object are reproduced on a dental radiograph.
● The sharpness of a film is influenced by the following Ans.
three factors:
This method uses equipment that automates all the pro-
a. Focal spot size
cessing steps.
b. Film composition
Types
c. Movement
i. Miniature roller-type
Q.3. Replenisher. ii. Automatic Dunking
Advantages
Ans. ● Uniformity of results
● Rapidity of the operation
Replenisher or developer replenisher
● Less floor space required and has daylight loading
● Developer becomes inactivated with use and by
capability
exposure to oxygen.
Disadvantages
● The developing solution of both manual and auto-
● High cost of the equipment and maintenance
matic developers should be replenished with fresh
solution each morning to prolong the life of the Q.7. Storage of X-rays films.
seasoned developer.
Ans.
● The recommended amount to be added daily is
8 ounces of replenisher per gallon of developing Storage of X-ray films

solution. Some of the used solution may need to be ● Film must be stored in areas that are adequately
removed to make room for the replenisher. shielded from sources of radiation.
Composition Optimum conditions
● The replenisher generally has the same composition ● To prevent film fog, unexposed, unprocessed film
as the developing solution, only thing is that it is must be kept in a cool, dry place.
more alkaline and does not contain restraining ● The optimum relative humidity level ranges from
bromide. 30% to 50%.
Uses ● The optimum temperature for film storage ranges
● Dilutes the developer. from 50°F to 70°F.

Other parameters Q.8. Requirements of darkroom.

● To prevent film fog, lead-lined or radiation-resistant
Ans.
film dispensers and storage boxes are ideal.
● The ‘first in, first out’ rule of thumb should be ap- [Ref LE Q.4]
plied to film use; the oldest film in stock always used
before any new film. Q.9. Coin test.
● All dental X-ray film has a limited shelf life.
Ans.
● Each box or container of film is clearly labelled with
an expiry date. [Ref SE Q.6]
Topic 5
Image Principles: X-Rays Quality Control
LONG ESSAYS:
.
1 Describe artefacts, blemishes and faults in dental radiography.
2. Discuss in detail factors responsible for obtaining an ideal radiograph.
3. Discuss ‘faulty intraoral (IO) radiographs’.
4. Discuss the causes of distortion and magnification of images in the radiographs.
5. Discuss the causes of faulty radiograph. How would you avoid it? [Same as LE Q.1]
6. Discuss in detail the faults in dental radiograph and prevention of these faults. [Same as LE Q.1]
7. Discuss in detail the various causes for faulty radiographs and measures to rectify them. [Same as LE Q.1]
8. What is an ideal radiograph? Enumerate the various factors influencing the quality of radiograph. [Same as LE Q.2]
9. Define an ideal radiograph. Describe basic principles to obtain an ideal radiograph. [Same as LE Q.2]
SHORT ESSAYS:
.
1 Artefacts on a radiograph.
2. Light radiograph.
3. Define an ideal radiograph. Enumerate the factors affecting the production of an ideal radiograph.
4. Dark radiograph.
5. Film fog.
6. Write note on image receptors.
7. Causes for dark radiographs. [Same as SE Q.4]
SHORT NOTES:
.
1 Cone-cut.
2. What are the causes of fog on radiograph?
3. Define faulty radiographs. [Ref LE Q.4]
4. Dark and light radiographs.
5. Artefacts. [Ref SE Q.1]
6. Define density and contrast in radiology.
7. Faulty X-rays. [Same as SN Q.3]
8. Four causes for dark radiographs. [Same as SN Q.4]
9. Radiographic density. [Same as SN Q.6]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Describe artefacts, blemishes and faults in dental x. Black lines and marks
radiography. ● Moisture contamination especially failure to
blot the film pocket results in black marks.

Ans.
● Writing lines are caused by writing on the film
Artefacts packet with a ball point pen or a lead pencil.
● Artefact is a structure or radiographic appearance that is xi. Yellow/brown stains
normally not present in the radiograph but produced by ● Depleted fixer
artificial means. ● Oxidized or exhausted developer
i. Blank radiograph ● Contaminated solutions
● Unexposed film. ● Insufficient washing/rinsing
● Exposed film dipped into the fixer solution be- Blemishes
fore it was placed into the developer solution. ● Blemishes are the defects or faults or errors on the ra-
ii. Partial image diographs.
● Only part of the film might have been immersed A wide variety of causes for the defective/faulty radio-
into the developer solution. graphs are grouped under the following headings:
iii. Blurring of image i. Errors in film storage and handling
● Exposure twice on the same film or movement ii. Errors in film placement and projection technique
of patient or tube head. iii. Errors in exposure parameters and processing technique
iv. Blisters on the film
i. Errors in film storage and handling
● Air-bubbles on film while developing.
a. Film fog
● Increased acidity of the developer solution.
● Outdated films.
● Films not agitated when first immersed in fixer.
● Films stored at high temperature or exposed to
v. Dark spot on the radiograph
radiation.
● Finger prints.
b. Emulsion peel
● Excessive bending of the film.
● Wet film in contact with finger nails.
● Film in contact with another film or tank walls
c. Dark spots or line
during the fixing procedure.
● Contamination with finger prints.
● Film contaminated with the developer solution
ii. Errors in film placement and projection technique
before the actual processing.
a. Type mark pattern
vi. Light spots on the radiograph
● Wrong side (opposite side) of the film exposed to
● Film contaminated with the fixer solution before
radiation.
the actual processing.
b. Cone-cut
● Film in contact with another film or tank walls
● Improper placement of the film and the position
during the developing procedure.
indicating device (PID).
vii. Foreign body image on the radiograph
c. Shortened image
● Radiopaque materials like ear rings, nose studs
● Increased vertical angulation used in bisecting
in the path of the X-ray beam.
angle technique.
● Placement of the finger between the X-ray tube
● Film not placed parallel to the long axis of the
and the film such as using the finger to stabilize
tooth in paralleling technique.
the film in the mouth.
d. Elongated image
viii. Static electricity artefact
● Decreased vertical angulation in bisecting angle
● Forceful unwrapping of the film from the pocket
technique.
or from the cassette.
● Film not placed parallel to the long axis of the
● Static electricity marks or smudge markings
tooth in paralleling technique.
may result from visible light produced by sparks
e. Overlapping of the teeth
caused by a relatively low potential electrical
● Incorrect horizontal angulation.
discharge in the air next to the film surface.
f. Blurred image
ix. Nail mark artefact
● Movement of the film or patient during the expo-
● Too much bending of the film.
sure causes totally blurred image.
● Excessive bending of the film causes partially ● A visible photographic record on the X-ray film pro-
blurred image. duced by passage of X-rays through an object or body
g. Crown portion of the teeth or apical ends of the teeth is called radiograph.
not imaged ● Dental radiograph is a photographic image produced
● Improper placement of the film. on the film by the passage of X-rays through teeth and
● Insufficient vertical angulation. related structures.
h. Double images According to H.M. Worth, ‘An ideal radiograph is one
● Film exposed twice to radiation. which has desired density and overall blackness and which
i. Tyre track effect (Herring bone effect) shows the part completely without distortion with maxi-
● Opposite side of film placed towards tube. mum details and has the right amount of contrast to make
iii. Errors in exposure parameters and processing tech- the details fully apparent’.
nique The characteristics of an ideal radiograph are as follows:
a. Film fog A. Visual characteristics
● Improper wattage of the safelight. B. Geometric characteristics
● Prolonged exposure of the film to safelight. C. Anatomic accuracy of radiographic images
● Safelight not at a proper distance from the work- D. Adequate coverage of the anatomic region of interest
ing place. The image quality and the amount of detail shown on a
● Light leaks from cracked safelight filters or ven- radiographic film depend on several factors mentioned
tilators. above and described in detail below:
b. Dark radiographs Visual characteristics
1. Exposure errors i. Density
● Excessive milliamperage (mA), kilovoltage ii. Contrast
peak (kVp) and exposure time.
i. Density
● Insufficient film and X-ray source distance.
● Factors affecting the density of a radiograph are as
2. Processing errors
follows:
● Improper safe lighting and accidental expo-
First-degree factors:
sure to light.
a. mA
● Too high developer temperature and concen-
b. Exposure time
tration.
c. Operating kVp
● Film developed for a longer period.
● Longer developing time. a. mA

● Inadequate fixation. ● An increase in mA produces more X-rays that
c. Light radiographs expose the film and result in increased film den-
1. Exposure errors sity.
● Insufficient mA, kVp and exposure time. ● If mA increases, then film density increases. If mA
● Film packet placed with the wrong side facing decreases, then film density decreases. Thus, den-
the X-ray source. sity varies directly and proportional to the mA or
● SFD (source–film distance) too large. the tube current.
2. Processing errors b. Exposure time
● Excessive fixation. ● An increase in the exposure time increases the film
● Depleted and diluted or contaminated devel- density. If exposure time is increased, then film
oper solution. density is increased and if exposure time is de-
● Too low temperature of the developer solution. creased, then film density is decreased.
d. Low contrast radiographs ● Exposure time and mA are interchangeable and
● kVp too high. are thus considered as a single factor.
● Under exposure or under development. c. Operating kVp
A quality-controlled radiographic service can be ● An increased kVp increases the penetrating power
given to patients if the dental surgeon can identify of X-rays, thereby increasing the density.
the causes of these errors and develop his/her own ● If kVp increases, then film density increases. If
chart for trouble shooting. kVp decreases, then film density decreases. Thus,
density varies directly and in proportion to the
Q.2. Discuss in detail factors responsible for obtaining
square of the relative kVp.
an ideal radiograph.
D a (kVp)2
Ans.
d. SFD ● A graphical relationship between film density and expo-

● The intensity of an X-ray beam varies inversely sure is called a characteristic curve or hand D curve.
as the square of the SFD; density also varies in- ● This curve is typical of a screen–film combination, and
versely as the square of the SFD. reveals information about film contrast, speed and lati-
tude.
(kVp)2 mA S
Hence, Density ● It can be seen from the curve that as exposure is in-
[(S F) dista n ce]2 creased, density also increases.
The film has greatest diagnostic value, at the relatively
Second-degree factors:
straight portion of the graph.
a. Subject thickness
ii. Contrast
b. Development conditions
● The difference in the degree of blackness (densities)
c. Type of film
between adjacent areas on a dental radiograph is
d. Screens
known as contrast.
e. Grids
● A radiograph is said to have a ‘high contrast’ if a
f. Amount of filtration used
dental radiograph has very dark areas and very light
g. Fog
areas, as the dark and the light areas are strikingly
a. Subject thickness: different.
● In a patient with an increased amount of soft tissue ● A radiograph that does not have very dark and very
or thick dense bones, fewer X-rays will reach the light areas, but instead has many shades of grey is
film and the radiograph will appear light and have said to have a ‘low contrast’.
less density. ● Radiographic contrast, i.e. the final visual difference
● If subject thickness increases, then density de- between the various black, white and grey shadows
creases. If subject thickness decreases, then den- depends on:
sity increases. a. Subject contrast
● Adjustments in the operating mA, kVp or expo- b. Film contrast
sure time can be made to compensate for varia- c. Fog and scatter
tions in size of the patient and subject thickness.
The next lower kVp and/or mA should be used, a. Subject contrast
if patient is thin and has a narrow facial bone ● The difference caused by different degrees of
structure. attenuation as the X-ray beam is transmitted

b. Development conditions: through different parts of the patient’s tissues is
Under or over development of the radiograph results known as subject contrast.
in a light or dark radiograph. ● It depends on:
c. Type of film: i. Differences in tissue thickness

● Film speed: High-speed films require less mA/s in ii. Differences in tissue density
order to obtain a density change. iii. Differences in tissue atomic number or
● Film latitude: It is measured as a range of expo- photoelectric absorption
sures that can be recorded as distinguishable den- b. Film contrast
sities on a film. ● This is an inherent property of the film itself. It
● Radiographic noise: It is the appearance of uneven determines how the film will respond to the dif-
density of a uniformly exposed radiographic film. ferent exposures it receives after the X-ray
It is seen on a small area of film as localized varia- beam has passed through the patient.
tions in density. ● Film contrast depends on four factors:
d. Screens: Use of screens requires less mAs in i. The characteristic curve of the film.
order to obtain a density change. ii. Optical density or degree of blackening of
e. Grids: The use of grids requires more mAs in the film.
order to obtain a density change. iii. Type of film – direct or indirect action.
f. Amount of filtration used: Reduction in the amount of iv. Processing.
added filtration used will increase the density. c. Fog and scatter
g. Fog: Film fog may result in an undesirable form of Radiographic contrast reduces as a result of stray
darkening of the film. radiation reaching the film either as a result of
Characteristic curve background fog, or owing to scatter from within
● Hurter and Driffield first described the relationship be- the patient, which produces unwanted film density
tween film density and exposure in 1890. or darkening.
Geometric characteristics ● The image magnification on a dental radiograph is

i. Sharpness or detail influenced by the following:
ii. Resolution or definition a. Target–film distance
iii. Magnification b. Object–film distance
iv. Distortion
a. Target–film distance
i. Sharpness or detail ● The distance between the source of X-rays
● The ability of the X-ray film to define an edge is and the film is known as the target–film dis-
known as image sharpness. tance also known as the SFD.
ii. Resolution or definition ● When a longer PID is used, more parallel rays
● Resolution, or resolving power of the film, is a mea- from the middle of the X-ray beam strike the
sure of the film’s ability to differentiate between object rather than the diverging X-rays from
different structures and record separate images of the periphery of the beam. As a result, a lon-
small objects placed very close together and is mea- ger PID and target–film distance result in less
sured in line pairs per mm. image magnification, and a shorter PID and
The main causes of loss of edge definition include: target–film distance result in more image
A certain degree of unsharpness is present in all magnification.
dental radiographs. The fuzzy, unclear area that sur- b. Object–film distance
rounds a radiographic image is termed ‘penumbra’. ● The distance between the object being radio-
● Geometric unsharpness: This type of unsharp- graphed, i.e. the tooth and the dental X-ray
ness is due to criss-crossing of rays at the edges film is known as the object–film distance.
of the object, resulting in a fuzzy image border. ● A decrease in object–film distance results in a
Size of the focal spot and target object distance decrease in magnification, and an increase in
affect geometric unsharpness. object–film distance results in an increase in
● Size of the focal spot: Smaller the focal spot, image magnification.
sharper the image produced. When a ‘point iv. Distortion
source’ is used, the normal focal spot size is ● Dimensional distortion of a radiographic image is a
0.6 mm2 to 1 mm2 and nonsharpness is produced. variation in the true size and shape of the object be-
● Object–film distance: This should be as small as ing radiographed.
possible to get a sharper image. ● A distorted image results from the unequal magnifi-
● Target–object distance: Should be as large as cation of different parts of the same object. Distor-
possible, to get a sharper image. tion results from improper film alignment or beam
● Motion unsharpness: It is caused by the patient angulation.
moving during the exposure. The factors influencing dimensional distortion of a
● Absorption unsharpness: It is caused due to radiographic image are:
variation in object shape, e.g. cervical burn-out a. Object–film alignment
at the neck of a tooth. ● To minimize dimensional distortion, the ob-
● Screen unsharpness: It is caused by the diffusion ject and film must be parallel to each other.
and spread of the light emitted from intensifying ● A distorted image may appear too long or too
screens. short.
● Poor resolution: Resolution is determined mainly b. X-ray beam angulation
by characteristics of the film including: type, di- ● To minimize dimensional distortion, the X-ray
rect or indirect action, speed and silver halide beam must be directed perpendicular to the
emulsion crystal size. tooth and the film.
iii. Magnification ● If the vertical angulation is increased, there
● Image magnification refers to a radiographic image will be shortening of the image and if it is
that appears larger than the actual size of the object decreased, there will be elongation of the
it represents. image.
● Magnification or enlargement of a radiographic ● If the horizontal angulation is increased mesi-
image results from the divergent paths of the ally or distally, there will be overlapping of
X-ray beam. Because of this some degree of im- structures.
age magnification is present in every dental radio- ● The geometric accuracy of any image depends
graph. on the position of the X-ray beam, object and
image receptor satisfying certain basic geo- Faulty radiographs resulting from faulty radiographic
metrical requirements: technique
● The object and the film should be in contact or Foreshortening of the image
as close together as possible. ● Foreshortening refers to images of the teeth that
● The object and the film should be parallel to appear too short.
one another. ● Excessive vertical angulation results in foreshort-
● The X-ray tube head should be positioned so ening of images.

that the beam falls at right angles on the object Elongation of the image
and the film. ● Elongation refers to images of the teeth that ap-
Alterations in geometric characteristics are mainly pear too long.

due to: ● Decreased vertical angulation results in elonga-
● X-rays originate from a definite area rather than tion of image.

a point source. Elongation of a few teeth
● X-rays travel in diverging straight lines as they ● Elongation of a few teeth refers to a few teeth ap-
radiate from their source of origin. pearing longer than normal, whereas other teeth
● Dental radiographs are a two-dimensional repre- are of normal size.
sentation of three-dimensional structures. This re- ● Excessive bending of the film in an attempt to
sults in unequal magnification of different parts of place in the mouth results in elongation of a few
an object, because of the varying distances of these teeth in the bent portion of the film.
parts from the film. Overlapping of proximal surfaces
Anatomic accuracy of radiographic images ● Improper horizontal angulation results in overlap-
● Anatomical accuracy means when the anatomical ping of proximal surfaces, which makes the radio-
structures are reproduced on the film in exact rela- graphs of less diagnostic value, especially in the
tionship as they normally appear. detection of proximal caries.
● A radiograph with anatomical accuracy will have a Crown portion of the teeth or apical ends of the teeth
minimum of superimposition of images of adjacent not seen on the image
tissues. ● Improper placement of the film.
Adequate coverage of the anatomic region of interest: ● Insufficient vertical angulation.
● It is important that the area of interest is well covered Blurred or distorted image
in the radiograph. Adequate coverage of the area of ● An image which appears hazy and without any
interest depends on following factors: sharpness is known as blurred or distorted image.

i. Proper alignment of the film and the radiation ● Blurring or distortion of the image is due to either
beam to the area of interest. the movement of the patient, the film placed in the
ii. Proper selection of the film types and projection patient’s mouth or the X-ray tube during exposure.
techniques. Cone-cut appearance
● Cone-cut appearance refers to a clear, unexposed
Q.3. Discuss ‘faulty intraoral (IO) radiographs’. area in a dental radiograph while in the rest of the
area of the film the image is seen.
Ans.
● This fault results from the X-ray beam not centred
over the film, or in other words, if the central

X-ray is not perpendicular to the centre of the film.
{SN Q.3} Phalangioma
● The term phalangioma was used by Dr David F.
● A diagnostic radiograph is one that provides a
great deal of information; the images have proper Mitchell.
● It refers to the image of phalanx or phalanges
density and contrast, have sharp outlines and are
of the same size and shape as the object radio- appearing in the film.
● It occurs when the patient holds the film in the
graphed.
● Faulty radiographs are nondiagnostic radiographs in
mouth in an incorrect way.
the sense that these radiographs are of no diagnostic Double exposure or double image
● Double exposure or double image appears due to
value as they do not provide adequate detail and
required information. repeated exposure of an already exposed film.
● Problems encountered in radiographic images
Reversed film
● Reversed film refers to a film exposed from the
are due to faulty technique of radiography or
processing. opposite side, i.e. the film placed in the mouth
reversed and then exposed.
● This results in light images with herringbone or Dark areas on the film
tyre-track or car-tyre appearance on the radio- ● Dark areas appear on film when overlap has
graph. occurred in the fixer solution.

Film creasing Straight white border
● Film creasing can result either in cracking of ● If the level of the developing solution is too low,
emulsion or a thin radiolucent line appearing in the film will not be fully immersed in the devel-
the radiograph. oper, resulting in a straight white border repre-
Crimp-marks senting the undeveloped portion of the film.
● Crimp-marks or nail-like curved dark lines result Straight black border
from sharp bending of the film. ● If the level of the fixer is too low, in the unfixed
Light image potion of the film, straight black border appears.

● A light image is devoid of proper contrast. A de- White marks on the film
crease in the exposure time, mA or kVp results in ● When air-bubbles are trapped on the film surface,
a light image. the processing solution does not come in contact

Dark image with the film. This results in white marks on the film.
● A dark image results from excessive exposure Nail marks
time, rnA or kVp. ● Nail mark artefacts are crescent-shaped when the
Faulty radiographs resulting from faulty processing emulsion is damaged by the finger nail due to
techniques rough handling of the film.
Light image Finger marks
● Less exposure time, mA and kVp, results in a ● Handling the film with wet fingers results in
light image. finger marks on the film.

● It can also result from inadequate development Scratched emulsion
time, inaccurate timer, low developer tempera- ● When the film comes in contact with sharp
ture and depleted or contaminated developing objects, the emulsion in that area is removed,
solution. causing scratched emulsion, as in these areas the
Dark image emulsion gets peeled off.
● A dark image is the result of excessive develop- Thin black branching lines or tree-like appearance
ment time, inaccurate timer, higher developer ● This appearance results from static electricity ex-
temperature and concentration. posing the film due to opening of the film packet
Cracked or reticulated image too quickly, humid conditions or rubbing of the
● When the film is subjected to a sudden tempera- film with the intensifying screen.
ture change between the developer and the water Fogging of the film
bath, it results in cracked or reticulated image. ● Fogged film refers to a film which appears grey
Dark spots on the film without image detail and contrast.

● The droplets of developing solution coming in ● It results from improper safe lighting conditions,
contact with an exposed film before it is devel- light leakage, improper storage conditions of the
oped results in dark spots or developer spots on film, expired or outdated film, contaminated process-
the film. ing solution or high temperature of the developer.
White spots on the film
● When droplets of fixing solution come in contact
Q.4. Discuss the causes of distortion and magnification
with an exposed film before it is developed results of images in the radiographs.
in white spots or fixer spots on the film. Ans.
Blank film
● Blank film refers to total absence of image. Distortion
● Immersing the exposed film in the fixing solution ● Dimensional distortion of a radiographic image is a
before it is immersed in the developing solution variation in the true size and shape of the object be-
results in blank film. ing radiographed.
● The film appears translucent as the entire emul- ● A distorted image does not have the same size and
sion is washed off. shape as the object being radiographed.

White area on the film ● A distorted image results from the unequal magnifi-
● During development when two films come in con- cation of different parts of the same object. Distor-
tact with each other, the overlapped portion ap- tion results from improper film alignment or beam
pears whiter. angulation.
The factors influencing dimensional distortion of a image magnification, and a shorter PID and
radiographic image are target–film distance result in more image
i. Object–film alignment magnification.
ii. X-ray beam angulation ii. Object–film distance
● The distance between the object being radio-
i. Object–film alignment
graphed, i.e. the tooth and the dental X-ray
● To minimize dimensional distortion, the object
film, is known as the object–film distance.
and film must be parallel to each other.
● The tooth and the X-ray film should always be
● If the object (tooth) and film are not parallel, an
placed as close together as possible. The closer
angular relationship results, which produces a
the tooth to the film, the less image enlarge-
variation of distances between the tooth and the
ment there will be on the film. A decrease in
film that results in a distorted image.
object–film distance results in a decrease in
● A distorted image may appear too long or too
magnification, and an increase in object–film
short.
distance results in an increase in image
ii. X-ray beam angulation
magnification.
● To minimize dimensional distortion, the X-ray
beam must be directed perpendicular to the Q.5. Discuss the causes of faulty radiograph. How would
tooth and the film. you avoid it?
● The central ray of the X-ray beam must be as
Ans.
nearly perpendicular to the tooth and film as
possible to record the adjacent structures in [Same as LE Q.1]
their true spatial relationships.
Q.6. Discuss in detail the faults in dental radiograph
● If the vertical angulation is increased, there
and prevention of these faults.
will be shortening of the image and if it is de-
creased, there will be elongation of the image. Ans.
● If the horizontal angulation is increased mesially
[Same as LE Q.1]
or distally, there will be overlapping of structures.
● The film should never be bent in the direction Q.7. Discuss in detail the various causes for faulty radio-
of long axis of tooth, and to prevent movement graphs and measures to rectify them.
during exposure, a film holder must be used.
Ans.
Magnification
● Image magnification refers to a radiographic image [Same as LE Q.1]
that appears larger than the actual size of the object
Q.8. What is an ideal radiograph? Enumerate the vari-
it represents.
ous factors influencing the quality of radiograph.
● Magnification, or enlargement of a radiographic im-
age, results from the divergent paths of the X-ray Ans.

beam. X-rays travel in diverging straight lines as they
[Same as LE Q.2]
radiate from the focal spot. Because of these diverg-
ing paths, some degree of image magnification is Q.9. Define an ideal radiograph. Describe basic princi-
present in every dental radiograph. ples to obtain an ideal radiograph.
● The image magnification on a dental radiograph is
Ans.
influenced by the following:
i. Target–film distance [Same as LE Q.2]
ii. Object–film distance
i. Target–film distance SHORT ESSAYS:
● The distance between the source of X-rays and
Q.1. Artefacts on a radiograph.
the film is known as the target–film distance,
also known as the SFD. Ans.
● The target–film distance is determined by the
length of the PID.

● When a longer PID is used, more parallel rays {SN Q.5}
from the middle of the X-ray beam strike the ● Artefact is a structure or radiographic appearance
object rather than the diverging X-rays from that is normally not present in the radiograph but
the periphery of the beam. As a result, a longer produced by artificial means.
PID and target–film distance result in less
● Depleted developer solution.

● Various artefacts seen on the radiograph are:
● Diluted or contaminated developer.
i. Black lines and marks
● Excessive fixation.
● Moisture contamination especially failure to
D. Processing errors can be corrected by:
blot the film pocket results in black marks.
● Setting the darkroom timer correctly and replacing
Blot the film packet after removal from the
inaccurate thermometer.
patient mouth to avoid black lines or marks.
● Raising the temperature of developer to 70°F.
● Black lines on the radiograph are caused
● Replacing the depleted developer solution.
due to routine bending of the film to reduce
● Adding replenisher or replacing developer or adding
patient discomfort.
more developer solution.
● To correct this, avoid unnecessary bending of
● Regulating the fixing time as per time table.
the film.
ii. Writing lines on the radiograph Q.3. Define an ideal radiograph. Enumerate the factors
● These are caused by writing on the film affecting the production of an ideal radiograph.
packet with a ball point pen or a lead pencil.
Ans.
● To prevent these lines use a crayon type pencil
to mark on the film. According to H.M. Worth, ‘An ideal radiograph is one
iii. Nail mark artefact which has desired density and overall blackness and which
● Too much bending of the film. shows the part completely without distortion with maxi-
● Avoid unnecessary bending. mum details and has the right amount of contrast to make
iv. Static electricity artefact the details fully apparent’.
● Forceful unwrapping of the film from the Factors affecting the production of an ideal radiograph
pocket or from the cassette. may also be classified as:
● Static electricity marks or smudge markings I. Factors related to the radiation beam
may results from visible light. a. mA
v. Random artefacts on film b. kVp
● Caused by contaminants like paper felt and dust. c. Exposure time
● To prevent this, check the screens inside the d. SFD
cassettes for contaminants. e. Size of the focal spot
f. Collimation and filtration
II. Factors related to the absorbing media or object
Q.2. Light radiograph.
a. Density and thickness of the object
Ans. III. Factors related to the technique
a. Position of patient’s head
Low-density film or light radiograph results from:
b. Placement and position of the film
A. Exposure errors resulting in light radiographs are
c. Angulation of the X-ray beam
● Under exposure, i.e. too short an exposure time.
IV. Factors related to recording of the radiographic image
● Using too large SFD.
of the object
● Use of too low kVp and mA.
a. Film storage
● Drop in the line voltage.
b. Secondary radiation
● Film packet placed with the wrong side facing the
c. Intensifying screens
tooth.
d. Processing of film
● Insufficient size of the power line.
● Use of incorrect film screen combination. Q.4. Dark radiograph.

B. Exposure errors can be corrected by
Ans.
● Setting exposure time correctly, checking the SFD,
increasing kVp and the mA. The causes of high density or dark radiographic film are as
● Placing the pebbled side of the film facing the tooth follows:
and towards the cone. Exposure errors
● Using a separate circuit for X-units and increasing ● Exposure time too long.
size of the power line or transformer. ● Too high mA or kVp for the stipulated exposure
● Always using the right screen–film combination. time.
C. Processing errors resulting in light radiograph are ● Too short SFD.
● Underdevelopment due to too low temperature, time ● Inaccurate timer.
too short, use of inaccurate thermometer. ● Incorrect combination of screen–film.
Developmental errors vii. Use time–temperature method for developing

● Too long developing time. films.
● Developer temperature too high. viii. Store film in a cool and dry place (70°F and 50%
● Inaccurate thermometer. relative humidity).
● High concentration of developer. ix. Limit supply and use older films first.
Exposure errors and developmental errors can be
Q.6. Write note on image receptors.
corrected by:
i. Use time temperature method with a darkroom Ans.
timer.
In dentistry, various image receptors are used to detect
ii. Reduce kVp and mA and exposure time.
X-rays. They are as follows:
iii. Measure the SFD.
i. Radiographic film
iv. Replace inaccurate thermometer and lower the
● Direct-action or packet film
developer temperature to 70°F.
● Indirect-action film used in conjunction with intensi-
v. Check tank capacity and concentration of dev
fying screens in a cassette
eloper.
ii. Digital receptors
vi. Set timer correctly and/or reduce exposure time.
● Solid-state sensors
vii. Too fast a film and/or screen for the kVp and/or
● Phosphor plates
mA setting should not be used. Make sure that
Radiographic film
appropriate screen–film combination be used.
● In dentistry, radiographic film has traditionally been
Q.5. Film fog. used as the image receptor and is still widely used.
There are two basic types:
Ans. a. Direct-action or nonscreen film:
● This type of film is sensitive primarily to X-ray
The causes of film fog are as follows:
photons.
. The causes of fogging due to light are
A
b. Indirect-action or screen film:
i. Light leaks in the darkroom.
● It is so called because it is used in combination
ii. Improper safelight.
with intensifying screens in a cassette.
iii. Improper filters in safelight.
● It is sensitive primarily to light photons, which
iv. Turning overhead (white) light on too soon.
are emitted by the adjacent intensifying screens.
v. Prolonged exposure of films to safelight.
● They respond to shorter exposure of X-rays,
vi. Smoking in the darkroom.
enabling a lower dose of radiation to be given
B. The causes of fogging due to chemicals are
to the patient.
i. High concentration of developer.
Digital receptors
ii. Developer temperature too high.
Direct digital image receptors available are of two types as
iii. Prolonged development time.
follows:
iv. Contaminated developer solution.
a. Solid-state (CCD or CMOS)
C. Deterioration of the film due to:
b. Photostimulable phosphor storage plates
i. Too high temperature and humidity of storage area.
Uses
ii. Strong fumes (ammonia and paint).
● Both of the above sensors can be used for i.o. (periapi-
iii. Outdated film.
cal and bitewing radiograph) and extraoral radiography
iv. Improper screen–film combination.
including panoramic and skull radiography.
v. Films exposed to radiation.
● Only phosphor storage plates are available for occlu-
D. The fogging can be prevented by following measures:
sal and oblique lateral radiography as it is currently
i. Checking for light leaks, vents, doors and walls,
too expensive.
and even cracked safelight filter are to be corrected.
ii. Reducing the wattage of the bulb and keeping ade- Q.7. Causes for dark radiographs.
quate (4 feet) distance between safelight and work
Ans.
area.
iii. Reducing exposure time of films to safelight. [Same as SE Q.4]
iv. Fix films for 1–2 min before turning on the light.
v. Store unexposed films in lead receptacles and away
from source of radiation in a protective compart-
SHORT NOTES:
ment.
Q.1. Cone-cut.
vi. Reduce temperature of developer and cleaning de-
veloper tank periodically. Ans.
● Cone-cut appearance refers to a clear, unexposed area in ● Film developed for a longer period.
a dental radiograph while in the rest of the area of the ● Developing time more.
film, image is seen. ● Inadequate fixation.
Causes Light radiographs

i. This occurs due to projection errors. This fault re- i. Exposure errors
sults from the X-ray beam not centred over the film, ● Insufficient mA, kVp and exposure time.
or in other words, if the central X-ray is not perpen- ● Film packet placed with the wrong side facing the
dicular to the centre of the film. X-ray source.

ii. PID not aligned properly with periapical film holder. ● SFD too large.
iii. Top of the film not completely immersed in devel- ii. Processing errors
oping solution. ● Excessive fixation.
● Correction. ● Depleted and diluted or contaminated developer
● Make sure that cone is properly centred over the solution.

area of interest and the film, both vertically and ● Too low temperature of the developer solution.
horizontally.
Q.5. Artefacts.
● PID and aiming ring should be properly aligned.
● Maintain the level of solution in the processing tanks. Ans.

Q.2. What are the causes of fog on radiograph? [Ref SE Q.1]
Ans. Q.6. Define density and contrast in radiology.
● Fogged film refers to a film that appears grey without Ans.
image detail and contrast.
i. Density: The overall blackness or darkness of a dental
● It results from:
radiograph is known as density.
i. Improper safelighting conditions
ii. Contrast:
ii. Light leakage in the darkroom
● The difference in the degrees of blackness (densities)
iii. Improper storage conditions of the film
between adjacent areas on a dental radiograph is
iv. Expired or outdated film
termed as contrast.
v. Contaminated processing solution
vi. High temperature of the developer Or
vii. Stray radiation reaching the film either as a result of
● Radiographic contrast may also be defined as the
background fog, or owing to scatter from within the
final visual difference between the various black,
patient, which produces unwanted film density or
white and grey shadows.
darkening
The image quality and the amount of detail shown on a
Q.3. Define faulty radiographs. radiographic film depend on several factors including
contrast.
Ans.
Q.7. Faulty X-rays.
[Ref LE Q.4]
Ans.
Q.4. Dark and light radiographs.
[Same as SN Q.3]
Ans.
Q.8. Four causes for dark radiographs.
Dark radiographs
Exposure errors Ans.
● Excessive mA, kVp and exposure time
[Same as SN Q.4]
● Insufficient film and X-ray source distance
Processing errors Q.9. Radiographic density.

● Improper safelighting and accidental exposure to
Ans.
light.
● Too high developer temperature and concentration. [Same as SN Q.6]
Topic 6
Intraoral Radiographic Techniques
LONG ESSAYS:
1. Write the principles of imaging and discuss the bisecting angle technique.
2. Name intraoral radiographic techniques.
3. Compare paralleling and bisecting techniques.
4. Describe the indications/advantages, disadvantages and technique of bitewing radiographs.
5. Describe the procedure of localizing an impacted left maxillary canine. Enumerate intraoral radiographic
technique.
6. Describe the procedure of periapical radiograph of the mandibular central incisor using short cone technique.
7. Describe in detail the bisecting angle technique of intraoral periapical radiography. [Same as LE Q.1]
8. Describe in detail technique, advantages and limitations of bisecting angle technique of periapical radiography.
[Same as LE Q.1]
9. Discuss the bisecting angle technique and intraoral periapical radiography and advantages and limitations of
bisecting angle technique of periapical radiography. [Same as LE Q.1]
10. Describe the bisecting technique for intraoral periapical radiographs in detail with advantages and disadvan-
tages. [Same as LE Q.1]
11. What are the uses of occlusal X-ray? Describe the techniques of occlusal X-ray of maxillary palate. [Same as LE Q.2]
12. What are indications for occlusal radiographs? Describe the radiographic techniques in taking maxillary and
mandibular cross-sectional occlusal radiographs. [Same as LE Q.2]
SHORT ESSAYS:
1 . Describe bisecting technique of lower third molar.
2. Define ideal radiograph. Enumerate the types of intraoral films.
3. Enumerate localization techniques, describe any one.
4. Occlusal radiograph. [Ref LE Q.2]
5. Clark’s technique.
6. Radiographic technique for maxillary standard occlusal view.
7. Give the indications of true occlusal radiograph. [Same as SE Q.4]
SHORT NOTES:
1 . Indications of bitewing radiographs.
2. Mention four disadvantages of the bisecting angle technique. [Ref LE Q.1]
3. How will you manage the problem of gagging in a patient during the periapical technique?
4. Indications of transorbital view.
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Write the principles of imaging and discuss the Basic principles of shadow casting
bisecting angle technique. i. Focal spot should be as small as possible.
ii. Focal spot–object distance should be as long as possible.
Ans.
i ii. Object–film distance should be as small as possible. point where the film is in contact with the
iv. The long axis of the object and the film placed teeth.
should be parallel. ● When the angle is bisected by an imaginary
v. X-ray beam should strike the object and film at right line, two congruent angles, with a common
angles. side (the imaginary bisector), are formed.
vi. There should be no movement of the tube, film or ● A line, representing the central ray of the
patient during exposure. X-ray beam will complete the third side of
● Smaller the focal spot, sharper the image. two triangles, when it is directed perpen-
● Larger the focal spot, greater the amount of pendicular to the bisecting line.
umbra and greater the unsharpness. ● Involves taking radiographs such that the long
● Longer the target–film distance, lesser is the axis of the rays is perpendicular to the bisector
magnification. between the long axis of the tooth and long
● Lesser the object–film distance, lesser is the axis of the film.
magnification. ● An 8-inch cone is normally used and kVp used
● If central ray is not perpendicular to tooth, short- is usually 55–65 kVp.

ening occurs. Advantages of bisecting technique
Intraoral periapical radiograph i. It can be used without a film holder when the anat-
● The intraoral periapical radiograph (IOPA) is the omy of the patient precludes the use of a film-
basic investigation that gives radiographic informa- holding device, e.g. shallow palate, bony growths
tion about the alveolar bone, periodontal areas and and sensitive mandibular premolars.
the hard tissues of the tooth. ii. Positioning is relatively easy, simple and quick.
● Two intraoral projection techniques may be used for iii. Positioning of the film packet is reasonably com-
periapical radiography: fortable for the patient.
a. Paralleling cone technique iv. A shorter exposure time is recommended, when a
b. Bisecting angle technique short (8 inch) PID is used with the bisecting technique.
v. If angulations are assessed properly, there will be no
a. Paralleling cone technique (long cone tech- changes in the dimensions of the tooth which is imaged.
nique/right angle technique)
● The rationale is that the central ray of X-ray
{SN Q.2}
beam is directed at right angles to the teeth and Disadvantages of bisecting technique
the film. i. Image distortion
● The X-ray film is kept parallel to the long axis
● Distortion occurs when a short PID is used,
of the teeth. because with a short PID there is an increased
● Special holders, which keep the film parallel to
divergence of X-rays, resulting in image mag-
the long axis of the tooth, may also be utilized, nification.
e.g. XCP® instruments (extension cone paral- ● Distortion also occurs when a tooth (three-
leling), the stab disposable film holder, and the dimensional structure) projected onto a film
Snap-A-Ray intraoral film holder. (two-dimensional structure) structure that is
● A long cone of 12 inches is used and the kVp
farther away from the film appears more elon-
used is usually 85–90 kVp. gated than those closer to the film.
● The X-rays are directed perpendicular to the film
ii. Angulation problems
and therefore there is minimum geometric dis- ● It is difficult for the dental radiographer to
tortion, less magnification and more definition. visualize the imaginary bisector and then de-
b. Bisecting angle technique termine the vertical angulation without the
● Bisecting angle technique is based on a simple
use of a film holder and aiming ring. Any er-
geometric theorem known as Cieszynski’s law ror in vertical angulation will result in image
of isometry, which states that two triangles are distortion either elongation or foreshortening.
said to be equal, when they share one complete iii. Unnecessary exposure
side and have two equal angles. ● When the patient stabilizes the film with a
● In dental radiography, this theorem is applied
finger, the patient’s hand is unnecessarily ex-
as follows: posed to the primary beam of X-ray radiation.
● The film is positioned as close as possible
iv. Incorrect horizontal angulation will result in over-
to the lingual surface of the teeth, resting lapping of the images, while incorrect vertical angu-
in the palate or in the floor of the mouth. lation will result in foreshortening or elongation of
● The plane of the film and the long axis of
the image.
the teeth form an angle with its apex at the
v. The periodontal bone levels are not well determined. ● To detect disease in the palate or floor of the mouth and
vi. The crowns of the teeth are often distorted and determine the medial and lateral extent of disease (cysts,
hence detection of proximal caries will be difficult. osteomyelitis, malignancies).
vii. The shadow of the zygomatic bone frequently over- ● To measure the changes in the size and shape of the
laps the periapical areas of maxillary molars. maxilla and mandible.

● To study the expansion of the palatal arch during the
Q.2. Name intraoral radiographic techniques.
orthodontic jaw expansion.}
Ans.
Maxillary occlusal projections
Classification of intraoral radiographic techniques is as There are three different maxillary occlusal projections:
follows: (i) topographic, (ii) lateral (right or left) and (iii) paediatric.
I. Intraoral radiographic techniques i. Topographic projection: The maxillary topographic
a. Bitewing radiography occlusal projection is used to examine the palate and
b. Periapical radiography: the anterior teeth of the maxilla.
i. Bisecting angle technique/short cone technique ii. Lateral (right or left) projection: The maxillary lat-
ii. Paralleling technique/long cone technique/right- eral occlusal projection is used to examine the palatal
angle technique roots of the molar teeth. It may also be used to locate
c. Occlusal radiography foreign bodies or lesions in the posterior maxilla.
i. Maxillary occlusal views iii. Paediatric projection: The maxillary paediatric oc-
ii. Mandibular occlusal views clusal projection is used to examine the anterior teeth
Maxillary and mandibular occlusal views are of the maxilla and is recommended for use in children
further divided into: 5 years old or younger.
i. Cross-sectional occlusal views Technique of maxillary topographic occlusal projection
ii. Topographic occlusal views – anterior/posterior ● Position the patient upright with the maxillary
iii. Paediatric occlusal views arch parallel to the floor, so that the sagittal plane
II. Intraoral localization radiographic techniques is perpendicular to the floor and occlusal plane is
a. Stereoscopy horizontal.
b. Buccal object rule ● Place a size-4 film with the white-side facing
c. Contrast radiography the maxilla and the long edge in a side-to-side
d. Tube shift technique/Clark’s rule direction.
e. Right angle technique/Miller’s technique ● Insert the film into the patient’s mouth, placing it
Occlusal radiography as far posteriorly as the patient’s anatomy permits
● Occlusal films are used to show larger areas of
usually till it contacts the anterior border of man-
the maxilla or mandible. The size of the film is dibular rami.
57 3 76 mm. ● Ask the patient to bite gently on the film, retaining
the position of the film in an end-to-end bite.

[SE Q.4]
● Position the PID so that the central ray is directed
{Indications of occlusal radiographs through the midline of the arch towards the centre
● To examine the area of cleft palate. of the film at a vertical angulation of 165° and a
● To precisely locate retained roots of extracted teeth, horizontal angulation of 0° towards the midline of
supernumerary teeth, unerupted and impacted teeth. the film. The top edge of the PID is placed be-
● This technique is especially useful for impacted ca- tween the eyebrows on the bridge of the nose. In
nines and third molars and also to localize foreign general, the central ray enters the patient’s face
bodies on the maxilla and mandible. through the bridge of the nose.
● To locate sialoliths in the ducts of sublingual and Maxillary lateral occlusal projection
submandibular glands. ● Position the maxillary arch parallel with the floor.
● To demonstrate and evaluate the integrity of the ● Position a size-4 film with the white side facing
anterior, medial and lateral outline of the maxillary the maxilla and the long edge in a front-to-back
sinus. direction. Insert the film into the patient’s mouth
● To aid in the examination of patients with trismus, who and place it as far posteriorly as the patient’s
can open their mouths only a few millimetres. anatomy permits. Shift the film to the side (right
● To obtain information about the location, nature, extent or left) of intended interest. The long edge of the
and displacement of fractures of the mandible and film should extend approximately ½ inch beyond
maxilla. the buccal surfaces of the posterior teeth.
● Instruct the patient to bite gently on the film, retain- vi. There should be no movement of the tube, film or
ing the position of the film in an end-to-end bite. patient during exposure.
● Position the PID so that the central ray is directed ● Under given conditions, both procedures would use
through the contact areas of intended interest. the same source of radiation. Hence, factors affecting
● Position the PID so that the central ray is directed rule 1 would be the same in both techniques.
at 160° towards the centre of the film. The top ● The paralleling technique more adequately fulfils rule 2
edge of the PID is placed above the corner of the for shadow casting. It ordinarily uses a long or
eyebrow. extended cylinder, which at least doubles the target–
Maxillary paediatric occlusal projection object distance as compared to the short cone or
● Position the maxillary arch parallel with the floor. cylinder bisecting technique.
● Position a size-2 periapical film with the white ● The bisecting technique can be used advantageously
side facing the maxilla and the long edge in a with either the short or extended distance.
side-to-side direction. Insert the film into the ● The tooth–film distance is somewhat greater in the par-
child’s mouth. alleling technique, particularly in the coronal area of the
● Instruct the child to bite gently on the film, retain- tooth. This separation of the tooth and film is due to
ing the position of the film in an end-to-end bite. anatomic limitations such as palatal curvature and mus-
● Position the PID so that the central ray is directed cle attachments. Thus, the bisecting technique more
through the midline of the arch towards the centre closely satisfies rule 3 of shadow casting. This inade-
of the film. quacy of the paralleling technique is compensated for
● Position the PID so that the central ray is directed by the increased target–object distance.
at 160° towards the centre of the film. The top ● The paralleling technique again excels in fulfilling rules
edge of the PID is placed between the eyebrows 4 and 5. The paralleling technique is so named because
on the bridge of the nose. the tooth and film are parallel.
Technique in mandibular cross-sectional occlusal view ● In the bisecting procedure, the film contacts the tooth at
Image field the occlusal or incisal surface and then diverges away
● This projection shows soft tissues of the floor from the long axis of the tooth. If the tooth and film are
of the mouth and delineates the lingual and not parallel, it is impossible for the rays to strike both
buccal plates of the jaw and the teeth from object and recording surface at right angles.
second molar to second molar. ● When the bisecting technique is used, it is impossible to
Film placement superimpose labial or buccal anatomic entities on their
● The film is placed in the mouth with its long palatal or lingual counterparts; invariably, when viewed
axis perpendicular to tile sagittal plane and the on the radiograph, the labial or buccal counter part of a
pebbled side towards the mandible. similar joint on the palatal or lingual surface will lie
● The anterior border of the film should be approxi- closer to the occlusal or incisal edge. This situation is
mately ½ an inch anterior to the mandibular not necessarily bad, but the interpreter must view the
central incisors. resultant films with this phenomenon in mind.
Projection of the central ray
In brief the bisecting angle technique and paralleling
● The central ray is directed at right angles to the
techniques are compared as follows:
centre of the film.
● The point of entry is in the middle through the floor
of the mouth approximately 3 cm below the chin. Bisecting angle technique Parallel line angle technique
Distortion of image occurs Sharpness is more as compared
Q.3. Compare paralleling and bisecting techniques.
to bisecting technique
Ans. Elongation and shortening of It is less compared to bisecting
image is more technique
● The paralleling and bisecting techniques will be com-
Bending of film is common Bending of film is uncommon
pared from the standpoint of the basic principles (rules)
for shadow casting mentioned below: Shadow of alveolar bone Alveolar crest is seen in true
i. Focal spot should be as small as possible. tends to fill the interproximal relationship with teeth
spaces
ii. Focal spot–object distance should be as long as possible.
iii. Object–film distance should be as small as possible. Super imposition of Superimposition of zygomatic
zygomatic arch occurs on arch occurs on apices of molar
iv. The long axis of the object and the film placed
apices of molar teeth teeth
should be parallel.
v. X-ray beam should strike the object and film at right Easier and less space Need trained technician and
required more space
angles.
Bisecting angle technique Parallel line angle technique Technique of bitewing radiographs
● In this technique, the patient is asked to bite on the
Cone cut is common It is uncommon
tab or bite block provided by the special bitewing
Distortion of film occurs due As film holder is used bending film holders.
to bending by finger pressure does not occur ● The bite platform should be positioned on the middle
of the film packet and parallel to the upper and lower

edges of the film packet.
● The patient head is positioned with the head sup-
Q.4. Describe the indications/advantages, disadvantages ported and with the occlusal plane horizontal; in case
and technique of bitewing radiographs. a film holder is used, position the film holder and
Ans. align the tube head.
● If a tab is attached to the film packet then the opera-
● Bitewing radiography is an intraoral technique which tor holds the film packet between the thumb and
allows the clinicians to evaluate initial lesions by pass- forefingers and inserts the film packet into the lingual
ing the primary ray perpendicular to the long axis of the sulcus of the dental arch.
respective teeth. ● If the tab is placed on to the occlusal surfaces of the tooth,
● In this technique, the patient is asked to bite on the bite the patient is asked to occlude the teeth firmly on the tab.
block provided by the special bitewing film holders. ● To ensure that the film packet and the teeth are in con-
● The exposed film is designed to show the crowns of the tact, the operator pulls the tab firmly between the teeth,
teeth and the alveolar crystal bone. once the patient closes the teeth and then releases.
Indications of bitewing radiographs ● The X-ray beam is directed through the contact ar-
● Screening for incipient proximal carious lesions. eas, at right angles to the teeth and the film packet,
● To check the health of the interdental alveolar bone with an approximate 5° to 8° downward vertical an-
in normal and periodontal diseases and detect calcu- gulation and the film is exposed.
lus deposits in interdental areas. ● For assessment of dental caries and restorations, films
● Detection of secondary caries under the restorations should be well exposed and should show good contrast
and to determine if restoration is fractured. to differentiate between the enamel and dentine.
● To know relationship of deciduous to the permanent ● Radiograph should show enamel-dentine junction
teeth in children during mixed dentition period. while assessing the periodontal status and the film
● Routine annual evaluation of all patients who come should be under exposed to avoid the burn out of the
to check up without any complaint. thin alveolar crest.
Disadvantages of bitewing radiographs Q.5. Describe the procedure of localizing an impacted
● As many variables are involved in this technique, it left maxillary canine. Enumerate intraoral radiographic
often results in the image being badly distorted. technique.
● Incorrect vertical angulation may result in foreshort-
Ans.
ening or elongation of the image.
● The periodontal bone levels are poorly shown. ● Localization technique is a method used to locate the
● The shadow of the zygomatic buttress frequently position of a tooth or any object in the jaws.
overlies the roots of the upper molars. Use
● Considerable skill is required as the horizontal and ● The dental radiograph is a two-dimensional picture of
vertical angles have to be assessed for every patient. a three-dimensional object. There are times when it is
● It is not possible to obtain reproducible views. necessary to establish the three-dimensional position
● Coning off or cone cutting may result if the central of a structure, such as a foreign object or impacted
ray is not aimed at the centre of the film, particularly tooth, within the jaws.
if using rectangular collimation. ● Localization techniques can be used to obtain this
● Incorrect horizontal angulation will result in overlap- three-dimensional information of foreign bodies, un-
ping of the crowns and roots. erupted or impacted teeth, retained roots, salivary
● The crowns of the teeth are often distorted, thus stones, jaw fractures, broken needles and instruments.
preventing the detection of proximal caries. Types of localization techniques
● The buccal roots of the maxillary premolars and i. Buccal object rule
molars are usually foreshortened. ii. Right-angle technique
i. Buccal object rule This technique is primarily used for locating objects
● The buccal object rule governs the orientation of in the mandible.
structures portrayed in two radiographs exposed at
different angulations. Q.6. Describe the procedure of periapical radiograph of
● Using appropriate technique and angulation, one
the mandibular central incisor using short cone technique.
periapical or bitewing film is exposed. Ans.
● A second periapical or bitewing film is then exposed
after changing the direction of the X-ray beam using Bisecting technique principle (short cone technique)
a different horizontal or vertical angulation. ● Bisecting angle technique is based on a simple geomet-
● A different horizontal angulation is used when trying ric theorem known as Cieszynski’s law of isometry,
to locate vertically aligned images (e.g. root canals), which states that, two triangles are said to be equal when
whereas a different vertical angulation is used when they share one complete side and have two equal angles.
trying to locate a horizontally aligned image, such as ● In dental radiography, this theorem is applied as follows:
the mandibular canal. ● The film is positioned as close as possible to the
● After the two films have been exposed and pro- lingual surface of the teeth, resting in the palate or
cessed, compare the radiographs with each other. in the floor of the mouth.
● When the dental structure or object seen in the second ● The plane of the film and the long axis of the teeth
radiograph appears to have moved in the same direction form an angle with its apex at the point where the
as the shift of the PID, the structure or object in question film is in contact with the teeth.
is positioned to the lingual. For example, if the horizon- ● When the angle is bisected by an imaginary line,
tal angulation is changed by shifting the position indicat- two congruent angles, with a common side (the
ing device (PID) mesially, and the object in question imaginary bisector), are formed.
moves mesially on the dental radiograph, then the object ● A line, representing the central ray of the X-ray beam
lies to the lingual (i.e. same side means lingual). will complete the third side of two triangles, when it
● Conversely, when the dental structure or object seen is directed perpendicular to the bisecting line.
in the second radiograph appears to have moved in ● Involves taking radiographs such that the long axis
the direction opposite the shift of the PID, the struc- of the rays is perpendicular to the bisector between
ture or object in question is positioned to the buccal. the long axis of the tooth and long axis of the film.
For example, if the horizontal angulation is changed ● An 8-inch cone is normally used and kVp used is
by shifting the PID distally, and the object in ques- usually 55–65 kVp.
tion moves mesially on the dental radiograph, then Placement of the film
the object lies to the buccal (i.e. opposite 5 buccal). ● As the rays are directed perpendicular to the
● In other words, when the two radiographs are com- imaginary plane, bisecting the film and the tooth,
pared, the object that lies to the lingual appears to the film can be placed in close contact with the
have moved in the same direction as the PID, and the tooth structure and alveolar mucosa.
object that lies to the buccal appears to have moved Position of the patient
in the opposite direction as the PID. Position of the patient depends upon the following
● The mnemonic ‘SLOB’ can be used to remember two planes:
the buccal object rule, i.e. Same side means Lingual, (a) Occlusal plane
Opposite side means Buccal. ● The occlusal plane is formed by the tangent
ii. Right-angle technique (Miller’s technique) passing through the occlusal surface of the max-
● The right-angle technique or Miller’s technique is illary and mandibular teeth when the teeth are in
another rule for the orientation of structures seen in centric occlusion.
two radiographs. ● It should be parallel to the plane of floor.
● One periapical film is exposed using the proper 1) In maxillary teeth, an imaginary line drawn
technique and angulation to show the position of the from the ala of nose to tragus of ear is almost
object in the superior–inferior and anterior–posterior parallel to maxillary occlusal plane.
relationships. 2) In mandibular teeth, when the patient opens
● The second one, an occlusal film is exposed directing the mouth, the occlusal plane of lower teeth
the central ray at right angles, or perpendicular (90°), changes its position and, therefore, does not
to the film. The occlusal film shows the object in the remain parallel to the floor. So to place the
buccal lingual and anterior–posterior relationships. occlusal plane of mandibular teeth in proper
● After that the two radiographs are compared with relationship to the floor, it becomes necessary
each other to locate the object in three dimensions. to tilt the head backward.
(b) Median sagittal plane Q.8. Describe in detail technique, advantages and limita-
● The plane vertically passing through the centre tions of bisecting angle technique of periapical radiography.
of head is known as midsagittal plane. This
Ans.
plane should be perpendicular to the floor, no
matter whether the head is tilted or not. [Same as LE Q.1]
● Adjusting these two planes is the first step in the
Q.9. Discuss the bisecting angle technique and intraoral
production of the radiograph and the deviation
periapical radiography and advantages and limitations
of this will seriously affect the angulation.
of bisecting angle technique of periapical radiography.
● Once these two planes are adjusted, horizontal and
vertical movement of the tube is considered. Ans.

Horizontal movement states that the central ray
must be directed perpendicular to the mean antero- [Same as LE Q.1]
posterior tangent of the teeth under examination. Q.10. Describe the bisecting technique for intraoral
● Horizontal movement is around the median sag- periapical radiographs in detail with advantages and
ittal plane and vertical movement is around the disadvantages.
occlusal plane.
● Vertical angulation is either positive or negative Ans.
depending upon whether the tube head is facing [Same as LE Q.1]
towards the floor (positive) or when the tube
head is facing upwards (negative). Q.11. What are the uses of occlusal X-ray? Describe the
Rules guiding the placement of film in oral cavity techniques of occlusal X-ray of maxillary palate.
The operator is advised to follow certain rules while Ans.
placing the film in the oral cavity. The rules are as
follows: [Same as LE Q.2]
● Avoid misshaping the film. Films can be bent
Q.12. What are indications for occlusal radiographs?
if necessary, but without crease. Describe the radiographic techniques in taking maxillary
● Carry film into mouth by thumb and forefingers.
and mandibular cross-sectional occlusal radiographs.
● Teeth under examinations should be in the
centre of the film. Ans.

● Position the lower margin of the film in such a way
[Same as LE Q.2]
that 1/8th inch of periapical area is included.
● The index finger of the patient will rest against
the side of the face, other fingers extending in SHORT ESSAYS:

such a way that these should not come in be-
Q.1. Describe bisecting technique of lower third molar.
tween the path of X-ray radiations.
Placement of film, angulation of tube and direction of Ans.
rays for various teeth (maxillary central, mandibular
Mandibular molar exposure using bisecting technique
central and lateral incisors)
● Centre the film holder and film packet on the second
● The mandibular anterior films, especially using
molar, so that the front edge of the film should be
narrow films, are easily inserted. The lower border
aligned with the midline of the second premolar.
of the film is placed in the floor of the mouth under
● Position the upper edge of the film parallel to the
the tongue. The palm of the finger tips should rest
occlusal plane so that an inch of it extends above the
on the edges of the teeth and not the film.
occlusal edges of the teeth.
● The film should not be pressed along the lingual
● Instruct the patient to ‘slowly close’ on the bite-block
surface of the teeth.
or film-holding device.
● The remaining fingers are elevated in such a way, so
● Establish the correct vertical angulation (set the ver-
that they may not come in operator’s line of vision.
tical angulation at 110°) and direct the central ray
● Angulations are adjusted and the rays are passed
perpendicular to the imaginary bisector.
along the symphysis menti.
● Establish the correct horizontal angulation by direct-
Q.7. Describe in detail the bisecting angle technique of ing the central ray between the contacts of the molars.
intraoral periapical radiography. ● Position the PID using the correct vertical and hori-
zontal angulations and centre it over the film and make

Ans.
certain that the PID is positioned far enough forward
[Same as LE Q.1] to cover both the maxillary and the mandibular second
premolars and is positioned evenly over the mandibu- III. Bitewing films
lar and maxillary arches to avoid a cone-cut. The ● Bitewing films are used to record the crowns of
middle of the PID should be directed at the level of the maxillary and mandibular teeth in one film.
occlusal plane. ● They help in detection of interproximal caries,
● After the vertical angulation, horizontal angulation, visualize the alveolar crest and assessment of
and PID position have been established, the film periodontal disease in easier way.
should be placed without moving the PID. Types of bitewing films
● Make certain that the patient’s occlusal plane is par- 1. Size 0 – For children – posterior (22 3 35 mm)
allel with the floor. If necessary, instruct the patient 2. Size 1 – For children – anterior (24 3 40 mm)
to lower the chin. 3. Size 2 – For adults – posterior (31 3 41 mm)
● Expose the film. 4. Size 3 – For adults – anterior (27 3 54 mm)
Uses
Q.2. Define ideal radiograph. Enumerate the types of
● They are particularly valuable for detecting inter-
intraoral films.
proximal caries in the early stages of development
Ans. before it becomes clinically apparent.
● In checking on the gingival margins of proximal
● Ideal radiograph is the one which has desired density and
fillings.
overall blackness, and which shows the part completely
● They are especially effective and useful for de-
without distortion with maximum details and has the
tecting calculus deposits in interproximal areas.
right amount of contrast to make details fully apparent.
● In determining the relationship of the permanent
● The intraoral radiograph is the image receptor used in
tooth buds to the deciduous teeth.
dental radiology, and is available in plastic film pockets.
● In periodic check-up of the teeth for detection of
They greatly help in diagnosis and treatment of the
new caries and early periodontal changes.
problems.
Types of intraoral radiographs based upon their use: Q.3. Enumerate localization techniques, describe any one.
I. Periapical films: These films are used to record crowns, Ans.
roots and periapical areas related to the tooth.
Types of periapical films ● A localization technique is used to locate the position of
a. No 0 – for children (22 3 35 mm) a tooth or objects in the jaws.
b. No 1 – for anterior adult projections (24 3 40 mm) ● The buccal object rule, a rule for the orientation of
c. No 2 – for posterior adult projections (31 3 41 mm) structures seen in two radiographs exposed at different
Uses angles, can be used as a localization technique.
● For assessment of periodontal status. ● The right-angle technique, another rule for the orientation of
● For detection of apical infection/inflammation. structures seen in two radiographs (one periapical and an-
● After trauma to assess the teeth and alveolar bone. other occlusal), can also be used as a localization technique.
● For assessment of position of unerupted teeth. Indications
● For detailed evaluation of apical cysts and other ● To locate foreign objects like salivary stones, broken
lesions within the alveolar bone. teeth, remnants of root stumps, filling materials,
● During endodontic therapy, preoperative assess- broken needles and other instruments.
ment and postoperative appraisal of apical surgery. ● To assess unerupted teeth, retained roots and root
II. Occlusal films positions in the jaws.

Occlusal films are used to show larger areas of the max- ● To assess mediolateral dimensions and relationships
illa or mandible. The size of the film is 57 3 76 mm. of impacted teeth to the adjacent structures.
Uses: ● To assess the relationship of the mandibular canal to
● To precisely locate supernumerary teeth, un- the apices of teeth.

erupted and impacted teeth as well as retained Types of localization radiographic techniques
roots of extracted teeth. ● Commonly used intraoral localization radiographic
● To locate stones in the ducts of sublingual and techniques are as follows:

submandibular glands. i. Buccal object rule
● To demonstrate and evaluate the integrity of the ante- ii. Tube-shift technique/Clark’s rule
rior, medial and lateral outline of the maxillary sinus. iii. Right angle technique/Miller’s technique
● For obtaining information about the location, Other techniques:
nature, extent and displacement of fractures of i. Stereoradiography
both the mandible and maxilla. ii. Contrast radiography
Buccal object rule Interpretations

● Buccal object rule is used to evaluate the relative ● When the dental structure or the object is seen in the
relationship of the root apices of the mandibular second radiograph, it appears to have moved in the
molars to the mandibular canal. same direction as the shift of the PID, the structure
● Buccal object rule states that the object will move or the object is said to be positioned lingually.
with a change in angulation of the PID (right or ● If the object appears to have moved in a direction
left/up or down). opposite to the shift of the PID, then the object in
Technique question is said to be positioned buccally.
● A conventional intraoral periapical radiograph of the ● It follows SLOB rule: Same Side Lingual and
mandibular third molar is taken. Opposite Side Buccal.

● A second radiograph is taken with a 220° vertical
Q.6. Radiographic technique for maxillary standard
angulation.
occlusal view.
Interpretation
● Both the radiographs are examined. If the mandibu- Ans.
lar canal in the second radiograph moves in direction
This projection shows the following:
superior to the apices of the mandibular molar, then
● The palate
the mandibular canal is said to be placed buccally in
● Nasal septum
relation to the apices of the mandibular third molar.
● Nasolacrimal canals
● If the canal appears to have moved in a direction in-
● The zygomatic process of the maxilla
ferior to the apices of third molar, the mandibular
● The anterior–inferior aspects of each antrum
canal is said to be placed lingually to the apices of
● The teeth from the right second molar to the left
third molar.
second molar
● If the canal in the second radiograph does not seem
Technique of maxillary occlusal view
to move as compared to the first radiograph, then the
Patient position
canal is assumed to be in the same plane as that of
● Seat the patient upright with the sagittal plane
the apices of the third molar.
perpendicular to the floor and occlusal plane
Q.4. Occlusal radiograph. horizontal.
Film placement
Ans.
● Place the film, with its long dimension perpendic-
[Ref LE Q.2] ular to the sagittal plane, cross-wise in the mouth.

● Gently push the film in backward until it contacts
Q.5. Clark’s technique.
the anterior border of mandibular rami.
Ans. ● The patient stabilizes the film by gently closing
the mouth.
Clark’s technique is also known as shift-cone technique.
Projection of the central ray
Principle
● The central ray is directed at a vertical angulation
The basic principle is that the relative position of the
of 165° and a horizontal angulation of 50° towards
radiographic images of two separate objects changes
the midline of the film.
when the projection angle at which the projection was
● In general, the central ray enters the patient’s face
made is changed.
through the bridge of the nose.
● A different horizontal angle is used when trying to
locate vertically aligned images, e.g. root canals. Q.7. Give the indications of true occlusal radiograph.
● A different vertical angulation is used when trying
Ans.
to locate horizontally aligned images, e.g. man-
dibular canal. [Same as SE Q.4]
Technique
● Two radiographs of the object are taken.
● First using the proper technique and angulations as

SHORT NOTES:
prescribed. Q.1. Indications of bitewing radiographs.
● Second radiograph is taken keeping all other param-
Ans.
eters constant and equivalent of those of the first
radiograph, only changing the direction of the cen- Indications of bitewing radiographs are as follows:
tral ray either with a different horizontal or vertical ● Diagnosis of interproximal canes and secondary caries.
angulation. ● To study the height of pulp chamber.

● To study the height of alveolar bone or assessment of ● Perform the examination in morning as the gag reflex is
bone loss. worse when the patient is tired.
● To study occlusion of teeth. ● Tongue should be very relaxed and positioned well
● Checking on the gingival margins of proximal fillings during placement of film.

and detecting calculus deposits in interproximal areas. ● Ask the patient to breathe rapidly through the nose.
● Determining the relationship of the permanent tooth ● Asking the patient to hold their breath/keeping a foot or arm
buds to the deciduous teeth. suspended during film; placement can create a distraction.
● Useful in periodic check-up of the teeth for the detec- ● In extreme cases, topical anaesthetic agents in mouth-
tion of new caries and of early periodontal changes. washes or spray can be administered to produce tempo-
rary numbness of the tongue and palate.
Q.2. Mention four disadvantages of the bisecting angle
technique. Q.4. Indications of transorbital view.
Ans. Ans.
[Ref LE Q.4] Indications of transorbital view are as follows:
Q.3. How will you manage the problem of gagging in a ● To examine the anterior view of Temporo mandibular
patient during the periapical technique? Joint (TMJ).

● Mediolateral dimension of articular eminence.
Ans. ● Condylar head and condylar neck.
● First relax and reassure the patient. ● To view the morphology of convex surface of condylar
● Radiologist can describe and explain the procedure. head.
Topic 7
Extraoral Radiographic Techniques
LONG ESSAYS:
1. Enumerate the radiographic techniques to study temporomandibular joint and describe any two in detail.
2. Write in brief the radiographic technique used for viewing the maxillary sinus.
3. Give the radiographic diagnosis of important pathological entities involving the antrum.
4. Describe the principle, procedure, indications and limitations of panoramic radiography.
5. How will you take lateral oblique view of mandible and give interpretations to that?
6. Discuss briefly about tomography.
7. Enumerate various skull radiographs and discuss in detail posteroanterior paranasal sinus and submentover-
tex view of skull.
8. Describe in detail the transcranial and transpharyngeal radiographic techniques of TMJ. [Same as LE Q.1]
9. Discuss the procedure, advantages and disadvantages of panoramic imaging. [Same as LE Q.4]
10. How will you take a lateral oblique radiograph of the mandible? Mention normal radiographic landmarks in
the same radiograph. [Same as LE Q.5]
11. Discuss briefly the theory of tomography. [Same as LE Q.6]
SHORT ESSAYS:
. Technique for better visualization of paranasal air sinus.
1
2. Oblique lateral radiograph of mandible.
3. Posteroanterior view.
4. Panoramic radiography. [Ref LE Q.4]

5. Radiographs to study the following: (A) fractures of the angle of mandible, (B) fracture in symphysis region
and (C) fracture zygomatic arch.
6. Define focal trough and write any two principal advantages of panoramic radiograph.
7. Technique of transcranial view of TMJ. [Ref LE Q.1]
8. Write in brief the radiographic techniques used for viewing the maxillary sinus.
9. Waters’ projection. [Same as SE Q.1]
10. Advantages of OPG. [Same as SE Q.4]
SHORT NOTES:
1. Principle of panoramic radiography.
2. Advantages of panoramic radiography.
3. Transorbital view. [Ref LE Q.1]
4. Give uses of lateral skull projection.
5. Name two radiographic techniques to study TMJ.
6. Mention the uses of Waters’ view.
7. Submentovertex view.
8. Name few extraoral radiographs.
9. Indications for extraoral radiographs.
10. Indications of PA view skull.
11. Bregma–Menton view. [Ref LE Q.2]
12. Name any two techniques for TMJ radiography. [Same as SN Q.5]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Enumerate the radiographic techniques to study [SE Q.7]
temporomandibular joint and describe any two in detail.
{Transcranial technique
Ans. ● This technique is also known as Lindblom tech-
nique. It is most useful in detecting arthritic
Temporomandibular joint (TMJ) radiography changes on the articular surface and it also helps
● In distinguishing among the disorders that may affect the to evaluate the joints’ bony relationship.
TMJ, radiography is the most important diagnostic aid. ● This technique is not helpful in detecting changes
● TMJ imaging depends on the clinical problem and on the central and medial surfaces.
the involvement of the hard or soft tissues. ● The cassette is placed flat against the patient’s ear
● The various radiographic techniques used to study and centred over the TMJ of interest, against the
TMJ are as follows: facial skin parallel to the sagittal plane.
a. Plain film radiography ● Patient’s head is adjusted so that the ala tragus
i. Reverse Towne line is parallel to the floor.
ii. Cephalometrics ● The view is taken with the patient’s mouth in
iii. Transorbital–frontal projection three positions:
iv. Transcranial–lateral projection i. Open mouth
v. Transpharyngeal–lateral projection ii. Rest position
vi. Xeroradiography iii. Closed mouth
vii. Posterior-anterior (PA) Waters’ view ● The point of entry is different according to the
b. Conventional tomography technique.
i. Linear tomography A. Point auricular or Lindblom technique
ii. Orthopan tomography ● Point of entry of the central ray is ½" behind and 2"
iii. Corrected tomography above the auditory meatus.
c. Computed tomography (CT) ● According to Lindblom, the central ray should be
d. Arthroscopy directed from posteriorly so that it passes along
e. Arthrography the long axis of the condyle and the medial pole of
f. Magnetic resonance imaging (MRI) the condyle is more posterior to the lateral pole.
B. Grewcock approach Uses

● The central ray enters through a point 2” above the ● This view is primarily intended to provide gross
external auditory meatus. visualization of the condyle.

C. Gill’s approach ● It is helpful in diagnosing fractures of the condyle
● The central ray enters through a point ½” anterior and neck and in detecting gross alterations in
and 2” above the external auditory meatus. condylar form.
● In all the three techniques, the central ray is ● Unobstructed view of the superior surface of the
directed caudally at an angle of 120° to 125°. The condyle.

point of exit is through the TMJ of interest. Transorbital technique
● The exposure parameters are kVp – 70, mA – 07,
seconds – 1.5.
Uses {SN Q.3}
● It is most useful in detecting articulating surfaces
changes caused by various forms of arthritis. ● This technique, also known as Zimmer projection/
● The relationship of the condyle to the articulating
transmaxillary projection, is the conventional frontal
surface of the joint is seen in this radiograph. TMJ projection, which is most successful in delin-
● It shows the lateral oblique view of the condylar
eating the joint with minimal super impositions,
head and articular fossa. It shows minute, subtle leading to the production of a relatively true ‘enface’
bony irregularities on the lateral bony surfaces.} projection.
Transpharyngeal technique
● This technique also known as Parma projection/
infracranial projection/MacQueen–Dell projec- ● The structures shown in this technique are the
tion is a lateral projection of the condylar head articular surface (convex) and the articular emi-
and neck, usually taken in the mouth open posi- nence (flat or convex).
tion, so that the joint is projected into the shadow ● The film is positioned behind the patient’s head at
of air containing spaces of the nasopharynx, an angle of 45° to the sagittal plane and the
which helps to increase the contrast of the various patient is positioned so that the sagittal plane is
parts of the joint. vertical. The canthomeatal line should be 10° to
● The cassette is placed flat against the patient’s ear the horizontal, with the head tipped downwards.
and is centred to a point 1⁄21/2 anterior to the exter- The mouth should be wide open.
nal auditory meatus, over the TMJ of interest, ● The tube head is placed in front of the patient’s
against the facial skin parallel to the sagittal plane. face and the central ray is directed to the joint of
● The patient is positioned so that the sagittal plane interest, at an angle of 120°, to strike the cassette
is vertical and parallel to the film, with the TMJ at right angles.
of interest adjacent to the film. ● The point of entry may be taken at:
● The film is centred to a point 1/2 anterior to the i. Pupil of the same eye, asking the patient to
external auditory meatus. The occlusal plane look straight.
should be parallel to the transverse axis of the ii. Medial can thus of the same eye.
film so that the soft parts of the nasopharynx are iii. Medial can thus of the opposite eye.
in one line with the TMJ. ● Exposure parameters are kVp – 70, mA – 07,
● The patient is instructed to slowly inhale through seconds – 0.5.

the nose during exposure, so as to ensure filling of Uses
the nasopharynx with air during the exposure. The ● This view is particularly useful for visualizing
patient should open his mouth so that the condyles condylar neck fractures.
move away from the base of the skull and the man- ● Morphology of the convex surface of the condylar
dibular notch of the opposite side is enlarged. head can be evaluated in the diagnosis of gross
● Radiograhphic tube head is directed from the op- degenerative changes or other anomalies.
posite side cranially, at an angle of –5° to –10° Advantages
posteriorly. It is directed through the mandibular ● The lack of serious super impositions over most
notch, which is a window between the coronoid, of the condylar process.

condyle and the zygomatic arch, of the side below ● Simplicity.
the base of the skull to the TMJ of interest. ● This view provides an anterior view of the TMJ
● Exposure parameters are kVp – 70, mA – 07, perpendicular to transcranial and transpharyngeal
seconds – 0.8. projections.
Limitations iii. PA Waters’ view

● In this view, only the condylar neck is visible be- ● This projection is primarily used to demonstrate the
cause the areas of the joint articulating surfaces maxillary sinus, frontal and ethmoidal sinuses. The
are obscured by superimposition of the temporal sphenoidal sinuses can be seen if the patient is asked
component on the condylar head. to open his mouth, where by the sphenoidal sinuses
are projected on the palate.
Q.2. Write in brief the radiographic technique used for
● The orbit, frontozygomatic suture, nasal cavity, cor-
viewing the maxillary sinus.
onoid process of the mandible and the zygomatic
Ans. arch are also seen.
● The cassette is placed perpendicular to the floor in a
The various radiographic techniques used for viewing the
cassette holding device. The long axis of the cassette
maxillary sinus are as follows:
is positioned vertically.
i. Standard occipitomental projection (0° OM)
● The patient is positioned such that the midsagittal
ii. Modified method (30ooccipitomental projection)
plane should be vertical and perpendicular to the
iii. PA Waters’ view
plane of the film and the patient’s head is extended so
iv. Bregma–Menton view
that only the chin touches the cassette. The cassette is
The various radiographic techniques used for viewing
centred around the acanthion (anterior nasal spine).
the maxillary sinus are described in detail below:
● The canthomeatal line should be at 37° to the plane
i. Standard occipitomental projection (0° OM)
of the film and the line from the external auditory
● This projection shows the facial skeleton and the
meatus to the mental protuberance should be per-
maxillary antra and avoids superimposition of the
pendicular to the film.
dense bones of the base of the skull. It is especially
● Waters (1915) specified that the tip of the nose
useful to detect middle third fractures (Le Fort I, II,
should be 0.5–1.5 mm away from the cassette.
III, zygomatic complex, nasoethmoidal complex,
Mahoney (1930) found that the petrosal shadows
orbital blowout) and coronoid fractures.
can be correctly placed by adjusting the orbitome-
● The cassette is placed perpendicular to the floor with
atal line at 37° to the horizontal.
its long axis of cassette positioned vertically.
● The patient’s head is extended as far as comfortable,
● The patient should be positioned such that the mid-
to make the lower border of the mandible as parallel
sagittal plane should be vertical and perpendicular.
to the cassette as possible. Only the chin touches
Only the nose and chin should touch the cassette.
the cassette. The canthomeatal line should also be
The head is tipped back so that the radiographic
approximately parallel to the plane of the film.
baseline is at 45° to the film.
● The central ray enters at the Bregma and exits at the
● The central ray is directed horizontally through the
Menton.
occiput.
● Exposure parameters are kVp – 65, mA – 10,
seconds – 2–3.
seconds – 2–3.
ii. Modified method (30° occipitomental projection)
● This projection shows the facial skeleton, from a dif-
{SN Q.11}
ferent angle enabling certain bony displacements to iv. Bregma–Menton view
be detected. It is useful in detecting middle third ● This projection is primarily used to demonstrate
fractures (Le Fort I, II, III) and coronoid process the walls of the maxillary sinus (especially in the
fractures. posterior areas), the orbits, the zygomatic arches
● The cassette is placed perpendicular to the floor in a and the nasal septum. It also demonstrates medial
cassette holding device. The long axis of the cassette or lateral deviations of any of the mandible.
is positioned vertically. ● The cassette is placed perpendicular to the floor
● The patient is positioned such that the midsagittal in a cassette holding device. The long axis of the
plane is vertical and perpendicular to the cassette cassette is positioned vertically.
and the head is centred, so that the nasion is in the ● The patient is positioned such that the midsagittal
centre of the cassette. Only the nose and chin touch plane should be vertical and perpendicular to the
the cassette; the head is tipped back so that the radio- plane of the film.
graphic baseline is at 45° to the film.
● The central ray is directed 30° to the horizontal,
Q.3. Give the radiographic diagnosis of important path-
centred through the lower border of the orbit.
ological entities involving the antrum.
seconds – 2–3. Ans.

The various pathologies involving the antrum are as ● Increased thickness of the radiopaque lining of the
follows: sinus, i.e. thickness of boundary walls.
i. Inflammatory changes thickened mucosal sinusitis II. Trauma
a. Acute ● Fractures are commonly demonstrated by conven-
b. Chronic tional radiographic techniques but CT is often neces-

ii. Empyema–fluid levels sary to show the fracture lines.
iii. Polyps, mucosal retention cysts and mucocoele a. Nasal fracture
iv. Carcinoma ● Most injuries affect the paired nasal bones, which
v. Postoperative maxillary cysts are best seen in the lateral skull view.
vi. Foreign objects within maxillary sinus b. Orbital blowout fracture
vii. Soft-tissue calcification like lymph nodes and sialoliths ● In pure ‘blowout’ fractures, the orbital rim is in-
Antral diseases and their radiographic appearances are as tact with no injury to the globe.
follows: ● On plain films, the bone fragments are dis-
I. Inflammatory diseases placed into the superior aspect of the maxillary

a. Acute sinusitis sinus and/or one end of the single fragment may
Acute sinusitis can be caused by: be in contact with the remaining walls, the so-
● Upper respiratory tract infection, e.g. common called ‘trap door’ appearance, which is repre-
cold. sented by a linear radiopacity that extends into
● Trauma, e.g. oroantral communication or a tooth the superior aspect of the maxillary sinus. This
fragment being pushed into the sinus. ‘trap door’ is a hallmark feature of the orbital
● Periapical infection of posterior teeth. A single blowout fracture.
maxillary posterior tooth with chronic apical peri- ● Waters’ view best demonstrates the intact orbital
odontitis may produce a localized inflammatory rim together with herniation of soft-tissue con-
response. It is known as ‘periapical mucositis’. tents into the maxillary sinus.
The radiographic picture would be: ● Coronal CT scans are the most favoured imaging
● Periapical picture depicting antral halo because of modality for identifying blowout fracture and
resorption and remodelling of antral floor. evaluating involvement of adjacent tissues.
● A periapical lesion that has resulted in an inward c. Orbital rim fractures
bulging of the sinus floor is characterized by a ● The Waters’ or Caldwell’s views are usually ade-
periapical radiolucency surrounded by a thin quate to demonstrate the integrity of the orbital
opaque line of bone. The radiographic appearance rims.
has been called the ‘halo effect’. ● Coronal CT may also be used, though the former
● Opaque zone at the base of the sinus because of can also be used to see the frontal sinuses. Be-
fluid collected in it. sides, an axial CT may be used to evaluate the
● Total opacity of sinus is because of mucosal hy- integrity of the anterior cranial fossa.
pertrophy and fluid in sinus. d. Zygomatic arch fractures
● Evidence of foreign body when applicable. ● Zygomatic arch fractures may occur singly or
b. Chronic sinusitis may be associated with either a tripod fracture or

Chronic sinusitis can be caused by: a Le Fort III fracture.
● Persistent infection of the sinus. ● The plain film study of choice is the ‘soft tis-
● Continued presence of a foreign body or commu- sue’ or low kVp submentovertex or ‘jug han-
nication. dle’ view.
The radiographic changes would be: ● Axial CT may be of use particularly in complex
● Irregular thickening of the radiopaque lining on fractures.

the inner side of sinus because of mucosal hyper- ● Three-dimensional CT scans have proved helpful
trophy. in evaluating degrees of displacement.

● Shrinkage of the radiolucent cavity of the sinus. e. Tripod fractures or zygomatic maxillary complex
● Radiopacity at the base of the sinus cavity due to fracture
collection of the fluid. ● The fracture of suggestive bone usually results in
● Round dome-shaped radiopacity seen in the cavity radiopacity of maxillary antrum because of the
may be because of a mucosal polyp. presence of blood.
Appearance of multiple, smooth, rounded opaci- ● Type I or nondisplaced or minimally displaced
ties on the sinus walls and floor is common with fractures can be visualized in plain films or in
patients suffering from allergic sinusitis. Waters’ view.
● Type II or segmented zygomatic arch or orbital iii. Dentigerous cysts

rim fractures result in subtle rotation of the frag- ● The dentigerous cysts appear as well-
ment. The coronal CT is the radiographic tech- corticated pericoronal radiolucencies ex-
nique of choice. ceeding 3.0 mm.
● Type III or fractures with substantial rotation or ● The margins are well corticated, thin and
displacement of the fracture fragment are best smoothly curved. A tooth is an integral part
seen on a coronal CT scan. of the dentigerous cyst.
● Type IV or comminuted fracture with gross rota- iv. Calcifying odontogenic cyst (Gorlin cyst)
tion or displacement is best seen by coronal CT ● The most common radiologic appearance is
scan. Three-dimensional CT scans have proved of a cystic radiolucency, which may be uni-
to be helpful in evaluating degrees of displace- locular or multilocular. Expansion and per-
ment. foration can be well demarcated or irregular
f. Transfacial fracture (Le Fort fracture) with characteristic calcifications. The radi-
● Le Fort fractures are complex fractures, Le Fort I opaque foci often are clustered around the
and Le Fort II involve the maxillary sinus and Le occlusal or incisal surfaces of an impacted
Fort III is a craniofacial disjunction. For such tooth.
fractures, plain film radiograph is inadequate and ● CT and MRI complement conventional
scans are the modality of choice for evaluating radiographs and show that calcifying
all transfacial injuries. odontogenic cyst originates as unilocular
III. Benign lesions of the maxillary sinus (cysts and lesion that may become multilocular with
tumours) time as CT and MRI display incomplete
● Cysts and tumours of the maxilla and maxillary antrum bony system.
are space-occupying lesions which increase in size B. Tumours
gradually to encroach on the contiguous structures i. Ameloblastoma
such as walls of sinus or the ostium. ● Ninety per cent of the maxillary lesions in-
● The signs and symptoms then follow. Radiographic volve the premolar–molar region.
analysis provides an immense database to aid in the ● On plain films and CT, the lesion appears
diagnosis of the sinus lesions. as a multilocular (soap bubble) lytic lesion

● A panoramic radiograph is useful as a beginning without mineralized components. Some-
investigation. Maxillary occlusal radiographs and times the sinus wall may be destroyed.
periapical radiographs are also useful in addition to ii. Odontoma
the more sophisticated modalities such as CT and ● Two-thirds of odontomes are found in
MRI. the anterior and posterior aspects of the

A. Cysts maxilla.
Cysts that develop outside the sinus may expand to ● Radiographically, the compound composite
produce a bowing inward of the sinus wall. odontome resembles an accumulation of

i. Radicular cysts small, fully formed teeth, whereas the com-
● The radicular cysts are most common of all plex composite odontome appears as an
cystic lesions and are most prevalent in the amorphous radiopacity.
anterior maxilla and appear as a rounded or iii. Squamous odontogenic tumour (benign epi-
ovoid radiolucency at the root end of a thelial odontogenic tumour)
tooth, often demarcated by marginal bone ● This rare, benign odontogenic tumour occurs
sclerosis. more often in the maxillary lateral canine re-
ii. Odontogenic keratocyst gion presenting as a triangular or semicircu-
● The odontogenic keratocyst radiographically lar radiolucency within the alveolar bone be-
presents as well-circumscribed radiolucency tween the roots of several teeth. Additionally,
with smooth margins and then radiopaque there is displacement of one or both the adja-
borders. cent roots, destruction of crestal bone and a
● Most of the lesions are unilocular, but larger sclerotic rim at the margin of the lesion.
lesions may be multilocular. They produce iv. Cementoma or periapical cemental dys-
buccal expansion rather than palatal. Large plasia
maxillary lesions are destructive, may be ● These are benign lesions that arise from
expansile and usually involve the sinus. cementum that surrounds the tooth root.
● Periapical cemental dysplasia begins as a ● In the OPG, the film is attached to a rotating system
radiolucent lesion but gradually calcifies to and moves in the same direction as the beam. The
appear as a radiopaque mass separated from film is given the correct speed by opposing this
tooth root by a radiolucent zone. movement with a contrary movement relative to the
● The ‘gigantiform cementoma’ appears as beam.
nodular, irregular-shaped radiopacities in Procedure
multiple locations. ● Explain the procedure to the patient.
v. Benign cementoblastoma or true cementoma ● Make the patient wear a lead apron without a thyroid
● Radiographically, benign cementoblastoma collar, and remove all objects from the head which
appears as well-defined radiopacity attached will interfere with film exposure. Also have the pa-
to the tooth root with loss of outline of the tient remove jacket or bulky sweater; this allows
affected root. more room between the bottom of the cassette holder
vi. Odontogenic myxoma and the patient’s shoulder.
● The radiographic appearance of myxoma is ● Load the panoramic film in the darkroom and
variable. The lesion may have a ‘mottled’ or a cover the bite block with a disposable plastic cover
‘honeycomb’ appearance, or it may present as slip.
an expanding radiolucency with an occasional ● Set the exposure factors and adjust the height of the
multilocular pattern. machine to accommodate the patient.

IV. Malignancy of maxillary sinus ● Instruct the patient to sit or stand with the back
Squamous cell carcinoma straight and erect, and ask him to bite on the plastic
● A sinus opacity and in most cases, antral wall de- bite block. The upper and the lower front teeth must
struction with adjacent bony involvement is patho- be placed in an end-to-end position in the groove of
gnomic of maxillary sinus carcinoma. the bite block.
● Besides the conventional views, 3–5 mm contigu- ● The midsagittal plane should be perpendicular to
ous section of CT scan permits accurate evaluation the floor and aligned with the vertical centre of the
of tumour extension. chin rest, and the Frankfort plane should be parallel
● The primary pathologic and imaging feature of to the floor, thus obtaining the correct position for
squamous cell carcinoma is the propensity to de- the occlusal plane. The patient’s head is tilted
stroy bone even in the presence of a relatively small downwards so that the tragus ala line is 5° down
mass. and forward.
V. Antroliths ● If the patient has a low palatal vault, increase the oc-
● An antrolith is a calcified mass in the maxillary si- clusal plane angulation slightly. If the patient has a
nus or antrum. high palatal vault, decrease the occlusal plane
Radiographic features slightly. The indicator lights in the machine help as a
● These are the small opaque bodies of varying guide and the patients head should be immobilized
sizes generally found in the bases of the sinus. by the head band.
● Generally, the antroliths are of homogeneous ● Centre the lower border of the mandible on the chin
density, and rarely, they may have a more radi- rest and equidistant from each side.
opaque area around. They usually have an irregu- ● Instruct the patient to position the tongue on the
lar border. palate and ask him to remain still while the machine
is rotating during exposure. Also explain that the
Q.4. Describe the principle, procedure, indications and cassette holder will not strike him, although it may
limitations of panoramic radiography. gently rub his ear and head at the limits as of the
Ans. excursion.
● After the exposure is complete the film is subjected
Panoramic radiography is a radiographic procedure that to routine processing.
produces a single tomographic image of the facial struc- Indications
tures including both maxillary and mandibular arches and ● As a substitute for full mouth intraoral periapical
their supporting structures. radiographs.
Principle ● For evaluation of developmental anomalies and tooth
● If the film moves at a speed that follows the moving development for children during the mixed dentition
projection of a certain point, this point will always be period as well as TMJ dysfunctions.
projected on the same spot on the film and will not ● To assess the patient for and during orthodontic
appear unsharp. treatment.
● To establish the site and size of lesions such as cysts ● Useful for mass screening.
and tumours in the body and ramus of the mandible. ● This view helps in localization of objects/pathology
● For progress of pathology and follow-up of treat- in conjunction with a topographic occlusal view or
ment, or postoperative bony healing. an intraoral periapical radiograph.
● Prior to any surgical procedures such as extraction of ● The radiation dose (effective dose equivalent) of app.
impacted teeth, enucleation of a cyst, etc. 0.08 mSv is about one-third of the dose from a full
● For detection of fractures of the middle third and the mouth intraoral film.}
mandible following trauma. Disadvantages or limitations
● In case of periodontal disease for an overall view of ● Areas of diagnostic interest outside the focal trough
the alveolar bone levels. may be poorly visualized, e.g. swelling on the palate
● Assessment for underlying bone disease before con- and floor of the mouth.
structing complete or partial dentures. ● Image quality: Comparatively this radiograph is of a
● Evaluation of the vertical height of the alveolar bone poor diagnostic quality, in terms of magnification,
before inserting osseointegrated implants. geometric distortion, poor definition and loss of
detail.
[SE Q.4]
● Tomograms inherently show magnification, geomet-
{Advantages ric distortion and poor definition. Because of poor

● OPG is an extraoral procedure, which is convenient definition, panoramic radiography is less effective in
for the patient and requires a minimal amount of detecting early interproximal or recurrent caries,
patient’s cooperation. disruptions in lamina dura, loss of crestal alveolar
● Useful in patients with trismus and gagging prob- bone and thickened periodontal membrane.
lems. Most units can be operated without radiation to ● In cases of pronounced inclination, the anterior teeth
demonstrate to the patient what the procedure will be are poorly registered.
like, before the actual exposure will be made. It vir- ● Number of radiopaque and radiolucent areas may be
tually eliminates problems with gaggers, patient with present due to the superimposition of real/double or
trismus, and fearful or uncooperative children. ghost images and because of soft-tissue shadows and
● Time required is minimal compared to a full mouth air spaces.
intraoral periapical radiographs. ● Due to prescribed rotation, patient with facial asym-
● Radiation dose to the patient is relatively low when metry or patients who do not conform to the rotation
compared with conventional full mouth intraoral curvature cannot be X-rayed with any degree of
radiography. satisfaction.
● Patient education: OPG films are a valuable aid in ● If the patient positioning is improper, the amount of
patient education and case presentation. vertical and horizontal distortion will vary from one
● Conditions such as impactions, eruption patterns of part of the film to another part of the film.
teeth, the need for replacement of missing teeth and ● The ease and convenience of obtaining an OPG may
fractures are more easily illustrated on panoramic views. encourage careless evaluation of a patient’s specific
● Size of the area radiographed: A broad anatomic re- radiographic needs.
gion is imaged. The OPG covers an area that includes ● Overlap: OPG units have a tendency to produce
the entire mandible from condyle to condyle and overlapping of teeth images, most particularly in the
maxillary region extending superiorly to the middle premolar area.
third of the orbits. Areas such as condyles, inferior ● Overuse: The ease and convenience in obtaining the
border, angle and ascending ramus of the mandible, OPG might lead to carelessness by substitution for
and entire maxillary sinus that are not visualized in other projection that might be adequate. This is one
intraoral surveys are seen routinely on OPG. of the prime concerns in regard to patient dosage.
● The anatomical structures are most identifiable and ● Cost: Because of its high cost, it is an extra invest-
the teeth are oriented in their correct relationship to ment for practitioners.
the adjacent structures and to each other. ● Artefacts are easily misinterpreted and are more
● It allows for the assessment of the presence and posi- commonly seen, e.g. nose ring as a periapical radi-
tion of unerupted teeth in orthodontic treatment. opaque lesion, earring as a calcification in the maxil-
● It demonstrates periodontal disease in a general way lary sinus.
manifesting a generalized bone loss.
Q.5. How will you take lateral oblique view of mandible
● All the parameters are standardized, and repetitive
and give interpretations to that?
images can be taken on recall visits for comparative
and research purposes. Ans.
Lateral oblique view of mandible can be used for large le- and the head is rotated 10°–15° from the true lat-
sions. The size of the cassette used is 5 3 7 inches. The eral line. For the molar and ramus region, the head
types of lateral oblique view are as follows: should not be turned away from the tube as this
i. Body of the mandible view will place the ramus behind the vertebral column.
ii. Ramus view ● The central ray is directed from under the mandi-
ble opposite to the side of examination, from 2 cm

I. Body of the mandible
below the angle of the mandible. The beam is di-
a. Anterior body of the mandible
rected upwards (–10° to –15°) and centred on the
● It shows anterior body of the mandible and teeth
body of the mandible. The beam must be directed
in the same area, helps to evaluate impacted teeth,
perpendicular to the horizontal plane of the film.
fractures, pathologic lesions located in the infe-
● Exposure parameters are kVp – 65–70, mA –
rior border of the mandible.
7–10, seconds – 0.8.
● The cassette is placed flat against the patient’s
II. Ramus of mandible
cheek, centred over the body of the mandible,
● The purpose of this view is to evaluate impacted
overlying the teeth and it should be positioned
third molar, retromolar area, angle of the mandible,
parallel to the body of the mandible. The patient
condyle and fractures that extend into the ramus of
must hold the cassette position with the thumb
the mandible.
placed under the edge of the palm against the
● The film placement should be such that the central beam
outer surface of the cassette.
is directed towards the centre of the imaged ramus, from
● The patient’s head is so adjusted that the ala tragus
2 cm below the inferior border of the opposite side of the
line is parallel to the floor. The mandible is pro-
mandible at the area of the first molar.
truded slightly. The sagittal plane is tilted so that it
Position of patient
is 5° to the vertical and rotated 30° from the true
● The patient’s head is so adjusted that the ala tra-
lateral position. For the bicuspid and incisor region,
gus line is parallel to the floor.
the patient can be turned slightly away from the
● The mandible is protruded slightly. The cassette is
tube so that chin approximates the cassette.
placed over the patient’s cheek and centred over
● Central ray is directed from under the mandible
the area of interest usually over the ramus and far
opposite the side of examination, from 2 cm behind
enough posteriorly to include the condyle.
the angle of the mandible. The beam is directed
● The lower border of the cassette is parallel and at
upwards (–10° to –15°) and centred on the anterior
least 2 cm below the inferior border of the man-
body of the mandible. The beam must be directed
dible. The head is tilted towards the side being
perpendicular to the horizontal plane of the film.
examined so that the condyle of the area of inter-
est and the contralateral angle of the mandible
7–10, seconds – 0.8.
form a horizontal line.
b. Posterior body of the mandible
● It shows position of the teeth in the same area, ra-
7–10, seconds – 0.8.
mus of the mandible, angle of the mandible. Helps
to evaluate impacted teeth, fractures and lesions Q.6. Discuss briefly about tomography.
located in the inferior border of the mandible.
Ans.
● The cassette is placed flat against the patient’s
cheek and is centred over the body of the mandi- ● Tomography is a process by which an image layer of
ble. The cassette also should be positioned paral- the body is produced, while the images of the struc-
lel to the body of the mandible. The patient must tures above and below that layer are made invisible by
hold the cassette in position with the thumb blurring.
placed under the edge of the cassette and the palm ● In normal radiography, the character of the pattern on
against the outer surface of the cassette. the radiograph formed by the anatomical structures of
● The patient’s head is so adjusted that the ala tragus interest is very often partially or sometimes even com-
line is parallel to the floor. The mandible is pro- pletely obscured by the shadows cast by the overlying
truded slightly to separate it from the vertebral or underlying structures.
column. The cassette is placed over the patient’s Principle
cheek and centred over the area of interest. The ● If the film moves at a speed that follows the moving
inferior border of the cassette should be parallel to projection of a certain point, this point will always be
the lower border of the mandible and below it. The projected on the same spot on the film and will not
sagittal plane is tilted so that it is 5° to the vertical appear unsharp.
Tomography may be classified into three types: relative position of the fulcrum between the
a. Conventional tomography tube and the film.
b. CT ii. The second design
c. Emission tomography ● It is so made that the distance between the
Conventional tomography fulcrum and the tube and the fulcrum and the
● Tomography is a generic term, formed from the film remains constant.
Greek word tomo (slice) and graph (picture) that was ● In this case, the film and the X-ray tube pass
adopted in 1962 by the International Commission on in opposite directions through proportional

Radiographic Units and Measurements to describe all arcs. Here the object of interest is posi-
forms of body section radiography. tioned with reference to the focal plane, and
● Body section radiography is a special X-ray tech- all the images contain the same degree of
nique that enables visualization of a section of the magnification.
patient’s anatomy, blurring regions of the patient’s Tomographic views that are used to examine various facial
anatomy above and below the section of interest. structures are as follows:
● This is achieved by a synchronized movement of the i. Tomography of sinuses affords the following advan-
film and the tube in opposite directions, about a ful- tages:
crum (i.e. the plane of interest in the patient’s body). ● It gives a more precise evaluation of sinus pa-
● Objects closest to the film are seen most sharply and thologies, which are poorly visualized on routine
objects farthest away are completely blurred. radiography.
● The thickness of the image layer depends on the an- ● When a pathology is strongly suspected clini-
gle of rotation or the amount of movement of the cally, but plain films are negative.
tube; thus, if the path of the X-ray tube is short, and ● Sphenoid and ethmoidal sinuses are more clearly
the angle is small then the image layer is relatively visualized.

thick. Whereas when the angle of the movement in- ii. Tomography of facial bones, to study facial frac-
creases, the thickness of the image layer decreases. tures and extent of orbital blowout fractures
● Some degree of image degradation also occurs within iii. Tomography of the mandible
the image layer. The greatest amount of blurring is at iv. Tomography of the TMJ, especially when the pa-
the periphery of the image layer, and the sharpest tient is unable to open his mouth or in conjunction
image is at the centre. with arthrography
The principles of tomography can be mechanically imple- v. For dental implant patients
mented in a variety of ways: CT
● The tube and the film move synchronously in a straight ● CT is a digital and mathematical imaging tech-
line in opposite directions in parallel planes. nique that creates tomographic sections where the
● The tube and the film move synchronously in oppo- tomographic layer is not contaminated by blurred
site directions in parallel planes, but with motions structures from adjacent anatomy. It enables dif-
other than a straight line, i.e. circular, cross, spiral, ferentiation and quantification and soft tissues,
hypocycloidal, trispiral and other multidirectional and is a noninvasive procedure.
movements. ● The discovery and development of CT revolution-
● The X-ray tube may move in arcs rather than in flat ized medical imaging technology.
planes. ● CT scanners use X-rays to produce sectional im-
● The blurring of objects outside a focal plane is ac- ages, but the radiographic film is replaced by very
complished most effectively by compound move- sensitive crystal or gas detectors.
ments of the X-ray tube and least effective by simple ● The detectors measure the intensity of the X-ray
movements. beam emerging from the patient and convert this

● There are two basic design options used in most into digital data, which is stored and manipulated
units: by the computer.
i. Adjustable fulcrum system ● The numerical information is converted into grey
● The image layer or plane of focus is changed scale representing different tissue densities, al-
by adjusting the point of rotation called the lowing a visual image to be generated. This can
fulcrum. provide tomographic sections of the body.
● The disadvantage of this system is that the im- ● The CT sections are reconstructed from profile
ages that are produced will have different X-rays taken at different angles from the structure
amount of magnification, depending on the to be imaged.
● It has the ability to detect minute differences in between the source and the detector, the atten-
tissue alteration. uation of the beam by the material in the object
● It gives highly accurate quantitative information being scanned.
about the tissues imaged. ● In its simplest form, a CT scanner consists of a
Indications of CT radiographic tube that emits a finely colli-
● Investigations of intracranial diseases includ- mated, fan-shaped X-ray beam directed to a
ing tumours, haemorrhage and infarcts series of scintillation detectors or ionization
● Investigations of suspected intracranial and chambers.
spinal cord damage following trauma to the ● Depending on the scanner’s mechanical geom-
head and neck etry, both the radiographic tube and detectors
● Assessment of fractures involving: The orbits may rotate synchronously about the patient.
and nasoethmoidal complex, the cranial base,
Or
cervical spine, etc.
● Tumour staging: Assessment of site, size and ● The detectors may form a continuous ring
extent of benign and malignant tumours affect- around the patient and the X-ray beam may
ing the maxillary antra, base of the skull, ptery- move in a circle within the detector ring (in-
goid region, the pharynx and larynx cremental scanners).
● Investigations of tumours and tumour-like
Or
discrete swellings intrinsic and extrinsic to
the salivary glands and also investigation of ● Spiral or helix scanners – here the gantry con-
the TMJ taining the X-ray tube and detectors revolves
● Preoperative assessment of maxillary alveolar around the patient, the table on which the pa-
bone height and thickness prior to inserting tient is lying continuously advances through
implants the gantry. This results in the acquisition of a
Equipment continuous spiral data, which provides multi-
● The X-ray gantry planar image reconstructions, reduced exami-
i. The X-ray tube: Stationary anode ener- nation time and a reduced radiation dose.
gized continuously and rotating anode op- ● The CT image is a digital image, reconstructed
erated in impulse mode by the computer, which mathematically ma-
ii. The radiation detector nipulates the mission data obtained from the
a. Scintillation detectors multiple projections. Penetration profile is
b. Gas counters stored in the computer, which calculates the
iii. The ancillary components: This embodies density or absorption at points on a grid formed
the mechanical system providing the mo- by the intersections of penetrating profiles.
tions required ● The image consists of a matrix of individual
Computer system points or pixels. The size of the pixel is deter-
● The data collected by the radiation detectors in mined by:
the X-ray gantry are utilized for the reconstruc- ● The geometry of the scan
tion of the tomographic section. ● The frequency and spacing of measurements
● The reconstructed section is displayed either in ● The number of penetration profiles
the analogue form as an image or as a numeri- ● The size of the X-ray source and detector
cal print out. ● Each number or pixel represents a calculation

● These functions are carried out by the com- of the actual attenuation of the X-ray beam by
puter system. A CT image is initiated by a materials. It represents the absorption charac-
process called scanning. teristics, or linear attenuation coefficient of
● Beams from one or several small X-ray sources that particular volume of tissue in the patient.
are passed through the body and intercepted by ● CT numbers, also known as Hounsfield units,
one or more radiation detectors. These detec- may range from –1000 to 11000, each consti-
tors produce electrical impulses that are pro- tuting a different level of optical density. The
portional to the intensity of the X-ray beam scale of relative densities is based on air
emerging from the body. (–1000), water (0) and dense bone (11000).
● That intensity is determined by various factors; ● The numbers may vary from one machine to
the energy of the X-ray source, the distance another depending upon various factors. For
any particular unit and energy, numbers de- Central ray

scribing the attenuation of biological materials ● Is directed to the midline of the skull so that
with densities lying between hair and bone can the X-ray beam passes through the canthome-
be described. Since the numbers represent at- atal plane perpendicular to the film plane.
tenuation or density, the computer constructs ● Exposure parameters are kVp – 65 mA – 10,
an image by printing the numbers or by assign- seconds – 3.

ing different degrees of greyness or different II. Waters’ projection/Caldwell projection
colours to each number. ● It is a variation of PA view.
● The CT image is recorded and displayed as a Synonyms

matrix of individual blocks called ‘voxels’ (vol- ● Occipitomental projection, paranasal sinus (PNS)
ume elements). Each square of the image ma- view of the skull or posteroanterior maxillary sinus
trix is a pixel. Whereas a pixel (about 0.1 mm) projection
is determined partly by the computer program Indications/uses
used to construct the image, the length of the ● It is particularly useful for evaluating the maxil-
voxel (about 1–2 mm) is determined by the lary sinuses.

width of X-ray beam, which in turn is con- ● It demonstrates the frontal and ethmoid sinuses,
trolled by the prepatient and postpatient colli- the orbit, the zygomaticofrontal suture and the
mators. Voxel length is analogous to the tomo- nasal cavity.
graphic layer in film tomography. ● It demonstrates the position of the coronoid pro-
cess of the mandible between the maxilla and the

Q.7. Enumerate various skull radiographs and discuss zygomatic arch.
in detail posteroanterior paranasal sinus and submento- ● In contrast to the horizontal film position, the left
vertex view of skull. or right position permits the detection of fluid
level in the maxillary sinuses.
Ans. Film placement
Posteroanterior projection/occipitofrontal projection ● The film may be placed in either a vertical or
i. Posteroanterior projection/Granger projection horizontal position.

ii. Modified posteroanterior projection/Caldwell pro- Patient position
jection ● The head is oriented in such a way that the sagittal
plane is perpendicular to the plane of the film and

I. Posteroanterior (granger) projection the chin is raised high to elevate the canthomeatal
● It is also known as the occipitofrontal projection of line to 37° above the horizontal plane.
the nasal sinuses. ● To avoid the superimposition of petrous portion of
● This view is excellent for evaluating the inner and the temporal bone over the maxillary sinus, the
middle ear because the petrous pyramid can be chin has to be elevated further.
viewed through the orbits. Frontal sinuses lying ● To investigate the sphenoid sinus, the projection
above the frontonasal suture, anterior ethmoidal cells needs to be taken with patient’s mouth open.
lying each on either side of the nasal fossa, sphenoi- Central ray projection
dal sinuses projected through the nasal fossa just ● The central ray should be perpendicular to the
below or between the shadows of the ethmoids. The film, through the midsagittal plane and at the level
upper part of the antrum is superimposed by dense of the maxillary sinus.
shadows of the petrosae. Exposure
Technique ● The exposure parameters vary based on the
Film placement type of X-ray machine and the distance from
● The cassette is placed perpendicular to the the source to the patient. Exposures recom-
floor in a cassette holding device. The long mended for film with intensifying screens are
axis of the cassette is positioned vertically. 70 kVp, 100 mA.
Position of patient Submentovertex projection
● The midsagittal plane should be vertical and ● A full axial view of the base of the cranium show-
perpendicular to the plane of the cassette. ing a symmetrical projection of the petrosae, the
● Only the forehead and nose should touch the mastoid process, foramen ovale, spinosum canals,
cassette. carotid canals, sphenoidal sinuses, mandible,
o
● The radiographic baseline is at 90 to the film. maxillary sinus, nasal septum, odontoid process
of the atlas and the entire atlas, axial inclination of a Frankfort horizontal angulation of 37–40° to the
the mandibular condyles. detector.
● It helps to study destructive/expansile lesions ● Patient’s midsagittal plane is perpendicular to the
affecting the palate, pterygoid region or base of plane of the detector and the central ray is directed
the skull, sphenoidal sinus. perpendicular to the detector through the midsagittal
● The film is placed such that the cassette is placed plane at the level of the maxillary sinus.
perpendicular to the floor in a cassette holding ● The three variations of the Waters’ projection are as
device. The long axis of the cassette is placed follows:

horizontally. i. Modified Waters’ view (23°):
● The patient is positioned in such a way that the ● It has reduced caudal angle to provide better
head is centred on the cassette, with the patient’s visualization of the floor of the maxillary sinus.
head and neck tipped back as far as possible; the ii. Open mouth Waters’ view:
vertex (top) of the skull touches the cassette. ● It is performed at standard caudal angle but
● Both the midsagittal plane and the radiographic the patient’s mouth is opened wide to provide
baseline should be perpendicular to the plane of better view of the sphenoid sinuses.
the film. iii. 45o Occipitomental view:
● The central ray is directed from below the man- ● It is taken with a greater caudal angle to provide
dible upwards, towards the vertex of the skull and better visualization of the sphenoid sinuses.
positioned far enough anterior to pass about 2 cm
Q.2. Oblique lateral radiograph of mandible.
in front of line connecting right and left condylar
processes. Ans.
Exposure parameters
Lateral oblique view of mandible can be used for large
● The target object distance is 18 inches and the
lesions and the size of the cassette used is 5 3 7 inches.
exposure time is 12 impulses (0.2 s).
Types of lateral oblique view
● For viewing the zygomatic arches specifically,
i. Body of the mandible view
exposure time is reduced to one-third that is used
ii. Ramus view
to visualize the skull.
● Shorter exposure time is needed because the i. Mandibular body projection
zygomatic arches are thin bony structures. ● The image receptor is placed against the patient’s
Uses cheek on the side of interest and centred in the

● To demonstrate base of skull molar–premolar area.
● Position and orientation of condyles ● The lower border of the cassette is parallel and at
● Detection of curvature of mandible, the lateral least 2 cm below the inferior border of the mandible.
wall of maxillary sinus ● The head is tilted towards the side being examined,
● To view fracture of zygomatic arch the mandible is protruded.

● The central beam is directed towards the molar–
premolar region from a point 2 cm below the angle
SHORT ESSAYS: of the opposite side of the mandible.
Q.1. Technique for better visualization of paranasal air ● A clear image of the teeth, alveolar ridge and the
sinus. body of the mandible should be obtained.

● If significant distortion is present, the head was tilted
Ans.
excessively. If the contralateral side of the mandible
● Waters’ projection is also known as ‘sinus view’. It is is superimposed over the area of interest, the head
used to view the maxillary sinus, orbital ridges and was not tilted sufficiently.
floor, frontal and ethmoidal sinus and the nasal cavity. ii. Mandibular ramus projection
● It is indicated in: ● The image receptor is placed over the ramus and far
i. Trauma to middle third of face more posteriorly to include the condyle. The lower
ii. To asses fluid levels and soft tissues of lateral, infe- border of the cassette is parallel and at least 2 cm
rior and medial wall of maxillary sinus below the inferior border of the mandible.
iii. To inspect the odontoid process of second cervical ● The head is tilted towards the side being examined so
vertebrae, mandible and condyles during trauma that the condyle of the area of interest and the contra-
Technique lateral angle of the mandible form a horizontal line.
● Tilt back the head to prevent superimposition of the ● The central beam is directed towards the centre of
highly dense petrous bone over the maxillary sinus. imaged ramus, from 2 cm below the inferior border
● The chin should rest on the detector and the nose is of the opposite side of the mandible at the area of the
approximately 3 cm away from the film approximating first molar.
● A clear image of the third molar–retromolar area, Q.6. Define focal trough and write any two principal
angle of the mandible, ramus and condyle head advantages of panoramic radiograph.
should be obtained. Ans.
● If significant distortion is present, the head was tilted
excessively. If the contralateral side of the mandible ● Focal trough is defined as that zone which contains
is superimposed over the area of interest, the head those object’s points that are depicted with optimum
was not tilted sufficiently. resolution. In other words, it is a three-dimensional
curved zone in which structures are clearly demon-
Q.3. Posteroanterior view. strated on a panoramic radiograph.
● The size and shape of the focal trough varies according
Ans.
to the manufacturer. The closer the rotation centre to the
● The purpose of the posteroanterior projection is to teeth, narrower the focal trough. In most machines, the
evaluate facial growth and development, trauma and focal trough is narrow in the anterior region and wide in
disease and developmental abnormalities. This projec- the posterior region.
tion also demonstrates the frontal and ethmoid sinuses, Advantages
the orbits and the nasal cavity. Principal advantages of panoramic radiograph:
● The cassette is placed perpendicular to the floor in a ● Convenient for the patient requiring very little patient
cassette holding device. The longaxis of the device compliance.
cassette is positioned vertically. ● Useful in patients with trismus and gagging problems.
● The patient faces the cassette such that the forehead and ● Time required is minimal compared to a full mouth
the nose both touch the cassette. The midsagittal plane intraoral periapical radiographs.
is positioned perpendicular to the floor, and the Frank- ● The patient exposure dose is relatively low compared
fort plane is positioned parallel with the floor. The head to a full mouth intraoral periapical.
is centred over the cassette.
Q.7. Technique of transcranial view of TMJ.
● The central ray is directed through the centre of the head
and perpendicular to the cassette. Ans.

● The exposure factors for the posteroanterior projection vary
[Ref LE Q.1]
with the film, intensifying screens and equipment used.
Q.8. Write in brief the radiographic techniques used for
Q.4. Panoramic radiography. viewing the maxillary sinus.
Ans. Ans.
[Ref LE Q.4] The various radiographic investigations to examine the
maxillary sinus for foreign body are as follows:
Q.5. Radiographs to study the following: (A) fractures
of the angle of mandible, (B) fracture in symphysis
Radiographic view Area of the antrum shown
region and (C) fracture zygomatic arch.
i. Intraoral Floor, base of the antral cavity, relation-
Ans. periapical ship with upper posterior teeth
radiograph
The radiographs to study the following fractures are as
ii. OPG Floor, posterior wall, base of the antral
follows:
cavity, relationship with the posterior
Fractures of the angle of mandible teeth, allows comparison with both sides
● Lateral oblique view is satisfactory technique of hav-
iii. Standard occip-
ing an extraoral view of the jaw; it is used to visual- itomental view
ize large lesions. It can show body of mandible from
canine to the angle of mandible, ramus of mandible, iv. Posterior Floor, lower half of the antral cavity,
topographic relationship with upper posterior teeth
body of maxilla, condyle and coronoid process. occlusal view
Fracture in symphysis region
v. True lateral Main antral cavity, posterior wall and
● Posteroanterior projection is used to visualize the
skull anterior wall (in this view the antral
facial symmetry, frontal and ethmoid sinus pathol- shadows superimpose each other)
ogy, the occipital and facial bones and the orbits.
vi. Linear tomogra- Main antral cavity, floor, anterior wall,
Fracture zygomatic arch
phy in coronal lateral wall, posterior wall, medial
● Submentovertex view allows the visualization of the
or sagittal plane wall, roof or upper border and allows
base of the cranium including the occipital bone, the comparison of both sides
sphenoid and ethmoids in uses, petrous ridge and
vii. CT Main antral cavity, floor, all walls roof
mastoid sinuses of the temporal bone. or upper border, surrounding structures
● Facial structures imaged include the hard palate, zy- allows comparison of both sides, images
gomatic arch and mandible including the condyles. hard and soft structures
SHORT NOTES: useful for visualizing condylar neck fractures and gross
degenerative changes or other anomalies.
Q.1. Principle of panoramic radiography.
Q.6. Mention the uses of Waters’ view.
Ans.
Ans.
● If the film moves at a speed that follows the moving
projection of a certain point, this point will always The uses of Waters’ view are as follows:
be projected on the same spot on the film and will not ● To evaluate the maxillary sinus
appear unsharp. ● To demonstrate the frontal and ethmoidal sinus, the
● In the OPG, the film is attached to a rotating system and orbits and nasal cavity
moves in the same direction as the beam. The film is Q.7. Submentovertex view.
given the correct speed by opposing this movement with
a contrary movement relative to the beam. Ans.
Q.2. Advantages of panoramic radiography. ● The purpose of submentovertex position is to identify
the position of the condyles, demonstrate the base of the
Ans. skull and evaluate the fractures of the zygomatic arch.
Advantages of panoramic radiography ● It also demonstrates the sphenoid and ethmoid sinuses
i. Convenient for the patient and requires very little patient and the lateral wall of the maxillary sinus.
compliance. Q.8. Name few extraoral radiographs.
ii. Useful in patients with trismus and gagging problems.
iii. Time required is minimal compared to a full mouth Ans.
intraoral periapical radiographs. ● Extraoral radiograph is a large inspection of the skull or
iv. The patient exposure dose is relatively low compared jaws. It requires the use of extraoral film that is placed
to a full mouth intraoral periapical radiographs. outside the mouth.
Q.3. Transorbital view. ● Examples of extraoral radiographs are as follows:
i. Lateral skull projection

Ans. ii. Submentovertex projection
[Ref LE Q.1] iii. Waters’ projection
iv. Posteroanterior skull projection
Q.4. Give uses of lateral skull projection.
Q.9. Indications for extraoral radiographs.
Ans.
Ans.
● It is a method used to examine posterior region of the
mandible and is used in children, in patients with Extraoral radiography is indicated for:
limited jaw opening due to a fracture or swelling, and in ● Evaluation of trauma
● Impacted third molars
patients who have difficulty in tolerating intraoral film
● Extensive dental or osseous disease known or suspected
placement.
● It is used to evaluate the teeth, the alveolar ridge and
large lesions
● Tooth development and retained teeth or root tips
the body of the mandible, third molar-retromolar area,
● Developmental anomalies
angle of the mandible, ramus and condyle head.
● Monitor growth and development as well as treatment. Q.10. Indications of PA view skull.
Q.5. Name two radiographic techniques to study TMJ. Ans.
Ans. ● The purpose of the posteroanterior projection is to
evaluate facial growth and development, trauma and
Two techniques used to study TMJ joint are as
disease and developmental abnormalities.
follows:
● This projection also demonstrates the frontal and
● Transcranial view: Transcranial technique is also
ethmoidal sinuses, the orbits and nasal cavity.
known as Lindblom technique. It is most useful in de-
tecting arthritic changes on the articular surface and it Q.11. Bregma–Menton view.
also helps to evaluate the joints’ bony relationship.
Ans.
● Transorbital view: Transorbital technique is also
known as Zimmer projection. This view is particularly [Ref LE Q.2]

Topic 8
Specialized Imaging Techniques
LONG ESSAYS:
1 . Sialography: describe the indications and contraindications of sialography. Describe the technique briefly.
2. Define sialography and describe in detail the contrast media used in sialography.
3. Describe sialography in detail and write briefly on its significance in various salivary gland disorders. Add a note
on its interpretation in various diseases of salivary glands.
4. What is tomography and describe in detail computed tomography?
5. Define sialography. Give the ideal requirements of the contrast media used in sialography. [Same as LE Q.2]
SHORT ESSAYS:
1 . Describe the procedure for sialography of parotid gland.
2. Digital radiography.
3. Applications of ultrasound in dentistry.
4. Salivary scintigraphy.
5. Radionuclide imaging – advantages and disadvantages.
6. Magnetic resonance image and its advantages.
SHORT NOTES:
1 . Two indications and contraindications of sialography. [Ref LE Q.1]
2. Digital radiography (radiovisiography). [Ref SE Q.2]
3. Mention few requirements of ideal contrast medium used for sialograph. [Ref LE Q.2]
4. Scanography.
5. Write notes on xeroradiography.
6. Indications of CT in oral and maxillofacial region. [Ref LE Q.4]
7. Contraindications of sialography. [Same as SN Q.1]
8. Indications of sialography. [Same as SN Q.1]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Sialography: describe the indications and contrain-
{SN Q.1}
dications of sialography. Describe the technique briefly.
Indications
Ans.
Sialography is used for:
Sialography is a specialized radiographic view taken by in- i. Detection of calculus or calculi or foreign bodies.
troduction of the radiopaque dye into the ductal system of the ii. Determination of the extent of destruction of the
major salivary glands, mainly parotid and submandibular. gland secondary to obstructing calculi or foreign
This technique is used to examine the ductal and acinar bodies. This will help in deciding treatment plan
systems of the major salivary glands. The sublingual and whether a total excision of the gland or a simple
the minor glands cannot be studied obviously because of lithotomy should be performed.
their small and numerous openings.
iii. If the gland has some degree of function, a drop of

iii. Detection of fistulae, diverticula or strictures.
saliva can be expressed by applying gentle pres-
iv. Determination and diagnosis of recurrent swell-
sure to the skin over main parotid area, thus iden-
ings and inflammatory processes.
tifying the location of the orifice.
v. Demonstration of a tumour and the determina-
iv. The submandibular excretory duct orifice is situated on
tion of its location, size and origin.
the summit of the small papilla at the side of the lingual
vi. Determining outline of the plane of the facial nerve
frenum, but care should be taken to differentiate it from
as a guide in planning a biopsy or dissection.
the sublingual gland orifices in the same region.
vii. Detection of residual stone or stones, residual
v. The duct can be explored with the lacrimal probe,
tumour, fistula or stones retention cysts following
after the appropriate orifice has been identified.
surgical procedures.
● In case of the submandibular gland, the probe
viii. Sialography has also been employed as a thera-
should pass through the length of the floor of the
peutic procedure because:
mouth to the level of the posterior border of the
● The dilatation of the ductal system produced
mylohyoid muscle, a penetration of about 5 cm.
during the study may aid in the drainage of
● Due to the tortuous course of the parotid duct, the
the ductal debris.
cheek has to be turned outward before the probe is
● A therapeutic effect is produced by the
inserted into the duct. The aversion of the cheek
iodinated contrast media when injected into
will help reduce the possibility of penetrating the
the ductal system.
duct at one of the sharp angles in its course.
Contraindications
● In both the parotid and submandibular ducts,
i. Patient with a known sensitivity to iodine com-
the probe should slide easily back and forth and
pounds and those who have experienced severe
also rotate freely without dragging.
asthmatic attacks or anaphylaxis following use
vi. When the duct orifice has been adequately sized
of iodine compounds in a prior radiologic ex-
and enlarged, the sialographic cannula is inserted
amination should not be considered as subjects
into the duct so that the tissue stop presses firmly
for this technique.
into the orifice to prevent dye reflux.
ii. The use of sialography during the period of acute
vii. After insertion of the cannula, the radiopaque dye
inflammation of the salivary system is contrain-
is slowly introduced into the duct. The amount of
dicated. During this period, the ductal epithelium
dye to be injected into the gland for adequate fill-
may be disrupted, and escape of the contrast
ing varies from patient to patient and depends on
medium from the ductal system into the paren-
the condition of the gland.
chyma can produce severe foreign body reaction,
viii. The amount used is best determined by fluoroscopic
accompanied by severe pain.
observation; the patient should be instructed to inform
iii. The administration and retention of the iodinated
the operator when the gland area feels tight or full.
contrast material used in sialography may inter-
Appropriate volumes of dye required vary from
fere with subsequent thyroid function tests,
0.76 to 1.00 mL for the parotid glands, and 0.0 to
hence such functional studies if required should
0.75 mL for submandibular glands. The cardinal
be done prior to the sialography procedure.
rule is that the injection should be stopped when
the gland is full, if the dye is extravasated, or when
Procedure the patient experiences mild discomfort.
Armamentaria required: Radiographic projections
● Polyethylene tubing with a special blunt end me- ● The filming procedure is carried out with the patient
tallic tip in the supine position. Often several films are ob-
● 5 or 10 cc syringe tained during the injection in order to monitor the
● Lacrimal dilators filling phase and degree of filling.
● Contrast media ● The lateral oblique projection or mandibular occlusal
● Sialagogue-like five lemon slices or lemon extract view is used to delineate the submandibular gland.
or chewing gum ● In the lateral oblique view, the duct pattern is not dis-
i. The parotid orifice is located at the base of the pa- torted, while a sialoliths is well demarcated on the occlu-
pilla in the buccal mucosa adjacent to the first or sal view. The anteroposterior (AP) view of both glands
second molar. demonstrates the medial and lateral gland structures.
ii. The area over the mucosa where the duct orifice is ● In case of the parotid gland, the patient should
depicted to be located should be dried with a small be asked to keep the mouth open. The panoramic
sponge. projection may also be taken, which is helpful in
studying erosion of bone or destruction of the man-

iii. Absence of local or systemic toxicity.
dible, in case of salivary tumours.
iv. Pharmacologically inert.
The evacuation (fat-soluble medium) or the parenchy-
v. Satisfactory opacification.
mal phase (water-soluble medium):
vi. Low surface tension and low viscosity to allow easy
● After the final sialographic views have been made,
filling of fine components of the ductal system.
the cannula should be removed from the duct orifice.
vii. Easy elimination, but should be durable for suffi-
The patient is instructed to chew gum or the lemon
cient time so as to permit time for satisfactory
slice and then asked to rinse. This is done to stimu-
radiographs.
late the gland and cause excretion of the dye.
viii. Residual contrast media should be absorbed by
● Lateral jaw, lateral oblique or AP view radiographs
the salivary gland and detoxified by the liver or
should be made 5 min after removal of the cannula.
excreted by the kidney.
They provide the information about the excretory
function of the gland.
● Normal salivary gland will excrete 100% of the con-
Two types of contrast media available are explained in the
trast dye within 5 min after removal of the cannula.
table below:
Additional views required to be taken to study special
features are as follows:
● Reverse basilar view to demonstrate the deep portion Water-soluble media Fat-soluble media (oil-based)
of the parotid. a. These are principally a. There are two types of
● A film made with the cheek in the blow-out position in iodinated benzene or fat-soluble contrast media
the AP view to demonstrate the superficial portion of pyridone derivatives i. Iodized oil
ii. Water-insoluble organic
the course of the Stensen’s duct of the parotid gland.
iodine compounds
● Occlusal view for the demonstration of the distal
submandibular gland’s Wharton duct. b. They have a low b. These are more viscous,
viscosity, less surface have more surface tension and
● Filming of the filling phase with the mouth open
tension and are are less miscible with the sali-
will reduce superimposition of the mandible on the more miscible with vary secretions
parotid gland. the salivary secretions
● Stereoscopic studies are invaluable for the study of
c. Their physical character- c. These compounds require a
tube spatial relationships of the gland and the duct. istics permit filling of higher injection pressure
● Subtraction views are of great value in the delineation the finer ductal system than that of the water-soluble
of the finer ducts and of the sublingual ductal system. under lower pressure media, to visualize finer ducts.
● Plesioradiography is a technique in which a small X-ray
and facilitate prompt Oil-based media is poorly
drainage eliminated and causes ductal
tube is placed in contact with the facial soft tissues obstruction
contralateral to the gland being examined in an attempt
to eliminate the obscuring overlying bony structures. d. They cause less pain or d. Usually accompanied with
discomfort, with no pain and a lot of discomfort.
Q.2. Define sialography and describe in detail the granulomatous reaction, Extravasation of the fat-soluble
contrast media used in sialography. in the glands media can produce severe
foreign body reaction with
Ans. focal necrosis of the
parenchyma and stroma
Sialography is a specialized radiographic view taken by in-
e. Opacification of the e. The fat-soluble contrast media
troduction of the radiopaque dye into the ductal system of the water-based media is on the whole produces a satis-
major salivary glands, mainly parotid and submandibular. not as good as that of factory degree of opacifica-
This technique is used to examine the ductal and acinar oil media tion. They are an excellent
systems of the major salivary glands. The sublingual and media if the ductal systems
under examination are intact
the minor glands cannot be studied obviously because of
their small and numerous openings. f. The excretion of this f. The excretion of this type of
Contrast media type of contrast media is contrast media is slow and
very rapid gives adequate time to carry
out the various radiographic
{SN Q.3} procedures
An ideal sialographic contrast media should have the g. Examples of the g. Example of the available
available water-soluble fat-soluble contrast media is
following characteristics:
contrast media are Ethiodol
i. Physiological properties similar to that of saliva. hydropaque and
ii. Miscibility with saliva. Renografin
Q.3. Describe sialography in detail and write briefly on ● Lacrimal dilators

its significance in various salivary gland disorders. Add ● Contrast media, e.g. Con ray 420
a note on its interpretation in various diseases of sali- ● Sialagogues-like five lemon slices or lemon extract
vary glands. or chewing gum

● Gauze sponge pads
Ans.
● Magnifying glasses
● Sialography is a specialized radiographic view taken by ● Good dental lighting
introduction of the radiopaque dye into the ductal sys- Procedure

tem of the major salivary glands, mainly parotid and ● The parotid gland and submandibular glands are
submandibular. more readily studied using sialography.

● This technique is used to examine the ductal and acinar ● Before the passage of cannula, a lacrimal or peri-
systems of the major salivary glands. The sublingual odontal probe is used to dilate the sphincter at the
and the minor glands cannot be studied obviously be- ductal orifice.
cause of their small and numerous openings. ● Cannula is connected by extension tubing to a sy-
Indications ringe containing contrast medium. Once the duct is

i. Detection of calculus or calculi or foreign bodies cannulated, the injection of contrast medium is made
and also ductal disorders of major salivary glands. with hand pressure. Patient may complain of mild
ii. Determination of the extent of destruction of the gland pain during injection. A slow constant injection tech-
secondary to obstructing calculi or foreign bodies. nique can accomplish complete ductal filling without
iii. To evaluate the extent of irreversible ductal dam- patient discomfort.
age caused by infection. This will help in deciding ● Patient sensation of glandular fullness is suggested
treatment plan whether a total excision of the by a sharp pain when the operator usually stops and
gland or a simple lithotomy should be performed. proceeds for radiography.
iv. Detection of fistulae, diverticula or strictures. ● Phases of sialography are as follows:
v. Determination and diagnosis of recurrent swell- i. Ductal phase

ings and inflammatory processes. ● This phase follows immediately after the in-
vi. Demonstration of a tumour and the determination jection of contrast medium.

of its location, size and origin. ● It allows visualization of major ducts.
vii. Determining outline of the plane of the facial ii. Acinar phase
nerve as a guide in planning a biopsy or dissection. ● This phase begins after the ductal system
viii. Detection of residual stone or stones, residual tu- becomes fully opacified.
mour, fistula or stone retention cysts following iii. Evacuation phase
surgical procedures. ● Evidence of retention of contrast medium.
ix. Sialography has also been employed as a therapeu- ● Retention of contrast medium beyond 5 min is
tic procedure because: normal.

● The dilatation of the ductal system produced Appearance
during the study may aid in the drainage of the i. Normal salivary glands
ductal debris. Normal salivary glands have a leafless-tree appear-
● A therapeutic effect is produced by the iodin- ance on sialograph.
ated contrast media when injected into the ii. Obstructive and inflammatory disorders
ductal system. a. Sialolithiasis: It has a cigar- or oval-shaped
● It may be used as a dilating procedure for mild radiopacity on sialogram.
ductal stenosis. For evaluation of diverticula, b. Bacterial sialadenitis: Ball-in-hand appearance.
strictures and fistula. c. Saccular dilatation of acini of the glands: Pro-
Contraindications duces focal narrowing of duct.
i. Acute infection of salivary gland, as it results in d. Autoimmune sialadenitis: Sialography is help-
foreign body reaction and severe pain. ful in diagnosis and staging of sialadenitis.
ii. Allergic reactions to any component of radiopaque (1) Early stage: Initiation of punctate and glob-
material to be used. ular spherical collection of contrast medium
iii. Thyroid disease due to iodine content of contrast evenly distributed
medium. (2) During progression of disease: Collection of
iv. Not indicated in minor salivary gland. contrast agent greater than 2 mm and irregu-
Armamentaria required lar in shape
● Polyethylene tubing with a special blunt-end metallic tip (3) At the end point: Complete destruction of
● 5 or 10 cc syringe the glands
e. Sicca syndrome: Gives snowstorm or cherry the exact location of the lesion is noted and its
blossom-like appearance size may even be precisely measured.
f. Sialectasis: Appearance of focal collection of ● Displacement of Stensen’s or Wharton duct by the
contrast medium presence of a tumour may also be detected sialo-

iii. Noninflammatory disorders graphically.
a. Sialodenosis: Enlargement of glands are seen. a. With forward displacement of the gland n
b. Cystic lesions: Cystic masses are visualized. buckling of the major duct is observed, with
c. Benign tumours: Sialography suggests a space oc- the posterior portion crowding upon its ante-
cupying mass or smoothly displaced mass around rior segment.
the lesion giving a ball-in-hand appearance. b. Posterior glandular displacement results in the
d. Sialodochitis: Sausage-link pattern. opposite effect n A distention and elongation
Interpretations of sialograph of the major duct.
● The sialographic appearance of the normal salivary c. Inferior or superior gland displacement inevi-
glands is that of a leafless tree. This radiograph tably causes n a disturbance in the course of
shows the main duct gradually going in secondary Stensen’s and Wharton ducts that may be visu-
branches and then into tertiary branches. alized sialographically.
● Various sialographic findings are described below:
● Sialography is an invaluable asset in the diagnosis

Q.4. What is tomography and describe in detail com-
of neoplastic diseases of salivary gland origin. puted tomography?
● Since the benign tumour develops at the expense
Ans.
of normal glandular structure, the sialogram will
often reflect its presence by revealing a filling ● Tomography is a process by which an image layer of the
defect, the latter being due to distortion and body is produced, while the images of the structures above
displacement of the normal duct system by the and below that layer are made invisible by blurring.
pressure of the expanding mass. ● In many cases, a distinction can be made by choosing
● A centrally located defect, devoid of ducts and appropriate orientation of the patient, or otherwise it is
surrounded by a whorl-like formation of ducts, is necessary to use a technique known as ‘body section
referred to as the ‘ball-in-hand’. radiography’ or tomography’.
● The tumour with no ductal structures in its midst Tomography may be classified into three types:
represents the ‘ball’ whereas the normal second- a. Conventional tomography
ary and tertiary ducts that have been pushed to the b. Computed tomography (CT)
periphery are supposedly the fingers and palm of c. Emission tomography
the ‘hand’. This pattern may be visualized on Conventional tomography
lateral and/or AP films. ● Tomography is a Greek word where tomo means
● The presence of localized puddling or widespread ‘slice’ and graph means ‘picture’, which was ad-
diffusion of the contrast medium throughout the opted in 1962 by the International Commission on
gland parenchyma suggests the diagnosis of a Radiographic Units and measurements to describe
malignant neoplastic disease. all forms of body section radiography.
● The invasive character of the malignant tumour ● Body section radiography is a special X-ray tech-
leads to partial destruction of ducts, and as the nique that enables visualization of a section of the
sialographic solution reaches these regions, it patient’s anatomy by blurring regions above and
escapes into the surrounding interstitial connec- below the section of interest.
tive tissue, either accumulating in localized pud- ● This is achieved by a synchronized movement of
dles or diffusing widely. the film and the tube in opposite directions, about
● Not all malignant tumours are portrayed in this a fulcrum.
manner. Occasionally, a malignant neoplasm ● Objects closest to the film are seen most sharply
gives the ‘ball-in-the hand’ pattern, since it, too, and objects farthest away are completely blurred.
may manifest a tendency to encapsulation in spite ● The thickness of the image layer depends on the
of its infiltrative character. angle of rotation or the amount of movement of

● When dealing with a parotid gland tumour, an AP the tube. Thus, if the path of the X-ray tube is
film may shed further light regarding its nature short and the angle is small, then the image layer
and more precise location. The parotid gland with is relatively thick. Hence, as the angle of the
its contained duct system may be displaced later- movement increases, the thickness of the image
ally away from the ramus of the mandible. Thus, layer decreases.
● The greatest amount of blurring is at the periphery of

● It also enables differentiation and quantification of
the image layer, and the sharpest image is at the centre.
soft tissues and is a noninvasive procedure.
The principles of tomography can be mechanically
implemented in a variety of ways:
● The tube and the film move synchronously in a ● CT scanners use X-rays to produce sectional
straight line in opposite directions in parallel planes. images, but the radiographic film is replaced by
● The tube and the film move synchronously in op- very sensitive crystal or gas detectors.
posite directions in parallel planes, but with mo- ● The detectors measure the intensity of the X-ray
tions other than a straight line, i.e. circular, cross, beam emerging from the patient and convert this
spiral, hypocycloidal, trispiral and other multidi- into digital data, which is stored and manipulated
rectional movements. by the computer.
● The X-ray tube may move in arcs rather than in ● The numerical information is converted into
flat planes. grey scale representing different tissue densities,

● The blurring of objects outside a focal plane is allowing a visual image to be generated.
accomplished most effectively by compound ● It has the ability to detect minute differences in
movements of the X-ray tube and least effective tissue alteration. It gives highly accurate quantita-
by simple movements. tive information about the tissues imaged.
There are two basic design options used in most units:
i. Adjustable fulcrum system: The image layer or
plane of focus is changed by adjusting the point of {SN Q.6}
rotation called the fulcrum. The disadvantage of
Indications
this system is that the images that are produced
● Used in investigation of intracranial diseases like
will have different amount of magnification, de-
tumours, haemorrhage and infarcts
pending on the relative position of the fulcrum
● Assessment of fractures involving the cranial base,
between the tube and the film.
orbits, nasoethmoidal complex and the cervical spine
ii. The second design: It is so made that the distance
● Tumour staging – assessment of site, size and
between the fulcrum and the tube and the fulcrum
extent of tumours either benign or malignant in
and the film remains constant. In this case, the film
various parts of the body
and the X-ray tube pass in opposite directions through
● Investigations of tumours and tumour-like discrete
proportional arcs. Here, the object of interest is posi-
swellings intrinsic and extrinsic to the salivary
tioned with reference to the focal plane, and all the
glands
images contain the same degree of magnification.
● Investigation of the TMJ
Tomographic views are used to examine various facial
● In implant dentistry for preoperative assessment
structures as follows:
of maxillary alveolar bone height and thickness
i. Tomography of sinuses:
● It gives a more precise evaluation of sinus
pathologies. Equipment
● When a pathology is strongly suspected clini- ● The X-ray gantry consists of:
cally, but X-ray films are negative. i. The X-ray tube:

● Sphenoid and ethmoidal sinuses are more ● Stationary anode energized continuously
clearly visualized. ● Rotating anode operated in impulse mode
ii. Tomography of facial bones: ii. The radiation detector:

● To study facial fractures ● Scintillation detectors
● Extent of orbital blow-out fractures ● Gas counters
iii. Tomography of the mandible iii. The ancillary components

iv. Tomography of the temporomandibular joint (TMJ) The CT sections are reconstructed from profile
v. For dental implant patients X-rays taken at different angles from the struc-
Computed tomography ture to be imaged.
The computer system
● The tomographic section is reconstructed from the
{SN Q.6} data collected by the radiation detectors in the
● CT is a digital and mathematical imaging technique X-ray gantry and is displayed either in the ana-
that creates tomographic sections where the tomo- logue form as an image or as a numerical printout.
● These functions are carried out by the com-
graphic layer is not contaminated by blurred struc-
tures from adjacent anatomy. puter system. A CT image is initiated by a
process called scanning.
● Beams from one or several small X-ray SHORT ESSAYS:

sources are passed through the body and in-
Q.1. Describe the procedure for sialography of parotid
tercepted by one or more radiation detectors.
gland.
These detectors produce electrical impulses
that are proportional to the intensity of the Ans.
X-ray beam emerging from the body.
Procedure of sialography for parotid glands
● In its simplest form, a CT scanner consists of
● The parotid is the largest of the salivary glands, lying just
a radiographic tube that emits a finely colli-
below the zygomatic arch in front and below the ear and
mated, fan-shaped X-ray beam directed to a
on the masseter muscle over the ramus of the mandible.
series of scintillation detectors or ionization
● The duct from the parotid gland (Stensen’s duct) runs
chambers.
along the outer surface of the masseter to the buccal
● The CT image is a digital image, recon-
mucous membrane opposite the upper second molar.
structed by the computer, which mathemati-
● A cannula tip is inserted into the opening of the
cally manipulates the mission data obtained
Stensen’s duct opposite second maxillary molar.
from the multiple projections.
● Each gland is examined turn wise and small amount
● Penetration profile is stored in the computer,
of contrast medium is injected.
which calculates the density or absorption at
The projections for parotid gland:
points on a grid formed by the intersections of
● They are the same as that of the ramus of the mandible
penetrating profiles. The image consists of a
a. In lateral positioning, the head is in exactly lateral
matrix of individual points or pixels.
position with angle of the mandible over shadow-
● Each number or pixel represents a calculation
ing each other. Central rays of X-rays are passed
of the actual attenuation of the X-ray beam by
over the angle of the mandible.
materials with the body.
b. In lateral oblique view, the head is straight almost
● It represents the absorption characteristics, or
similar to lateral view. The only difference is cen-
linear attenuation coefficient, of that particu-
tral ray is projected below and behind the angle of
lar volume of tissue in the patient.
the jaw away from the film, 25° towards the head.
● CT numbers, also known as Hounsfield units,
c. In frontal position (AP), the median plane is kept at
may range from –1000 to 11000, each consti-
right angle to the film. The head is slightly raised
tuting a different level of optical density. The
and the chin lowered towards the chest. In these
scale of relative densities is based on air
cases, the main duct is well shown as it crosses to
(–1000), water (0) and dense bone (11000).
mandible, but the gland region is overexposed with
The numbers may vary from one machine to
intraglandular ducts largely obliterated.
another depending upon various factors.
● Since the numbers represent attenuation or Q.2. Digital radiography.
density, the computer constructs an image by
Ans.
printing the numbers or by assigning different
degrees of greyness or different colours to
each number.
{SN Q.2}
● The CT image is recorded and displayed as a
matrix of individual blocks called ‘voxels’ (vol- ● Digital radiography refers to a method of capturing a
ume elements). Each square of the image matrix radiographic image using a sensor, breaking it into
is a pixel. Whereas a pixel (about 0.1 mm) is electronic pieces and presenting and storing the image
determined partly by the computer program using a computer.
used to construct the image, the length of the ● Three methods to obtain a digital image are as follows:
voxel (about 1–2 mm) is determined by the i. Direct digital imaging
width of X-ray beam, which in turn is controlled ii. Indirect digital imaging
by the prepatient and postpatient collimators. iii. Storage phosphorous imaging
● Voxel length is analogous to the tomographic
i. Direct digital imaging: Here a sensor is placed in
layer in film tomography.
the mouth and exposed. The sensor captures the
Q.5. Define sialography. Give the ideal requirements of image and transmits to a computer monitor.
the contrast media used in sialography. ii. Indirect digital imaging: An X-ray film is digitized
using Charged coupled device (CCD) cameras that
Ans.
scans the image, digitizes and converts the image to
[Same as LE Q.2] display it on computer screen.
iii. As a screening process to detect atheromatous

iii. Storage phosphor imaging: Wireless digital sys-
plaques in the carotid artery, tumours of carotid
tem. Here, a reusable imaging plate coated with
sheath and venous thrombosis.
phosphors is exposed and a high-speed scanner is
In dentistry
used to convert information to electronic files.
i. Used for ultrasound-guided fine-needle aspira-
Clinical applications
tion biopsy (FNA).
i. To evaluate growth and development
ii. For detection of fractures of the orbital wall.
ii. To confirm or classify suspected disease
iii. Examination of congenital and inflammatory
iii. Detection of lesions, diseases and conditions of
neoplasms.
the teeth and surrounding structures
iv. Examination of thyroid gland and parathyroid
iv. To illustrate changes secondary to caries, peri-
glands and the lymph nodes.
odontal diseases or trauma
v. Examination and detection of salivary gland
v. To provide the information during the dental
masses. It also helps to differentiate between
procedures like root canal instrumentation and
cystic and solid lesions and to locate calculus in
surgical placement of implants
the ducts or parenchyma of the gland.
Advantages
Advantages
i. Effective patient education tool
i. It is widely available and inexpensive.
ii. Reduced exposure to radiation
ii. Gives good differentiation between soft tissues.
iii. Lower equipment and film cost
Disadvantages
iv. Easy reproducibility
i. Ultrasound technique is operator dependent.
v. Superior grey-scale resolution
ii. It has limited application in head and neck region as
vi. Enhancement of diagnostic image
the sound waves are absorbed by bone.
vii. Increased efficiency and speed of image
iii. Images are difficult to interpret for inexperienced
viewing
operators as image resolution is often poor.
viii. Image processing, enlargement and recon-
struction for specific diagnostic purpose are Q.4. Salivary scintigraphy.
possible
Ans.
ix. Excellent quality image
Disadvantages ● Scintigraphy is a radionuclide diagnosis imaging tech-
i. Initial set-up is costly. nique used for the detection of salivary gland disorders
ii. Image quality is still a source of debate. and other disorders.
iii. Sensor size is thicker than intraoral films, ● For this, technetium 99m pertechnetate is injected to the
hence it is not patient compliant and also it artery and salivary glands, which if rapidly metabolized
has to be covered adequately in a disposable will preferentially bind to it.
plastic wrapper. Phases of salivary scintigraphy
iv. Over-exposure and overloading of CCD sen- ● The imaging is done under the following three phases:
sors creating the phenomenon of blooming. i. Dynamic phase:

v. Large pixels result in poor resolution and ● Spread of radioactive marker through the vascu-
structures may not be represented accurately. lar system occurs during this phase.
vi. Loss of image quality and resolution on hard ● A set of radiographs are taken in first 30–120 s.
copy printouts when using thermal, laser or ii. Static phase:

inkjet printers. ● Concentration in the gland
● Radiographs taken every 10 min for 30–45 min
iii. Secretory phase:

Q.3. Applications of ultrasound in dentistry. ● Secretion of the marker by the gland. Patient is given
sialagogue and the final sets of radiographs are taken.

Ans.
Advantages
● Diagnostic ultrasound is a noninvasive investigation that i. Scintigraphy is much more sensitive to early or small
uses a very high frequency (7.5–20 MHz) pulsed ultra- changes in salivary metabolism than other techniques.
sound beam, rather than ionizing radiation, to produce ii. It provides valuable information concerning the
high-resolution images of more superficial structures. functional capacity of the salivary glands, which
Clinical application have undergone radiotherapy.
In medical field iii. It has been successfully used to image a wide vari-
i. Assessment of blood flow in the carotids and ca- ety of salivary gland disorders including sarcoid-
rotid body tumours. osis, Sjogren syndrome, sialadenitis, salivary gland
ii. Assessment of ventricular systems in babies. tumours and postoperative healing.
Disadvantages of many atoms of the body, including hydrogen atoms to

i. It cannot resolve lesions smaller than l cm. align themselves with the magnetic field. After application
ii. Ductal obstruction can trap the radionuclide tracer of an RF signal, energy is released from the body, detected
and cause a distorted image. and used to construct the MR image by the computer.
iii. A single scan of technetium 99 m pertechnetate can ● Two types of images are produced:
result in full body radiation of 1 m Gy which is i. T1-weighted image:

equivalent to 33% of the annual radiation. ● T1-weighted images are called fat images, because
of the shortest T1 relaxation time, short repetition

Q.5. Radionuclide imaging – advantages and disadvantages.
time between RF pulses and a short signal recov-
Ans. ery time. Intense MR signal is obtained.
● T1 gives a good image contrast and T1-weighted
● Radionuclide imaging uses radioactive compounds that
images are helpful for depicting small anatomical
have affinity for particular tissues called target tissues.
lesions like TM joint.
● Here radioactive compounds are injected into the patient,
● In TI-weighted images, cerebrospinal fluid ap-
concentrated in the target tissue and their radiation emis-
pears black.
sions are detected and imaged using gamma camera.
● Used to visualize normal anatomical structures.
● It provides the only means of assessing physiologic
ii. T2-weighted images:
change. It allows the examination of function and struc-
● These images are called water images because
ture of the target tissues to be examined under static and
they have the longest T2 relaxation time and
dynamic conditions.
appear as bright image.
Indications
● These T2-weighted images are used to see inflam-
● Metastases: The assessment of the sites and extent of
matory or pathologic changes.
metastases in tumour staging.
Advantages
● Salivary gland function: Assessment of the salivary
● It is an ionizing radiation.
gland function.
● No biological effects due to exposure.
● Graft assessment: It is also useful in bone grafts
● Highly effective tissue contrast, even blood ves-
assessment.
sels are clearly seen.
● Growth pattern: It is used in assessing continued
● Excellent differentiation between soft tissues is
growth of condylar hyperplasia.
possible between normal and abnormal tissues.
● Thyroid examination: Investigation of the thyroid.
● The region of the body imaged in MRI is con-
● Brain: Brain scans and investigation for the break-
trolled electronically; direct multiplanar imaging
down of the blood–brain barrier.
is possible without reorienting the patient.
Advantages
● High-resolution images can be constructed in all
● Functional details: Functional details of the target
the three planes.
tissue are investigated.
● No need for using any contrast media with their
● More area coverage: All similar target tissues can be
associated risks to enhance image contrast.
examined during one investigation, e.g. the bone scan
images the whole skeleton.
● Computer analysis: Computer analysis and image SHORT NOTES:
enhancement are possible.
Q.1. Two indications and contraindications of sialography.
Disadvantages
● Poor resolution: Anatomical details of the target Ans.
tissue are not obtained due to a decreased resolution.
[Ref LE Q.1]
● High radiation dose: Radiation dose to the patient’s
whole body is high as compared to that in conven- Q.2. Digital radiography (radiovisiography).
tional radiography.
Ans.
● Less specific image: Image obtained is less specific.
[Ref SE Q.2]
Q.6. Magnetic resonance image and its advantages.
Q.3. Mention few requirements of ideal contrast me-
Ans.
dium used for sialograph.
● MRI works on nuclear magnetic resonance to produce
Ans.
signal that can be used to construct an image.
● Uses nonionizing radiations from the radio frequency [Ref LE Q.2]
band of the Electromagnetic spectrum (EMS).
Q.4. Scanography.
● The patient is placed inside a large magnet, which induces
a relatively strong external magnetic field that causes nuclei Ans.

● The scanography technique uses a narrowly collimated, Uses

fan-shaped beam of radiation to scan the area of inter- ● Mammography
est, sequentially projecting image data relative to this ● Cephalometry
area onto a moving film. ● Sialography
● Produces images with a higher contrast and greater detail. ● TMJ tomography
● The commercially available X-ray unit capable of Indications

performing both rotational and linear scanography is ● Detailed assessment of periodontal and periapical
Soredex SCANORA®. bone lesions

● Scanography is useful for the assessment of periodontal ● To show fine duct structures on sialography
disease and detection of periapical lesions. ● To show required hard and soft tissue landmarks on
one cephalometric radiographic film

Q.5. Write notes on xeroradiography.
● Assessment of soft tissue shadows in pharynx and
Ans. larynx
● Xeroradiography is based on electrostatic process simi- Q.6. Indications of CT in oral and maxillofacial region.
lar to that used for xeroxing. It does not require films
Ans.
commonly used for conventional radiography.
● There are two systems in xeroradiography: [Ref LE Q.4]
i. The Medical 125 system
Q.7. Contraindications of sialography.
ii. The Dental 110 system
● Conventional X-ray source is used in the production of [Same as SN Q.1]
xeroradiographs.
Q.8. Indications of sialography.
● Xeroradiograph can be viewed in reflected or transmitted
light. [Same as SN Q.1]
Topic 9
Radiographic Interpretations
LONG ESSAYS:
1. Describe the normal anatomical landmarks in intraoral radiographs.
2. Describe the radiolucent and radiopaque anatomic landmarks seen on the IOPA radiographs of mandible.
3. Radiographic features of fibro-osseous lesions of the jaws.
4. Discuss the differential diagnosis of periapical radiolucencies.
5. Describe various radiopaque lesions at the root of mandibular premolar.
6. Describe the radiographic appearance of different types of osteomyelitis of jaws.
7. Name the malignant tumours of the jaws. Describe the radiographic appearance of carcinomas and sarcomas
of the jaws.
8. Describe the radiographic appearance of different cysts of maxilla and mandible.
9. Describe in detail periapical radiolucent areas. [Same as LE Q.4]
10. Describe briefly the characteristics of the malignant tumours of the jaws. Describe the radiographic appear-
ance of the same. [Same as LE Q.7]
SHORT ESSAYS:
1. Describe various radiographic landmarks of the maxilla. Why is it important to know radiographic landmarks
of maxilla?
2. Multilocular radiolucencies.
3. Enumerate the various radiographic techniques for the diagnosis of fracture of mandible.
4. Cemento-ossifying fibroma.
5. Describe radiographic appearance of dentigerous cyst.
6. Describe in detail the radiographic appearance of various odontomas and give the differential diagnosis.
7. Enumerate the radiopaque lesions of the jaws.
8. Discuss the radiological features of cementoma.
9. Radiographic features of periodontal disease.
10. Radiographic appearance of adenomatoid odontogenic tumour.
11. Radiographic appearance of (A) multiple myeloma and (B) cherubism.
12. Radiographic appearance of osteosarcoma.
13. Radiographic appearance of Paget disease.
14. Describe the radiological appearance of fibrous dysplasia.
15. Discuss any three multilocular lesions of the mandible. [Same as SE Q.2]
16. Periapical radiopacities. [Same as SE Q.7]
17. Differential diagnosis of periapical radiopacities. [Same as SE Q.7]
18. Discuss: (A) adenoameloblastoma and (B) ameloblastoma. [Same as SE Q.10]
19. Describe the radiological appearance of jaws in osteogenic sarcoma. [Same as SE Q.12]
SHORT NOTES:
1. Cotton-wool appearance on radiograph.
2. Lamina dura.
3. Name the anatomical landmarks seen on upper posterior periapical film.
4. ‘Onion-peel’ appearances on a radiography.
5. Radiographic appearance of ameloblastoma.
6. Name four conditions showing soap-bubble appearance on skull radiograph.
7. Herring bone pattern.
8. Moth-eaten appearance.
9. Line of Ennis.
10. Radiographic appearance of compound composite odontomes. [Ref SE Q.7]
11. Radiopaque landmarks of maxilla. [Ref SE Q.1]
12. Radiographic appearance of dentigerous cyst.
13. Radiographic appearance of hyperparathyroidism.
14. Name a few periapical radiopacities.
15. Discuss the radiological appearance of chronic osteomyelitis.
16. Describe the radiographic appearance of myxoma.
17. Enumerate the landmarks seen on the intraoral periapical view of upper third molar region. [Same as SN Q.3]
18. Onion-skin appearance. [Same as SN Q.4]
19. Soap-bubble appearance. [Same as SN Q.6]
20. Tyre track appearance. [Same as SN Q.7]
21. Radiographic features of chronic osteomyelitis. [Same as SN Q.15]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Describe the normal anatomical landmarks in The normal bony landmarks that frequently appear in
intraoral radiographs. maxillary periapical radiographs are as follows:
i. Incisive foramen
Ans.
● The incisive foramen or nasopalatine foramen
Normal anatomic landmarks in intraoral radiographs are as is an opening or hole in bone through which
follows: nasopalatine nerve exits the maxilla located at
A. Bony landmarks of the maxilla the midline of the anterior portion of the hard
All the bones of the face articulate with the maxilla, palate directly posterior to the maxillary central
with the exception of the mandible. The maxilla forms incisors.
the floor of the orbit of the eyes, the sides and floor of ● On a maxillary periapical radiograph, the inci-
the nasal cavities and the hard palate. sive foramen appears as a small, ovoid or round
radiolucent area located between the roots of the ● On an IOPA radiograph, the anterior nasal spine
maxillary central incisors. appears as a V-shaped radiopaque area located
ii. Superior foramina of incisive canal at the intersection of the floor of the nasal cavity
● The nasopalatine nerve enters the maxilla through and the nasal septum.
the superior foramina, travels through the incisive ix. Inferior nasal conchae
canal and exits at the incisive foramen. ● The inferior nasal conchae are wafer thin,
● On a maxillary periapical radiograph, the supe- curved plates of bone that extend from the lat-
rior foramina appear as two small, round radio- eral walls of the nasal cavity. They are seen in
lucencies located superior to the apices of the the lower lateral portions of the nasal cavity.
maxillary central incisors. ● On a maxillary IOPA radiograph, the inferior
iii. Median palatal suture nasal conchae appear as a diffuse radiopaque

● The median or midpalatal suture is the immov- mass or projection within the nasal cavity.
able joint between the two palatine processes of x. Maxillary sinus
the maxilla extending from the alveolar bone ● The maxillary sinuses are paired cavities or com-
between the maxillary central incisors to the partments of bone located within the maxilla.
posterior hard palate. ● On a maxillary periapical radiograph, the maxil-
● On a maxillary periapical radiograph, the me- lary sinus appears as a radiolucent area located
dian palatal suture appears as a thin radiolucent above the apices of the maxillary premolars and
line between the maxillary central incisors. molars. The floor of the maxillary sinus is com-
iv. Lateral fossa posed of dense cortical bone and appears as a
● The lateral fossa also known as the canine fossa radiopaque line.
is a smooth, depressed area of the maxilla lo- xi. Inverted ‘Y’ of Ennis
cated just inferior and medial to the infraorbital ● On a maxillary periapical radiograph, the inverted
foramen between the canine and lateral incisors. ‘Y’ appears as a radiopaque upside-down Y,
● On a maxillary periapical radiograph, the lat- formed by the intersection of the lateral wall of
eral fossa appears as a radiolucent area between the nasal fossa and the anterior border of the
the maxillary canine and lateral incisors. maxillary sinus.
In some periapical radiographs, the lateral fossa ● The lateral wall of the nasal cavity and the
may appear as a distinct radiolucency. anterior border of the maxillary sinus are
v. Nasal cavity composed of dense cortical bone and appear as
● The nasal cavity also known as the nasal fossa a radiopaque line or band. The inverted Y is
is a pear-shaped compartment of bone located located above the maxillary canine.
superior to the maxilla. xii. Maxillary tuberosity
● On a maxillary periapical radiograph, the nasal ● The maxillary tuberosity is a rounded promi-
cavity appears as a large, radiolucent area above nence of bone that extends posterior to the third
the maxillary incisors. molar region.
vi. Nasal septum ● On a maxillary periapical radiograph, the max-
● The nasal septum is a vertical bony wall or par- illary tuberosity appears as a radiopaque bulge
tition that divides the nasal cavity into the right distal to the third molar region.
and left nasal fossae. xiii. Hamulus
● On a maxillary periapical radiograph, the nasal ● The hamulus or the hamular process is a small,
septum appears as a vertical radiopaque partition hook-like projection of bone extending from
that divides the nasal cavity. The nasal septum may the medial pterygoid plate of the sphenoid
be superimposed over the median palatal suture. bone, and is located posterior to the maxillary
vii. Floor of nasal cavity tuberosity region.
● The floor of the nasal cavity is a bony wall ● On a maxillary periapical radiograph, the ham-
formed by the palatal processes of the maxilla ulus appears as a radiopaque hook-like projec-
and the horizontal portions of the palatine bones. tion posterior to the maxillary tuberosity area.
● On a maxillary periapical radiograph, the floor of The radiographic appearance of the hamulus
the nasal cavity appears as a dense radiopaque varies in length, shape and density.
band of bone above the maxillary incisors. xiv. Zygomatic process of maxilla
viii. Anterior nasal spine a) On a maxillary periapical radiograph, the zygo-
● The anterior nasal spine is a sharp projection of matic process of the maxilla appears as a
the maxilla located at the anterior and inferior J-shaped or U-shaped radiopacity located supe-
portion of the nasal cavity. rior to the maxillary first molar region.
xv. Zygoma ● On a mandibular periapical radiograph, the

● The zygoma or ‘cheekbone’ also known as the mental fossa appears as a radiolucent area
malar bone or zygomatic bone articulates with above the mental ridge.
the zygomatic process of the maxilla. The zy- vi. Mental foramen
goma is composed of dense cortical bone. ● The mental foramen is an opening or hole in
● On a maxillary periapical radiograph, the zy- bone located on the external surface of the man-
goma appears as a diffuse radiopaque band ex- dible in the premolar region. Blood vessels and
tending posteriorly from the zygomatic process nerves that supply the lower lip exit through the
of the maxilla. mental foramen.
B. Bony landmarks of the mandible ● On a mandibular periapical radiograph, the
The bony landmarks that frequently appear in mandibu- mental foramen appears as a small, ovoid or
lar periapical radiographs are as follows: round radiolucent area located in the apical
i. Genial tubercles region of the mandibular premolars.
● The genial tubercles are tiny bumps of bone that ● The mental foramen is frequently misdiagnosed
are located on the lingual aspect of the mandible. as a periapical lesion (periapical cyst, granu-
● On a mandibular periapical radiograph, the ge- loma or abscess) because of its apical location.
nial tubercles appear as a ring-shaped radiopac- vii. Mylohyoid ridge
ity below the apices of the mandibular incisors. ● The mylohyoid ridge is a linear prominence of
ii. Lingual foramen bone located on the internal surface of the man-
● The lingual foramen is a tiny opening or hole in dible extending from the molar region down-
bone located on the internal surface of the man- ward and forward towards the lower border of
dible near the midline and is surrounded by the the mandibular symphysis.
genial tubercles. ● On a mandibular IOPA radiograph, the mylohy-
● On a mandibular periapical radiograph, the lin- oid ridge appears as a dense radiopaque band
gual foramen appears as a small, radiolucent dot that extends downward and forward from the
located inferior to the apices of the mandibular molar region and may be superimposed over the
incisors. The lingual foramen is surrounded by roots of the mandibular teeth.
the genial tubercles, which appear as a radi- viii. Mandibular canal
opaque ring. ● The mandibular canal is a tube-like passageway
iii. Nutrient canals through bone that travels the length of the man-
● The nutrient canals are tube-like passageways dible. It extends from the mandibular foramen
through bone that contain nerves and blood ves- to the mental foramen and houses the inferior
sels that supply the teeth. alveolar nerve and blood vessels.
● On a mandibular periapical radiograph, nutri- ● On a mandibular periapical radiograph, the
ent canals appear as vertical radiolucent lines. mandibular canal appears as a radiolucent band
They are readily seen in areas of thin bone and below or superimposed over the apices of the
they may be more prominent in the edentulous mandibular molar teeth.
mandible. ● The mandibular canal is outlined by two thin
iv. Mental ridge radiopaque lines that represent the cortical

● The mental ridge is a linear prominence of corti- walls of the canal.
cal bone located on the external surface of the ix. Internal oblique ridge
anterior portion of the mandible and it extends i. The internal oblique ridge is a linear promi-
from the premolar region to the midline and nence of bone located on the internal surface of
slopes slightly upward. the mandible that extends downward and for-
● On a mandibular periapical radiograph, the men- ward from the ramus. It may end in the region
tal ridge appears as a thick radiopaque band that of the mandibular third molar or it may con-
extends from the premolar region to the incisor tinue as the mylohyoid ridge.
region and often appears superimposed over the ii. On a mandibular periapical radiograph, it ap-
mandibular anterior teeth. pears as a radiopaque band that extends down-
v. Mental fossa ward and forward from the ramus.
● The mental fossa is a scooped-out, depressed x. External oblique ridge
area of bone located on the external surface of ● The external oblique ridge is a linear promi-
the anterior mandible above the mental ridge in nence of bone located on the external surface of
the incisor region. the body of the mandible.
● On a mandibular periapical radiograph, the ex- Lamina dura

ternal oblique ridge appears as a radiopaque ● The lamina dura is the wall of the tooth socket
band extending downward and forward from the that surrounds the root of a tooth and is made up
anterior border of the ramus of the mandible. of dense cortical bone.
xi. Submandibular fossa ● On a dental radiograph, the lamina dura appears
● The submandibular fossa or the mandibular fossa as a dense radiopaque line that surrounds the root
or submaxillary fossa is a scooped-out, depressed of a tooth.
area of bone located on the internal surface of the Alveolar crest
mandible inferior to the mylohyoid ridge. ● It is the most coronal portion of the alveolar bone
● On a mandibular periapical radiograph, the sub- found between the teeth. The alveolar crest is
mandibular fossa appears as a radiolucent area made up of dense cortical bone and is continuous
in the molar region below the mylohyoid ridge. with the lamina dura.
xii. Coronoid process ● On a dental radiograph, the alveolar crest appears
● The coronoid process is a marked prominence radiopaque and is typically located 1.5–2.0 mm
of bone on the anterior ramus of the mandible. below the junction of the crown and the root
● The coronoid process is not seen on a mandibu- surfaces (CEJ).
lar periapical radiograph but does appear on a PDL space
maxillary molar periapical film. It appears as a ● The PDL space is the space between the root of
triangular radiopacity superimposed over or in- the tooth and the lamina dura. It contains connec-
ferior to the maxillary tuberosity region. tive tissue fibres, blood vessels and lymphatics.
Normal tooth anatomy in both maxilla and mandible ● On a dental radiograph, the PDL space appears as
Tooth structures that can be viewed on IOPA radio- a thin radiolucent line of uniform thickness around
graphs are as follows: the root of a tooth.
i. Enamel
Q.2. Describe the radiolucent and radiopaque anatomic
ii. Dentine
landmarks seen on the IOPA radiographs of mandible.
iii. The dentinoenamel junction (DEJ)
iv. Pulp cavity Ans.
Normal anatomical landmarks seen on the mandibular peri-
i. Enamel
apical radiographs are classified as:
● Enamel is the densest structure found in the
A. Radiolucent
human body. It is the outermost radiopaque
B. Radiopaque
layer of the crown of a tooth.
ii. Dentine A. Radiolucent landmarks of mandible
● Dentine is found beneath the enamel layer of i. Mental foramen
a tooth surrounding the pulp cavity. It appears ● It is present below the roots of first and second
radiopaque and makes up most of the tooth premolars. Usually, it is corticated.
structure, but is not as radiopaque as enamel. ● The shape of the foramen may vary from round to
iii. DEJ oblong and the size may vary from 1 mm to 0.5 mm.
● The DEJ is the junction between the dentine ii. Mandibular foramen
and the enamel of a tooth. ● It is only visible in lateral jaw films as a small
● The DEJ appears as a demarcating line where rounded or funnel-shaped black shadow over the
the enamel meets the dentine. ramus of mandible.
iv. Pulp cavity iii. Mandibular canal
● The pulp cavity consists of a pulp chamber ● It commences from mandibular foramen in the
and pulp canals. It contains blood vessels, ascending ramus and appears as a radiolucent
nerves and lymphatics and appears relatively area covered superiorly and inferiorly by radi-
radiolucent on a dental radiograph. opaque margin.
● The pulp cavity is generally larger in children ● Position of canal varies; usually, it lies below the
than in adults due to the formation of second- roots of the molars and little distance below the
ary dentine. bicuspids. Sometimes, the apices of the molars
Supporting structures may appear to be superimposed over the canals.
The alveolar process, or alveolar bone, serves as the Anatomically, the canal lies buccal to the molars
supporting structure for the teeth of the jaws. and premolars.
The anatomic landmarks of the alveolar process in- iv. Mental fossa
clude the lamina dura, the alveolar crest and the ● The mental fossa is a depression found on the la-
periodontal ligament (PDL) space. bial aspect of the mandible on the anterior region.
v. Pharyngeal space the molar region towards ramus. Sometimes

● This is seen as a radiolucent area, only in lateral overlaps the molar apices.
jaw films, as a broad dark area extending verti- iv. External oblique ridge
cally on ramus. It is caused by patients swal- ● The external oblique ridge is a linear promi-
lowing when the film is being exposed. nence of bone located on the external surface of
vi. Submandibular fossa the body of the mandible.
● The submandibular fossa or the mandibular fossa ● White line on the anterior portion of ascending
or submaxillary fossa is a scooped-out, depressed ramus. Sometimes it overshadows the roots of

area of bone located on the internal surface of the the molars.
mandible inferior to the mylohyoid ridge. v. Internal oblique ridge
● On a mandibular periapical radiograph, the sub- ● The internal oblique ridge is a linear promi-
mandibular fossa appears as a radiolucent area nence of bone located on the internal surface of
in the molar region below the mylohyoid ridge. the mandible that extends downward and for-
vii. Nutrient canals or interdental canals ward from the ramus. It may end in the region
● The nutrient canals are often seen in mandibu- of the mandibular third molar or it may con-
lar periapical radiographs as tube-like passage tinue as the mylohyoid ridge.
ways that carry neurovascular bundle in the jaw ● On a mandibular periapical radiograph, it ap-
bones and supply the teeth and gingival tissues. pears as a radiopaque band that extends down-
● On a mandibular periapical radiograph, nutrient ward and forward from the ramus.
canals appear as vertical radiolucent lines. They vi. Inferior border of mandible
are readily seen in areas of thin bone and they may ● It appears as a heavy white line on the radio-
be more prominent in the edentulous mandible. graph. This is seen on IOPA whenever increased
● Width of nutrient canal may vary from 100 micron negative angulation is given in mandibular pos-
to 1 mm. Margins of the canal may reveal a thin terior radiography.
white cortical plate, which may be slightly irregular. vii. Enamel
viii. Pulp cavity ● Enamel is the densest structure found in the hu-
● The pulp cavity consists of a pulp chamber and man body. It is the outer most radiopaque layer
pulp canals. It contains blood vessels, nerves of the crown of a tooth.
and lymphatics, and appears relatively radiolu- viii. Dentine
cent on a dental radiograph. ● Dentine is found beneath the enamel layer
● The pulp cavity is generally larger in children of a tooth surrounding the pulp cavity. It
than in adults due to the formation of secondary appears radiopaque and makes up most of the
dentine. tooth structure, but is not as radiopaque as
ix. PDL space enamel.
● The PDL space is the space between the root of ix. Cementum
the tooth and the lamina dura. It contains connec- ● Cementum is found beneath the dentine layer
tive tissue fibres, blood vessels and lymphatics. of a root surrounding the pulp cavity. It appears
● On a dental radiograph, the PDL space appears radiopaque and makes up most of the root
as a thin radiolucent line of uniform thickness structure, but is not as radiopaque as dentine.
around the root of a tooth. x. Lamina dura
B. Radiopaque landmarks of mandible ● The lamina dura is the wall of the tooth socket
i. Genial tubercle that surrounds the root of a tooth and is made up

● They are usually seen in occlusal films and are of dense cortical bone.
four in number, two on either sides of the median ● On a dental radiograph, the lamina dura appears
line on internal surface of mandibular incisors. as a dense radiopaque line that surrounds the
● They appear as a white ring with a dark centre root of a tooth.
immediately beneath and between lower central xi. Alveolar crest
incisors. ● It is the most coronal portion of the alveolar
ii. Mental ridge bone found between the teeth. The alveolar
● A dark white ridge extending from symphysis to crest is made up of dense cortical bone and is
the bicuspid region. Sometimes superimposed by continuous with the lamina dura.
apices of lower anterior teeth. ● On a dental radiograph, the alveolar crest
iii. Mylohyoid ridge appears radiopaque and is typically located

● This appears as a white line starting from lower 1.5 –2.0 mm below the junction of the crown
border of symphysis and continuing upwards in and the root surfaces (CEJ).
Q.3. Radiographic features of fibroosseous lesions of the Ossifying fibroma

jaws. ● Ossifying fibroma, a rare neoplasm, is also
called as fibro-osteoma.
Ans.
● It is an encapsulated lesion within which
● The fibro-osseous lesions are a diverse group of condi- the highly cellular fibrous tissue undergoes
tions. A common feature of all these lesions is that, calcification.
there is replacement of the normal bone by a tissue ● It usually affects young adults. Females have a
composed of collagen fibres and fibroblasts that contain slightly greater predilection. The lesion is slow
varying amounts of mineralized substances that may be growing and causes displacement of the teeth.
either osseous in nature, cementum-like or combination. Usually it involves the mandible.
● The radiographic appearance of these lesions is also ● Radiographic findings depend on the stage of
variable, either as diffuse, ground-glass appearance or development of the lesion. It may either appear
well-defined cystic areas that may be radiolucent or radiolucent or multiple radiopaque foci may be
containing varying amounts of calcified material. seen within the radiolucency.
● There is no acceptable classification for these lesions. ● Eventually these foci coalesce together. Borders
● A simple way of classifying the fibro-osseous lesions is of the lesion are well defined, often showing
to broadly divide these lesions into two groups based on radiolucent ring suggestive of fibrous capsule.
their site of origin. There may be displacement of the teeth.
A. The fibro-osseous lesions of PDL origin are as follows: Periapical cemental dysplasia
● Cementifying fibroma ● Periapical cemental dysplasia was earlier
● Ossifying fibroma called as cementoma.

● Cemento-ossifying fibroma l It is also variously named as fibrocementoma,
● Fibroma sclerosing cementoma, periapical osteofibrosis

B. The fibro-osseous lesions originating from the medul- or periapical fibro-osteosis.
lary bone are as follows: ● It is considered as a reactive fibro-osseous
● Fibrous dysplasia lesion.

● Fibro-osteoma ● The lesion usually occurs in the middle age
● Giant cell tumour and females are affected more than the males.
● Aneurysmal bone cyst ● The lesion usually occurs in the periapical re-
● Jaw lesions associated with hyperparathyroidism gion of the mandibular anterior teeth and the
● Cherubism lesions may be multiple.
● Paget disease ● The affected teeth are vital and it is an asymp-
Radiographic features of various fibro-osseous lesions tomatic lesion and most often is detected dur-
of the jaws are as follows: ing a routine radiographic examination.
Fibrous dysplasia ● Radiographic appearance of the lesion depends
● Fibrous dysplasia is a benign fibro-osseous lesion. on the stage of development of the lesion. Ac-
● Two types of fibrous dysplasia have been rec- cordingly, it may be radiolucent (fibrous),
ognized, the monostotic or the solitary form mixed radiolucent–radiopaque (fibrous and
and the polyostotic form. calcified elements) or radiopaque (calcified
● Fibrous dysplasia predominantly involves the stage). The margins of the lesion may be well
maxilla than the mandible and is unilateral. defined or ill-defined.
The tumour usually manifests between 10 and ● Usually no treatment is required for periapical
30 years of age. Often the posterior region of cemental dysplasia.

the jaw is involved. Florid cemento-osseous dysplasia
● The radiographic appearance varies with the ● Florid osseous dysplasia is also called as gigan-
degree of maturation and the stage of the lesion. tiform cementoma, chronic sclerosing osteo-
● In lesions with more fibrous tissue, it may be myelitis, sclerosing osteitis, multiple enostosis
radiolucency either unilocular or multilocular. and sclerotic cemental mass.
● Lesions with osseous tissue have a mottled ap- ● This lesion has a female predilection, usually
pearance. Lesions with excessive osseous tis- occurring in the middle age. Both the jaws are
sue appear radiopaque. usually involved simultaneously. Sometimes it
● The typical radiographic appearance is termed occurs only in the mandible.
as ‘ground-glass’ or ‘orange-peel’ appearance. ● Often the lesion does not cause any symptoms.
Usually the lesion is well circumscribed. Occasionally pain or swelling may be noted.
● Radiographically the lesion appears radiolu- can be drifting of the teeth and malocclusion.
cent with dense radiopaque masses within. It Edentulous patients often complain of ill-
has a similarity to ‘cotton-wool’ appearance of fitting dentures.
Paget disease. Individual lesions often exhibit ● Serum alkaline phosphatase level is increased
a cortical outline. in these patients.
Cementoblastoma ● Radiographic appearance of this lesion depends
● Cementoblastoma is a rare neoplasm originat- on the stage of formation. Accordingly, it may
ing in the PDL. be radiolucency of granular or ‘ground-glass’
● Males have a greater predilection and it usually appearance or dense radiopaque or the so-called
occurs before 25 years of age. ‘cotton-wool’ appearance. In the skull, the early
● Most common in the mandible and it appears lesions are lytic and appear as multiple radiolu-
as a solitary lesion. The involved tooth is vital. cencies called osteoporosis circumscripta.
● Radiographically it appears as a well-defined radi- ● The management of this lesion is done
opacity at the apex of a premolar or molar. Usually with calcitonin or sodium etidronate therapy.
the calcified mass shows radiolucent halo. Surgery is indicated for cosmetic purposes.
Cherubism
● Cherubism is characterized by bilateral benign,
Q.4. Discuss the differential diagnosis of periapical
firm, painless swellings in the mandible and radiolucencies.
usually in the angle region. Ans.
● The lesion usually develops in the infancy and
continues to grow causing greatest expansion ● A periapical lesion is a lesion that is located around the
in the first and second years after the onset. As apex of a tooth.
the age advances, the deformity becomes less ● Periapical lesions cannot be evaluated on a clinical basis
obvious. The lesion has a familial tendency. alone. On dental radiographs, periapical lesions may
● The lesion has derived the name as the affected appear either radiolucent or radiopaque.
children have characteristic chubby, cherubic Various periapical radiolucencies
facial appearance. ● Periapical granulomas, cysts and abscesses are
● Typically, the affected individuals have ‘eyes common periapical radiolucencies that can be seen
raised to the heaven’ appearance, if the lesion in- on dental radiographs.
volves the maxilla. The characteristic radiographic ● Because it is impossible to distinguish between these
appearance is multiple cyst-like radiolucencies three periapical lesions based on their radiographic
in the mandible. The lesions have multilocular appearance, hence they should be referred to simply
appearance and the borders are well defined. as ‘periapical radiolucencies’.
● Cortical plate expansion is seen in the occlusal Periapical granuloma
or PA views. Maxillary lesions project into the ● A periapical granuloma is a localized mass of
maxillary sinus. The developing tooth buds are chronically inflamed granulation tissue at the
usually displaced. There is usually premature apex of a nonvital tooth.
exfoliation of the deciduous teeth. ● The periapical granuloma results from pulpal
● As the lesion is self-limiting, no treatment is death and necrosis and is the most common
required. sequelae of pulpitis (inflammation of the pulp).
Paget disease (osteitis deformans) ● A periapical granuloma may give rise to a periapi-
● Paget disease was described as a clinical entity cal cyst or periapical abscess.
by Sir James Paget in 1877 and is character- ● A tooth with a periapical granuloma is typically
ized by abnormal bone destruction followed by asymptomatic but has a previous history of pro-
bone formation involving several bones. longed sensitivity to heat or cold.
● Though this disease mainly affects the skull, ● On a dental radiograph, a periapical granuloma is
the femur, the sacrum and the pelvis, jaw in- initially seen as a widened PDL space at the root apex.
volvement is rarely seen bilaterally. ● With time, the widened PDL space enlarges and
● The disease usually occurs above 50 years of appears as a round or ovoid radiolucency.
age. Males are affected more than the females. ● The lamina dura is not visible between the root
● Symptoms of the lesion are bone pain, in- apex and the apical lesion.
creased temperature, curvature of the spine, ● Treatment for a periapical granuloma may include
enlargement of the skull and facial bones and endodontic therapy or removal of the tooth with
bone deformity. In dentulous patients, there curettage of the apical region.
Periapical cyst ● Odontomes: compound and complex

● A periapical cyst also known as a radicular cyst is ● Root remnants: hypercementosis
a lesion that develops over a prolonged period. B. Conditions of variable radiopacity affecting the bone
● Cystic degeneration takes place within a periapical ● Developmental exostoses including tori mandibular
granuloma and results in a periapical cyst. The peri- or palatal

apical cyst results from pulpal death and necrosis. ● Inflammatory low-grade infections, sclerosing osteitis
● Periapical cysts are the most common of all tooth- and osteomyelitis
related cysts and comprise 50%–70% of all cysts ● Tumours:
in the oral region. a. Odontogenic (late stages)

● Periapical cysts are typically asymptomatic. On ● Calcifying epithelial odontogenic tumour (CEOT)
a dental radiograph, the typical periapical cyst ● Adenomatoid odontogenic tumour
appears as a round or ovoid radiolucency. ● Calcifying odontogenic cyst
● Treatment may include endodontic therapy or b. Nonodontogenic

extraction of the tooth as well as curettage of the ● Benign: e.g. osteoma and chondroma.
apical region. ● Malignant: e.g. osteosarcoma and osteogenic
Periapical abscess secondary metastases.

● The periapical abscess is a localized collection of c. Fibro-osseous lesions (late stages)
pus in the periapical region of a tooth that results ● Fibrous dysplasia
from pulpal death. ● Ossifying fibroma
● Periapical abscesses may be acute or chronic. An ● Cementifying fibroma
acute periapical abscess has features of an acute pus- ● True cementoma (cementoblastoma)
producing process and inflammation. The periapical ● Periapical cemental dysplasia
abscess refers to a tooth with an infection in the pulp. d. Others

● An acute abscess may result from an acute inflam- ● Paget disease
mation of the pulp or an area of chronic infection, ● Osteopetrosis
such as a periapical granuloma. C. Superimposed soft-tissue calcifications

● A chronic periapical abscess has features of a ● Salivary calculi
long-standing, low-grade, pus-producing process. ● Calcified lymph nodes
● A chronic abscess may develop from an acute ● Calcified tonsils
abscess or a periapical granuloma. ● Phleboliths
● An acute periapical abscess is painful; the pain may ● Calcified acne scars
be intense, throbbing and constant. The tooth is non- D. Foreign bodies

vital and is sensitive to pressure, percussion and heat. ● Intrabony, within the soft tissues on or overlying the skin
● Chronic periapical abscesses are usually asymp- Periapical radiopacities

tomatic because the pus drains through bone or Condensing osteitis, sclerotic bone and hypercemen-
the PDL space. tosis are a few of the common periapical radiopacities
● With an acute periapical abscess, no radiographic that can be seen on dental radiographs.
change may be evident. Condensing osteitis
● Early radiographic changes include an increased ● Condensing osteitis is also known as chronic fo-
widening of the PDL space. cal sclerosing osteomyelitis and is a well-defined

● A chronic periapical abscess appears as a round or radiopacity that is seen below the apex of a nonvi-
ovoid apical radiolucency with poorly defined tal tooth with a history of long-standing pulpitis.
margins. ● It is the most common periapical radiopacity
● The lamina dura cannot be seen between the root observed in adults.
apex and the radiolucent lesion. ● The opacity represents a proliferation of periapi-
● Treatment of the periapical abscess includes cal bone that is a result of a low-grade inflamma-
drainage and endodontic therapy or extraction. tion or mild irritation.
● The inflammation that stimulates condensing
Q.5. Describe various radiopaque lesions at the root of osteitis occurs in response to pulpal necrosis.
mandibular premolar. ● The tooth most frequently involved is the man-
Ans. dibular first molar.

● It may vary in size and shape and does not appear
Commonly occurring radiopaque lesions to be attached to the tooth root.
A. Abnormalities of teeth ● Teeth associated with condensing osteitis are non-
● Unerupted and misplaced teeth including supernu- vital and typically have a large carious lesion or
meraries large restoration.
No treatment is necessary, because condensing

●
Pathology Radiographic appearance
osteitis is believed to represent a physiologic reac-
iv. Diffuse sclerosing Ill-defined osteolytic lesions with
tion of bone to inflammation. osteomyelitis (OPG/ osteosclerotic zones, which progres-
Sclerotic bone lateral oblique view) sively become more osteosclerotic
● Sclerotic bone also known as osteosclerosis or
v. Chronic subperios- Shortening of the roots, moth-eaten
idiopathic periapical osteosclerosis is a well- teal (OPG/lateral appearance, and cortical sequestra-
defined radiopacity that is seen below the apices oblique view) tion onion-skin appearance
of vital, noncarious teeth.
vi. Garre osteomyelitis Ragged, patchy ‘moth-eaten’
● The cause of sclerotic bone is unknown; however, it
(occlusal radiograph) appearance
is not believed to be associated with inflammation.
● The lesion is not attached to a tooth and varies in
size and shape. Q.7. Name the malignant tumours of the jaws. Describe
● The margins may appear smooth or irregular and the radiographic appearance of carcinomas and sarco-
diffuse. The borders are continuous with adjacent mas of the jaws.
normal bone, and no radiolucent outline is seen.
Ans.
● Sclerotic bone is asymptomatic and is usually dis-
covered during routine radiographic examination. Characteristics of malignant lesion

Hypercementosis ● As a result of change in the nature of the lesion, the
● Hypercementosis is the excess deposition of cemen- lesion grows and disrupts the normal anatomy there
tum on root surfaces. Hypercementosis results from by causing obvious changes in the anatomic and ra-
supraeruption, inflammation or trauma; sometimes diographic picture of the tissue and the surrounding
there is no obvious cause. structures.
● On dental radiographs, hypercementosis is visible ● The nature of the lesion, rate of its growth and sur-
as an excess amount of cementum along all or part rounding tissues are the factors, which ultimately
of a root surface. elicit a radiographic picture specific to some extent
● The apical area is most often affected and appears to a particular lesion.
enlarged and bulbous. ● The various features to be analysed and the reasons
● Root areas affected by hypercementosis are sepa- for those features being so specific have been dis-
rated from periapical bone by a normal-appearing cussed below in comparison to benign lesions.
PDL space, the surrounding lamina dura appears (a) Border of the lesion
normal as well. ● Benign lesions characteristically have well-
● No signs or symptoms are associated with hyper- defined borders, which is because of their inher-
cementosis; most cases are discovered during ent nature of being nonaggressive and slow
routine radiographic examination. growth.
● Teeth affected by hypercementosis are vital and ● They grow gradually and hence have a rounded
do not require treatment. or oval extent.

● On the other hand, malignant lesions are aggres-
Q.6. Describe the radiographic appearance of different
sively expanding outwards and cause virtual
types of osteomyelitis of jaws.
erosion of the surrounding tissues. As a result of
Ans. this the borders are irregular, ragged and ill-
defined. They have a mosaic form and blend
with the normal tissue; for this reason radio-
Pathology Radiographic appearance graphic extent of the lesion is difficult to define.
Osteomyelitis ● Fuzzy or blurred appearance of ● Acute infection causes bony destruction, hence
i. Acute the trabeculae, with small areas results in sclerosing osteitis and a conforming
ii. Acute subperiosteal ● Erosion of cortex, moth-eaten
(occlusal view) appearance. Evidence of new
radiographic picture of well-defined radiopaque
subperiosteal bone formation margin.
usually beyond the area of ● It is not only the radiograph or the clinical pic-
necrosis, particularly along the ture alone, which always is diagnostic of a pa-
lower border of the mandible thology, but both act as adjuncts to each other.
iii. Chronic suppurative ● Moth-eaten appearance, (b) Adjacent cortical bone
osteomyelitis (OPG/ sequestra is seen ● The benign lesions are slow growing and hence
lateral oblique view) ● Sclerosis of surrounding bone result in displacement of the surrounding struc-
● Involucrum formation
tures like the cortical bone.
● With the elevation of the periosteum, there is a Carcinomas

stimulated formation of layers of reactive bone Squamous cell carcinoma
termed as onion-skin appearance as it appears ● It is a tumour of epithelial origin arising mostly in
like peels of onion on a radiograph. the oral mucosa.

● The growth pattern of malignant lesion is by de- ● It is the most common type of oral cancer spread-
struction and invasion of the adjacent structures. ing by invasion of the soft tissues, neurovascular
Hence, the expansion of the lesion causes destruc- tissue, and through the bone.
tion of the cortex and drags the bony material along ● Subsequent advancement brings them in contact
its path of expansion. It forms a trail of bone, hence, with bone resulting in bony involvement.
giving a typical picture of sunburst appearance. Aetiology
(c) Radiodensity There is no specific aetiology but many factors have
● Depending upon the tissue involved, the radioden- been accounted for:
sity of the lesion is variable, e.g. an osteoma is a ● Spirit and alcohol
radiopaque lesion while a central haemangioma is ● Spices
radiolucent; both are benign. ● Smoking
● Malignant lesions such as carcinomas are radio- ● Sharp margins
lucent except in case of metastatic lesion, e.g. Clinical features

carcinoma of the prostrate gland. ● Occurs predominantly in men over 50 years of age.
● There is simultaneous resorption and deposition ● The most predominant site is the posterolateral
of bone in case of sarcomas, a feature diagnostic border of the tongue and lower lip, less frequently
of sarcomas. floor of mouth, alveolar mucosa, palate and buc-
(d) Dental involvement cal mucosa.
● Teeth are more calcified than the bone. ● Size and bony involvement: Osseous involvement
● When the lesion is expanding, the response of is most frequently in third molar region of man-
the teeth is recorded in the following two ways: dible where it is closest to the bone. Small lesions
1. Displacement , 1.0 cm in diameter are generally asymptomatic.
● Usually the benign lesions are slow grow- It is only when the lesion enlarges that there is
ing and put slight persistent pressure on pain, anaesthesia or swelling. With the gradual
the teeth resulting in gradual displacement increase in size of the lesion, if lying close to the
of the teeth. tooth there occur loosening of the tooth with some
● In malignant lesion, the rate of expansion root resorption or at times leading to exfoliation.
of the lesion is reasonably high for the ● Further increase in size may lead to metastasis
teeth to respond to the pressure. through the lymphatic channels to submental and
● The roots are well within the border of the submandibular lymph nodes.
lesion; therefore, in malignant lesions there Radiographic features
is a typical picture of floating teeth, more ● It appears as a destructive lesion. There is gradual
so, the teeth lie in their actual position. erosion of the bone resulting in ill-defined margins
2. Resorption of roots all along the tumour or at some specific points.
● As far as resorption of roots is concerned, ● In the mandible, gradual growth of the lesion may
benign lesions cause resorption. lead to complete erosion of the bone resulting in a
● In a malignant lesion, the contact period is pathological fracture.
relatively less; hence, resorption is not a ● Usually a combination of posteroanterior view,
specific feature of a malignant lesion as in occlusal view and lateral oblique view are helpful
benign lesion. in understanding the extent of the lesion and in the
(e) Radiographic features demonstration of such fractures.
● Since radiograph is a two-dimensional image of ● Usually the lesion has an irregular border but at
the tissues, superimposition of various structures times the border of the tumour is lined by a radi-
occurs thereby making it difficult for the ob- opaque margin as in condensing osteitis.
server to analyse the extent of the features of the ● Also, sometimes specks of radiopaque materials
lesion. Radiographic exposure at two angula- signifying pieces of left over bone by the rapidly
tions can solve this problem to some extent. advancing tumour (especially in central squamous
● Computed tomographic (CT) scan or computer- cell carcinoma).
ized tomography is good answer to this problem. Management
● With CT scan, the invasion of the lesion into the (a) The management is by radiotherapy, surgery or
soft tissue can also be analysed. both.
Metastatic carcinoma ● First sign of the disease is swelling, occasionally

● It is the most common malignant tumour of the associated with pain having a fairly short history.
skeleton resulting from metastasis of primary car- ● Teeth may become loose and paraesthesia may
cinoma from a distant site to the bone. develop.

● The metastatic carcinoma of the jaws is relatively ● The rate of growth of lesion is very high; it dou-
rare, only 1% –8% of all malignant tumours of the bles in about a month.
oral region. Radiographic features
Clinical features ● The radiographic feature of an osteosarcoma is
● Mandible is more susceptible for metastatic quite variable.

carcinoma than the maxilla. ● Widening of PDL membrane or radiolucency
● The most common site is premolar and molar around teeth could be one of the earliest signs of
region. the lesion.
● Age varies from 40 to 60 years. Metastasis ● It may present itself in any of the three types as de-
may occur from breasts, lungs, kidneys, pros- scribed earlier, i.e. sclerosing, osteolytic or mixed.
trate glands, colon, testis and stomach. ● In the osteolytic type, there is only resorption
● Oral findings are usually the first indication of thereby giving a picture as that of a carcinoma.
the disease. ● In the sclerosing and mixed type, there may be
● The lesion is asymptomatic. obliteration of the trabecular pattern imparting it a

● Only when the mandibular nerve is involved dense granular or sclerotic appearance.
by the lesion, there is pain, paraesthesia or an- ● Further growth of the lesion results in the perfora-
aesthesia. tion of the cortical plate.

● The teeth may become loose or get exfoliated ● As a result of rapid advancement of the lesion, the
with occasional evidence of root resorption. sclerosing nature of the lesion is depicted by
● Prognosis for the patient with metastasis is traces of bone formation parallel to the direction
poor. of advancement of lesion, since the bone forma-
Radiographic features tion in this direction is suffering least resistance
● The features for metastatic carcinoma are sim- from the advancing lesion. This phenomenon re-
ilar to those of primary carcinoma having a sults in the formation of sun-ray pattern.
radiolucent picture with ill-defined margins. ● At times the sun-ray pattern may not be present
● The lesions may be single or multiple or of and bone formation may be perpendicular to the
variable size. advancing lesion and result in the formation of
Sarcomas onion-peel pattern.
Osteosarcoma Chondrosarcoma
● It is the most common malignant tumour of the ● This tumour is a malignant lesion of cartilaginous
bone, which arises from the undifferentiated bone- origin.

forming mesenchymal tissue. ● It may arise centrally in the bone, peripherally in
● Depending upon the nature of the lesion, sarcoma the periosteum or in the connective tissues con-
can be of three types: taining cartilage.
a. Sclerosing: This type forms neoplastic osteoid ● The origin is generally from the bone and can be:
and bone. ● Centrally or medullary: if arising from within
b. Osteolytic: This type does not form bone and the bone.
elicits a picture of only resorption of bone. The ● Peripheral: if arising from cartilaginous caps
rate of growth of this type is more. on the bone.

c. Mixed: It is one, which has both the compo- Clinical features
nents, i.e. resorption and formation of bone. ● The lesion is rare in the jaws, but when present it
Clinical features is mostly in the maxilla.

● The mean age of occurrence of an osteosarcoma ● The average age group is 30 years (20–60 years).
is around 50 years. ● Males are more prone to this lesion and are af-
● It involves the maxilla (antrum or alveolar ridge fected twice more than females.
excluding palate) or the mandible (body of man- ● First symptom is innocuous hard swelling result-
dible) equally and does not favour any sex. ing in facial asymmetry.
● Incidence of this lesion is more in bones that have ● The affected tooth may get loosened, resorbed or
been irradiated, subjected to trauma or affected by even exfoliated. Irradiation can be one of the pre-
Paget disease. cipitating factors.
● The transition from a benign to malignant lesion Clinical features

is also common. ● Though the lesion may occur at any age, it is most
● The rate of growth of lesion is relatively less than common in the second decade of life, i.e. mostly
osteosarcoma and it seldom metastasizes. below 30 years.
● Recurrence of the lesion after surgery is common ● Males are affected twice more often than females.
and death results by local aggressive nature. ● It usually affects long bones and about 10% affect
Radiographic features the jaws.

● Like osteosarcoma, the radiographic picture of the ● By nature, it is a fast spreading and a highly inva-
lesion is highly variable. sive tumour.

● There is resorption of the bone, which may and ● The involved bone is painful, tender to palpation,
may not depict sclerosis. In addition, it may ap- swollen and there is a feeling of warmth in the area.
pear as a cystic lesion. ● Metastasis may occur to other bones, lymph nodes
● The lobules of cartilage may give a soap-bubble and lungs.

appearance. ● The teeth may become loose and there may be
● There may also be a sun-ray pattern (in one-fourth paraesthesia of the soft tissue.
of the cases) or a ground-glass appearance. Radiographic features
● With the passage of time, irregular small dense ● The radiograph shows osteolysis with ill-defined
calcification may appear in the outer region. irregular borders.

● The widening of PDL membrane may also be ● The picture is most likely to be confused with
evident as in osteosarcoma. osteomyelitis.

● As all these features are characteristics of a malig- ● Areas of sclerosis may develop at the border of
nant lesion, the radiographic picture cannot be the lesion.

pathognomonic but suggestive of a malignant lesion. ● There may be expansion of the cortical bone and
Fibrosarcoma subsequent formation of new bone subperioste-

● It is a primary malignant fibroblastic tumour, ally. Hence, it may give an onion-peel appearance
which fails to exhibit bone or osteoid formation occasionally.
and also does not metastasize. ● Sun-ray pattern may be seen in advanced cases.
● It arises either from periosteum or periodontal

Q.8. Describe the radiographic appearance of different
membrane or endosteal connective tissue.
cysts of maxilla and mandible.
Clinical features
● Mostly the lesion is centrally arising in the bone Ans.
but may also arise in the periosteal tissues.
Radiographic appearance of various cysts of maxilla and
● The usual age of occurrence is fifth decade, the
mandible are as follows:
range being 20–50 years.
● Clinical examination reveals hard painful swell-
ing with or without covering of oral mucosa. Type of cyst Radiographic appearance
● Paraesthesia is noted in one-third of the cases.
Odontogenic ● Associated with the tooth forming
Radiographic features cysts apparatus.
● There are no specific radiographic features of the le- ● Attached or in relation with a tooth or
sion, which helps to distinguish it from other lesions. in place of a tooth.
● May cause external root resorption or
● The general features of a malignant lesion, namely
displacement of the tooth.
osteolytic changes, ill-defined borders and dis-
placement of teeth with or without root resorption Radicular cyst ● Well-defined unilocular radiolucency at
the periphery of nonvital teeth with a
may also be noted.
distinct sclerotic margin, continuous
Management with lamina dura.
● The tumour is resistant to radiotherapy.
Dentigerous cyst ● Unilocular cystic cavity with a well-
● The recurrence after surgery is common especially
defined border associated with the
when removal of the lesion by surgical excision is crown of an unerupted tooth.
limited. ● Adjacent teeth may be displaced.
● Prognosis depends on analysis of extent of the ● Buccal or medial expansion, may be
lesion and well-planned surgery. extensive, with a large cyst causing
facial asymmetry and displacement of
Ewing sarcoma
the antrum.
a) It is a primary malignant tumour originating in the
bone marrow from the mesenchymal connective Residual cyst ● Round to ovoid radiolucency with a regu-
lar margin in relation to an empty socket
tissues.
Type of cyst Radiographic appearance Q.10. Describe briefly the characteristics of the malig-
nant tumours of the jaws. Describe the radiographic
Odontogenic ● Unilocular or multilocular, hazy radio-
keratocyst lucency due to the keratin-filled lumen,
appearance of the same.
with a thin sclerotic border, which may Ans.
be smooth or scalloped.
● Adjacent teeth may be distally displaced [Same as LE Q.7]
● Expansion and perforation of cortical
plate is rare.
Basal cell naevus ● Bifid ribs, multiple jaw cysts; usually
SHORT ESSAYS:
syndrome unilocular odontogenic keratocysts in Q.1. Describe various radiographic landmarks of the
the mandible.
● Multiple nevoid basal cell carcinoma
maxilla. Why is it important to know radiographic land-
with occasional malignant transforma- marks of maxilla?
tion with or without foci.
Ans.
Primordial cyst ● Radiolucent lesion with well-defined
hyperostotic border with no involve- Various radiographic landmarks of maxilla are as follows:
ment of unerupted teeth. Radiolucent areas
Lateral ● Well-defined, round or oval radiolucency i. Incisive foramen or incisal foramen or anterior
periodontal cyst with hyperostotic margins, usually gingi- palatine foramen
val cyst, less than 1 cm in diameter. ii. Intermaxillary suture
Nonodontogenic ● May be fissural, developmental or iii. Nasal fossae or nostrils
cysts traumatic. iv. Nasopalatine canals
● Located along lines of fusion, embry- v. Antrum of Highmore or maxillary sinus
onic processes or at the site of trauma. vi. Nasolacrimal duct
● May cause divergence of roots with an
intact lamina dura.
vii. Posterior palatine foramen
viii. Median palatine suture
Globulomaxillary ● Well-defined unilocular pear-shaped
cyst radiolucency, causing divergence of
upper canine and lateral incisor
(displaced teeth are vital). {SN Q.11}
Median ● Circular, well-defined, unilocular radio- Radiopaque areas
mandibular lucent lesion with sclerotic border in i. Lamina dura
cyst the symphyseal region.
ii. Lower border of maxillary sinus
Nasopalatine cyst ● Well-defined heart-shaped radiolu- iii. Internasal septum
cency between the upper centrals, with
iv. Anterior nasal spine
a sclerotic border.
● There may be loss of definition of the v. Pterygoid plate
lateral wall of the incisive canal. vi. Inverted Y of Ennis.
Median palatine ● Well-defined radiolucency behind the
cyst (occlusal) incisive canal in the premolar–molar
area. Radiolucent landmarks of maxilla
Nasoalveolar cyst ● Soft-tissue cyst not visible on the 1. Incisive foramen or incisal foramen or anterior pala-
radiograph. tine foramen:
Postoperative ● Unilocular or multilocular radiolu- ● It is the oral termination of nasopalatine canal,
maxillary cyst cency, on the inferior extension of the transmitting nasopalatine nerves and vessels.
floor of the maxillary sinus. May cause Present palatally at the middle of central incisors.
pressure resorption of the maxillary ● It can be of various shapes such as mere slit,
alveolar bone.
rounded, oval, rhomboid and heart-shaped.
Static bone cavity ● Ovoid radiolucency with well-defined bor- 2. Intermaxillary suture:
ders found near the angle of the mandible ● Also known as median palatine suture. This ap-
below inferior alveolar canal or adjacent
to the inferior border of the mandible.
pears between two portions of the premaxilla as a
thin radiolucent line between the centre of roots
of incisors.
Q.9. Describe in detail periapical radiolucent areas. ● This is visible usually in young children. It ap-
pears as a dark line extending from central inci-

Ans.
sors to the posterior aspect of the palate. Width of
[Same as LE Q.4] the suture is almost uniform.
● Only in very young patients, it may terminate as its open end directed superiorly. It is seen often in
funnel-shaped widening at the anterior end. the maxillary sinus radiolucency.
Margins are lined by cortical bone which appears ii. Zygoma or malar bone:
radiopaque. ● It appears as an irregular radiopaque shadow
3. Nasal fossae or nostrils: covering the third molar apices which may
● These appear as dark shadows over the lateral in- extend up to the apices of second molars.
cisors. The nasal cavities are air filled; therefore, ● In cases where palatal vault is low, this shadow
they appear as radiolucent areas in periapical ra- of malar bone may be misinterpreted as hyperce-
diographs of anterior teeth. Nasal septum, a dark mentosis or as ankylosis of second and third
radiopaque line, divides the two fossae. molars.
● The margins of the fossae are lined with compact iii. Hamular process or sphenoid bone:
bone. Therefore, in radiograph, the dark shadow ● This is seldom visible in intraoral films. In extra-
of the cavities is lined with narrow white lines. oral films, this appears as a thick radiopaque line
4. Nasopalatine canals: terminating just below the region of maxillary
● This is usually not seen in periapical film but can tuberosity.
be viewed in occlusal films. iv. Nasal septum:
● This canal originates at the floor of the nasal ● It is seen as a pear-shaped radiopaque area
cavity. The openings are on either side of the nasal extending backwards from the incisive foramen
septum. in between two central incisors.
5. Antrum of Highmore or maxillary sinus: v. Inverted ‘Y’ of Ennis:
● This appears as dark shadows over the posterior ● In an IOPA radiograph, in the periapical region
teeth usually from premolar to the tuberosity re- of the maxillary canine, the lateral wall of
gion. This appears quite dark because it contains the nasal fossa and the anterior border of the
air. Maxillary sinus is the largest of the paranasal maxillary sinus form an inverted Y, which is
sinuses. The two sinuses right and left can be of termed as inverted Y of Ennis after one of the
similar shape or different. senior researchers in oral radiology Dr Ennis.
● On the intraoral periapical radiograph, it appears vi. Coronoid process of mandible:
as either U-shaped or W-shaped with one septa or ● It is a triangular grey area of radiopacity seen on
rarely with two or more septae. In the IOPA, there the radiograph of maxillary molar region.
is always U-shaped radiopacity, which is the
shadow of the zygoma. It is also termed as malar Q.2. Multilocular radiolucencies.
process by some authors. Ans.
● Sometimes, the maxillary sinus exhibits uniform
shadows of nutrient canals. They can follow any ● Multilocular appearance is the radiographic appearance
directions; usually the course is convex towards of certain conditions.
the alveolar process. ● Septa represent residual bone that has been organized
6. Nasolacrimal duct: into long strands or walls. If these septa divide the inter-
● This is seen in occlusal films and very rarely in nal structure into at least two compartments, the term
periapical films. This is round or oval-shaped ra- multilocular is used.
diolucent area over the roots of the first molar. It ● Straight, thin septa in small number are seen in odonto-
can be slightly mesial or distal to it. This can be genic myxoma. Septa seen in giant cell granuloma are
superimposed over the apices of either second described as Wispy or Granular. Curved, coarse septa seen
bicuspid or first and second molar. in ameloblastoma give internal pattern a multilocular,
7. Posterior palatine foramen: soap-bubble appearance.
● This is seen only in occlusal films and very rarely ● Pathological conditions which shows multilocular
in periapical films. This is a round or oval-shaped appearance are as follows:

radiolucent area over the roots of the first molar. i. Ameloblastoma
8. Median palatine suture: ii. Cherubism
● Seen in occlusal films as a thin radiolucent line in iii. Odontogenic myxoma
the centre of the palate. iv. Aneurysmal bone cyst
Radiopaque landmarks of maxilla v. Ameloblastic fibroma
i. Zygomatic process and the bone: vi. Odontogenic keratocyst
● In the periapical radiograph, the zygomatic pro- vii. Central giant cell granuloma
cess appears as a U-shaped radiopaque line with viii. Brown tumour
Various multilocular radiolucencies seen in the mandi- iv. Aneurysmal bone cyst
ble are described in detail as follows: ● The aneurysmal bone cyst is characterized as a false
i. Ameloblastoma cyst because it does not have an epithelial lining.

● Ameloblastoma is usually locally invasive be- ● It is a slow-growing lesion that affects mandible
nign tumour; 88%–89% lesions occur in mandi- more commonly than maxilla.
ble where 61% of the total tumour involves the ● It occurs as a unilocular or multilocular radiolu-
third molar region and ascending ramus area. cency and, when it is large, frequently balloons
● It grows very slowly without any clinical signs in out of the cortex.
the early stages. In advanced stages, this neo- ● Grossly the lesion is soft and reddish-brown;
plasm may expand cortical plates but frequently because of its rich blood supply, it resembles a
erodes them and invades the soft tissue. sponge filled with blood.
● It can be unilocular or multilocular. Multilocular ● On microscopic examination, it contains giant
images may be of soap-bubble or honeycomb cells scattered through a fibrous stroma that
appearance. contains cavernous, thin-walled blood spaces.
● Radiographically, these multilocular lesions may Bone spicules and osteoid may be present.
appear in a soap-bubble, honeycomb or tennis-
racket appearance. Q.3. Enumerate the various radiographic techniques for
● Extraosseous ameloblastomas are rare lesions the diagnosis of fracture of mandible.
that occur mostly on the gingiva. They are found Ans.
in older individuals and follow a nonaggressive
course. ● For assessing mandibular fractures although the pan-
ii. Cherubism oramic image may be a good initial image to make, the
● It occurs in patients between 2 and 20 years. intraoral cross-sectional occlusal view of the mandible
● Cherubism is seen bilaterally in the rami of the may provide important information about body or al-
mandible and becomes apparent as painless veolar process fractures in the tooth-supporting areas.
swelling of the face. Sometimes whole mandible ● If a panoramic image is not available, lateral oblique
is involved. views of the mandible should be made.

● The lesion grows slowly, expanding but not per- ● The open mouth Townes view may be particularly useful
forating the cortex. At puberty, the lesion begins in cases of suspected trauma to the mandibular condylar
to regress. head and neck areas. These views are important to sup-
● Radiologically, cherubism occurs with two or plement lateral views of the TMJ, especially in cases of
more separate, multilocular appearing lesions. nondisplaced greenstick fractures of the condylar neck.
● Sometimes the interlocular bone becomes so in- ● For suspected multiple and complex fractures of the man-
distinct that the multilocular appearance is lost. dible, CT is the imaging modality of choice. Magnetic reso-
● Usually the bony architecture returns to normal nance imaging may be useful to assess soft-tissue injury to
by the age of 30, except for a few instances in the temporomandibular joint capsule or articular disc.
which the involved bone of the ramus retains in Radiographic features of mandibular body fractures
appearance that resembles ground glass on radio- ● The radiographic examination of a suspected man-
graphic examination. dibular fracture may include intraoral or occlusal

iii. Odontogenic myxoma views, a panoramic view, posteroanterior or submen-
● The odontogenic myxoma is an infiltrative be- tovertex plain radiographic views or CT.
nign tumour of the bone that occurs almost in the ● Intraoral images may, given their higher resolution,
jawbones. The approximate ratio of maxillary to reveal fractures that extraoral plane images may fail
mandibular occurrence is 3:4. to reveal.
● The main feature of the lesion is slowly enlarging ● The margins of fracture planes usually appear as
painless expansion of the jaw with the possible sharply defined radiolucent lines of separation that
spreading, loosening and migration of the teeth. are confined to the structure of the mandible. They
● Radiographically, lesion produces several pat- are best visualized when the X-ray beam is oriented
terns unicystic, multilocular, pericoronal and along the plane of the fracture.
radiolucent–radiopaque. ● Displacement of the fragments results in a cortical
● Fine intralesional trabeculation occurs in most of discontinuity or ‘step’ or an irregularity in the occlu-
the multilocular and in some of the unicystic sal plane. Occasionally, the margins of the fracture
types, as a soap-bubble, honeycomb or tennis- overlap each other, resulting in an area of increased
racket pattern. radiopacity at the fracture site.
Nondisplaced mandibular fractures may involve one

● ● Displacement of the teeth may be an early clinical fea-
or both buccal and lingual cortical plates. ture, although most lesions are discovered during rou-
● An incomplete fracture involving only one cortical tine dental examinations.
plate is often called a greenstick fracture; these usu- ● In cases of juvenile ossifying fibroma, rapid growth may
ally occur in children. occur in a young patient, resulting in deformity of the

● An oblique fracture that involves both cortical plates involved jaw.
may cause some diagnostic difficulties if the fracture Radiographic features
lines in the buccal and lingual plates are not superim- ● Cemento-ossifying fibroma (COF) appears almost
posed. In this case, two lines are seen that converge exclusively in the facial bones and most commonly
at the periphery, suggesting two distinct fractures in the mandible, typically inferior to the premolars
when in reality only one exists. A right-angle view and molars and superior to the inferior alveolar ca-
such as an occlusal view may be useful. nal. In the maxilla, it occurs most often in the canine
Radiographic features of mandibular condyle fractures fossa and zygomatic arch area.
● Nondisplaced fractures of the condylar process may be ● The borders of COF lesions usually are well defined. A
difficult to detect on plain radiographic or panoramic im- thin, radiolucent line, representing a fibrous capsule,
ages. CT is the imaging modality of choice because it will may separate it from surrounding bone. Sometimes,
enable the clinician to visualize the three-dimensional the bone next to the lesion develops a sclerotic border.
relationship of the displaced condylar head to the glenoid ● The internal structure of a COF lesion is a mixed
fossa and to adjacent anatomical structures in the skull radiolucent-radiopaque density with a pattern that
base and infratemporal fossa. depends on the amount and form of the manufac-
● Studies of remodelled previously fractured condyles tured calcified material.
show that young persons have much greater remodel- ● In some instances, the internal structure may appear al-
ling potential than do adults. The most common most totally radiolucent with just a hint of calcified mate-
deformities are medial inclination of the condyle, rial. In the type that contains mainly abnormal bone, the
abnormal shape of the condyle, shortening of the pattern may be similar to that seen in fibrous dysplasia,
neck, erosion and flattening. or a wispy (similar to stretched tufts of cotton) or floc-
● Early condylar fractures commonly result in hypo- culent pattern (similar to large, heavy snowflakes) may
plasia of the ipsilateral side of the mandible. be seen. Lesions that produce more cementum-like mate-
Radiographic features of fractures of the alveolar rial may contain solid, amorphous radiopacities (ce-
processes menticles) similar to those seen in cemental dysplasia.
● Periapical radiographs, if they can be made, will Effects on surrounding structures
often not reveal fractures of a single cortical wall of ● COF tends to grow concentrically within the medul-
the alveolar process, although evidence exists that lary part of the bone with outward expansion ap-
the teeth have been luxated. proximately equal in all directions. This can result in
● A fracture of the anterior labial cortical plate may be displacement of teeth or of the inferior alveolar canal
apparent on an occlusal radiograph or on a lateral and expansion of the outer cortical plates of bone.
extraoral image of the mandible if bone displacement ● The COF lesion can grow into and occupy the entire
has occurred maxillary sinus, expanding its walls outward; how-

● It may be difficult to differentiate a root fracture ever, a bony partition always exists between the in-
from an overlapping fracture line of the alveolar ternal aspect of the remaining sinus and the tumour.
bone. Several images produced with different projec- The lamina dura of involved teeth usually is missing,
tion angles may help with this differentiation. and resorption of teeth may occur.
● If the fracture plane is truly associated with the tooth,
Q.5. Describe radiographic appearance of dentigerous
the line should not shift relative to the tooth. Frac-
cyst.
tures of the posterior alveolar process may involve
the floor of the maxillary sinus and result in abnor- Ans.
mal thickening of the sinus mucosa or the accumula-
● Dentigerous cyst is also called as follicular cyst. It is the
tion of blood and sinus secretions, in which case an
most common type of odontogenic cyst, which encloses
air-fluid level may be appreciated.
the crown of the unerupted tooth.
Q.4. Cemento-ossifying fibroma. ● Radiographically it appears as well-defined radiolu-
cency usually associated with hyperostotic borders.

Ans.
● Usually it is unilocular but sometimes may appear
● Cemento-ossifying fibroma consists of highly cellular, multilocular, due to ridges in the bony wall.
fibrous tissue that contains varying amounts of abnor- ● It may envelop the crown symmetrically but may
mal bone or cementum-like tissue. expand laterally from the crown.

Radiological types of dentigerous cysts are as follows: the degree of radiopacity from one another, reflecting
According to Thoma variations in amount and type of hard tissue that has
i. Central type: When the cystic cavity envelops been formed.
the crown of the impacted tooth symmetrically ● A dilated odontoma has a single calcified structure
from all sides, it is called central type. with a more radiolucent central portion that has an
ii. Lateral type: In this type, the cystic cavity is overall form like a donut.
located on one side of involved crown. ● Odontomas can interfere with the normal eruption of
iii. Circumferential type: When cystic cavity appears teeth.

to enclose the entire tooth, it is called circumfer- ● Most odontomas are associated with abnormalities
ential type. such as impaction, malpositioning, diastema, aplasia,

According to Mourshed malformation and devitalization of the adjacent teeth.
i. Class I: Dentigerous cyst associated with com- Large complex odontomas may cause expansion of
pletely unerupted teeth. the jaw with maintenance of the cortical boundary.
ii. Class II: Dentigerous cyst associated with par- Differential diagnosis
tially erupted teeth. ● A tooth-like appearance of the radiopaque structures
Effects on surroundings structures within a well-defined lesion leads to easy recognition

i. Associated teeth may get displaced in any direction. of a compound odontoma.
ii. There may be resorption of roots of adjacent teeth. ● Complex odontomas differs from cement-ossifying
iii. In maxilla, third molar may get displaced into max- fibromas by their tendency to associate with un-
illary sinus or adjacent nasal fossa or floor of orbit. erupted molar teeth and because they usually are
more radiopaque than cemento-ossifying fibromas.
Q.6. Describe in detail the radiographic appearance of
● Odontomas can develop in a very younger age group
various odontomas and give the differential diagnosis.
patient than do the cemento-ossifying fibromas.
Ans. ● Periapical cemental dysplasia may resemble com-
plex odontomas but lesions are usually multiple and

● The term odontoma is used to identify a tumour that is
centred on the periapical region of teeth.
radiographically and histologically characterized by the
● If the cemental dysplastic lesion is solitary and lo-
production of mature enamel, dentine, cementum and
cated in an edentulous region of the jaws, the differ-
pulp tissue.
ential diagnosis may be more difficult.
Synonyms
● The periphery of the cemental dysplasia usually has
Compound composite odontome; complex odontoma;
a wider, uneven sclerotic border, whereas odontomas
complex composite odontoma, odontogenic hamartoma;
have a well-defined cortical border and usually the
calcified mixed odontomes, cystic odontoma.
soft-tissue capsule is more uniform and better de-
fined with odontomas than in cemental dysplasia.
● Dense bone islands are radiopaque but do not have a
{SN Q.10} soft-tissue capsule, as is seen with odontomas.

● Compound odontome is mostly seen (62%) in the Q.7. Enumerate the radiopaque lesions of the jaws.
anterior maxilla in association with the crown of an
Ans.
unerupted canine.
● Seventy per cent of complex odontomes are found in Various periapical radiopacities are as follows:
the mandibular first and second molar areas. Superimposed periopaque shadows–normal
● The borders are well defined and may be smooth or ● Mylohyoid ridge
irregular. These lesions have a cortical border ● Body of the zygoma
and adjacent to that cortical border is a soft-tissue ● Area of sclerotic bone (dense bone islands)
capsule. Periapical radiopaque lesions–abnormal

● The contents of these lesions are largely radiopaque. True periapical radiopacities
● Compound odontomes have a number of tooth-like ● Hypercementosis
structures or denticles that look like deformed teeth. ● Rarefying osteitis
● Focal sclerosing osteitis
● Benign osteoblastoma
● Complex odontomes contain an irregular mass of ● Benign cementoblastoma
calcified tissue. ● Idiopathic osteosclerosis
● The degree of radiopacity is equivalent to or exceeds ● Periapical cemental dysplasia
that of the adjacent tooth structure and may vary in ● Central cementifying fibroma
Rarities any tooth can be involved, and in rare cases the

● Calcifying odontogenic cyst maxillary teeth may be involved.
● Chondroma and chondrosarcoma ● In most cases, the lesion is multiple and bilateral,
● Focal or diffuse sclerosing osteomyelitis but occasionally a solitary lesion arises.

● Mature complex odontoma Periphery and shape
● Osteogenic sarcoma ● In most cases, the periphery of a PCD lesion is
● Paget disease – Intermediate and mature stages well defined. Often a radiolucent border of varying
False periapical radiopacities width is present, surrounded by a band of sclerotic
● Anatomic structures like impacted teeth, supernu- bone that also can vary in width.
merary teeth and compound odontomas, tori, exosto- ● The sclerotic bone represents a reaction of the
ses and peripheral osteomas. immediate surrounding bone. The lesion may be
● Retained root tips irregularly shaped or may have an overall round
● Foreign bodies or oval shape centred over the apex of the tooth.
Ectopic calcifications Internal structure
● Sialoliths The internal structure varies, depending on the maturity
● Rhinoliths and antroliths of the lesion:
● Calcified lymph nodes i. In the early stage:
● Phleboliths ● Normal bone is resorbed and replaced with
● Arterial calcifications fibrous tissue that usually is continuous with

Rarities the PDL causing loss of the lamina dura.
● Calcified acne lesion ● Radiographically, this appears as a radiolu-
● Calcified hematoma cency at the apex of the involved tooth.

● Calcinosis cutis ii. In the mixed stage:
● Hamartomas ● Radiopaque tissue appears in the radiolucent
● Mineralized tumours structure. This material usually is amorphous,

● Multiple osteomas of the skin has a round, oval or irregular shape and is
● Myositis ossificans composed of cementum or abnormal bone.
● Pathologic soft-tissue masses ● Sometimes the cementum-like material forms
● Tumoural calcinosis a swirling pattern. These structures some-

times are called cementi.
Q.8. Discuss the radiological features of cementoma. ● Internal structure may appear dramatically ra-
Ans. diolucent if cavities resembling simple bone

cysts form within the cemental lesions. In some
Synonyms: Periapical cemental dysplasia/cementoma cases, the simple bone cyst extends beyond the
Periapical cemental dysplasia/cementoma original margin of the cemental lesion.
● Periapical cemental dysplasia is a localized change iii. Mature stage:
in normal bone metabolism that results in the re- ● Internal aspect may be totally radiopaque
placement of the components of normal cancel- without any obvious pattern.
lous bone with fibrous tissue and cementum-like ● Thin radiolucent margin can be seen at the
material, abnormal bone or a mixture of the two. periphery, because this lesion matures from
● By definition, the lesion is located near the apex of the centre to outward.
a tooth. The involved teeth are vital, and the pa- Effects on surrounding structures
tient usually has no history of pain or sensitivity. ● The normal lamina dura of the teeth involved with
● The lesions usually are diagnosed as an incidental the lesion is lost, making the PDL space either
finding during a periapical or panoramic radio- less apparent or giving it a wider appearance.
graphic examination made for other purposes. ● The tooth structure usually is not affected, although
The lesions can become quite large, causing a in rare cases some root resorption may occur.
notable expansion of the alveolar process and may ● Also, occasionally hypercementosis occurs on the
continue to enlarge slowly. root of a tooth positioned within the lesion.
Radiographic features ● Larger lesions may cause expansion of the jaw, an
Location area that is always bordered by a thin, intact outer
● The PCD lesion usually lies at the apex of a tooth. cortex similar to that seen in fibrous dysplasia. The
● The condition has a predilection for the periapical expansion is usually undulating in shape. This le-
bone of the mandibular anterior teeth, although sion may elevate the floor of the maxillary antrum.
Q.9. Radiographic features of periodontal disease. c. Periodontal abscess

● It occurs when coronal portion of pocket becomes
Ans. occluded.
Depending on the radiographic features, periodontitis is Q.10. Radiographic appearance of adenomatoid odon-
classified into: togenic tumour.
i. Early periodontitis
ii. Moderate periodontitis Ans.
iii. Advanced periodontitis
Adenomatoid odontogenic tumour
i. Early periodontitis ● Adenomatoid odontogenic tumours are uncommon
● Areas of localized erosions of alveolar bone crest. nonaggressive tumours of odontogenic epithelium in
● In the anterior region, there will be blunting of al- variety of patterns mixed with mature connective
veolar bone. tissue stroma.
● In posterior region, alveolar bone appears round off Radiographic features
with irregular and diffuse borders. Location
ii. Moderate periodontitis ● At least 75% of adenomatoid odontogenic
a. Horizontal bone loss tumours occur in the maxilla. The incisor-

● It may be localized or generalized depending canine-premolar region, especially the cuspid
on the areas involved and it may be mild, se- region, is the usual area involved in both jaws.
vere and moderate depending on the amount of It occurs more commonly in the maxilla.
bone loss. ● This tumour may have a follicular relationship
● In horizontal bone loss, both buccal and lingual with an impacted tooth; however, often it does
bone plates and intervening interdental bone not attach at the cementoenamel junction but
resorbed. surrounds a greater part of the tooth, most
b. Osseous defects often a canine.
● Interproximal crater is a trough-like depression Periphery
that occurs in the crest of interproximal septal ● The usual radiographic appearance is a well-
bone between two adjacent teeth. Craters that are defined corticated or sclerotic border.
radiographically detected are about 1 mm or Internal structure
more in depth. ● Radiographically, radiopacities develop in about
● Proximal infrabony defect is a vertical defect two-thirds of cases. One tumour may be com-
within the bone. It extends apically, from the al- pletely radiolucent, another may contain faint
veolar crest and is surrounded by three walls of radiopaque foci and some may show dense clus-
the bone ters of ill-defined radiopacities. Occasionally,
● Hemisepta is the bone of interdental septum that the calcifications are small with well-defined
remains on the roots of uninvolved adjacent tooth borders, like a cluster of small pebbles.
after destruction of either distal or mesial portion ● Intraoral radiographs may be required to demon-
of interproximal bone septum. strate the calcifications within the lesion, which
● Interproximal hemisepta occurs in the anterior or may not be seen on panoramic radiographs.
posterior teeth and it is of U or V shaped. ● Microscopic studies have verified that the size,
● Bony pockets are the extensions of the proximal number and density of small radiopacities in the
bony defect. They are surrounded by roots of in- central radiolucency of the lesion vary from tu-
volved teeth and cortical bone. mour to tumour and seem to increase with age.
iii. Advanced periodontitis Effects on surrounding structures
a. Furcation involvement ● As the tumour enlarges, adjacent teeth are dis-
● The most common area for furcation involvement placed. Root resorption is rare. This lesion also
is maxillary first molar region from mesial side. may inhibit eruption of an involved tooth. Al-
Triangular-shaped radiolucency between mesio/ though some expansion of the jaw may occur, the
distobuccal roots and palatal roots. outer cortex is maintained.
b. Alveolar bone dehiscence Ameloblastoma
● It results when the marginal bone chips apically ● The ameloblastoma, a true neoplasm of odon-
and exposes lengths of root. On radiographs, it togenic epithelium, is a persistent and locally
will appear as a faint radiopaque line representing invasive tumour; it has aggressive but benign
its apical extension. growth characteristics.
● Ameloblastomas grow slowly, and few, if any, ● An occlusal radiograph may demonstrate cyst-
symptoms occur in the early stages. like expansion and thinning of an adjacent
● The mucosa over the mass is normal, but teeth cortical plate leaving a thin ‘eggshell’ of bone.
in the involved region may be displaced and ● CT images often reveal regions of perforation
become mobile. of the expanded cortical plate as a result of the

● In most cases, patients with ameloblastomas inability of the production of periosteal new
do not have pain, paraesthesia, fistula, ulcer bone to keep up with the rate of growth of the
formation or tooth mobility. expanding ameloblastoma.
● As the tumour enlarges, palpation may elicit a Effects on surrounding structures
bony hard sensation or crepitus as the bone thins. ● There is a pronounced tendency for ameloblasto-
If the lesion destroys overlying bone, the swell- mas to cause extensive root resorption. Tooth
ing may feel firm or fluctuant. As it grows, this displacement is common. Because a common
tumour can cause bony expansion and sometimes point of origin is occlusal to a tooth, some teeth
erosion through the adjacent cortical plate with may be displaced apically.
subsequent invasion of the adjacent soft tissues.
● An untreated tumour may grow to great size
Q.11. Radiographic appearance of (A) multiple myeloma
and is more of a concern in the maxilla, where and (B) cherubism.
it can extend into vital structures and reach into Ans.
the cranial base. Tumours that develop in the
maxilla may extend into the paranasal sinuses, Multiple myeloma
orbit, nasopharynx or vital structures at the ● Multiple myeloma is a malignant neoplasm of plasma
base of the skull. cells. It is the most common malignancy of bone in

Radiographic features adults.
Location ● Single lesions are called plasmacytoma, and multiple
● Most ameloblastomas develop in the molar lesions are termed multiple myeloma.
ramus region of the mandible, but they may ● Multiple myeloma is a fatal systemic malignancy.
extend to the symphyseal area. The patient may complain of fatigue, weight loss,
● Most lesions that occur in the maxilla are in the fever, bone pain and anaemia, although the typical
third molar area and extend into the maxillary presenting feature is low back pain.
sinus and nasal floor. ● Characteristic Bence Jones protein is present in the
Periphery urine, which causes the urine to be foamy. The disease

● The ameloblastoma is usually well defined and is more common in men. When this clonal cellular
frequently delineated by a cortical border. The bor- proliferation occurs, these cells occupy first cancel-
der is often curved, and in small lesions the border lous and later cortical bone, replacing the normally
and shape may be indistinguishable from a cyst. radiopaque bone with areas of radiolucency.
● The periphery of lesions in the maxilla is usu- ● Orally, patients may complain of dental pain, swell-
ally more ill-defined. ing, haemorrhage, paraesthesia and dysaesthesia, or
Internal structure they may have no complaints.
● The internal structure varies from totally radio- Radiographic features
lucent to mixed with the presence of bony Location
septa creating internal compartments. ● Multiple myeloma is seen more frequently in
● These septa can be straight but are more com- the mandible than the maxilla but is uncom-
monly coarse and curved and originate from nor- mon in either.
mal bone that has been trapped within the tumour. ● The incidence of jaw involvement has been re-
● Because this tumour frequently has internal ported to vary from 2% to 78%. In the mandible,
cystic components, these septa are often re- the posterior body and ramus is favoured. Maxil-
modelled into curved shapes providing a hon- lary lesions usually appear in posterior sites.
eycomb or soap-bubble patterns. Generally, the ● The periphery of multiple myeloma lesions is
loculations are larger in the posterior mandible well defined but not corticated; it lacks any
and smaller in the anterior mandible. sign of bone reaction.
● In the desmoplastic variety, the internal struc- ● The lesions have been described as appearing
ture can be composed of very irregular sclerotic ‘punched out’. However, many appear ragged
bone resembling a bone dysplasia or bone- and even infiltrative. Some lesions have an oval
forming tumour. or cystic shape.
● Untreated or aggressive areas of destruction Q.12. Radiographic appearance of osteosarcoma.

may become confluent, giving the appearance
Ans.
of multilocularity.
● If the lesion is located in the periapical PDL ● Osteosarcoma or osteogenic sarcoma is the most
space, it may have a border similar to that seen common malignant tumour of bone. It is derived from
in inflammatory or infectious periapical disease. osteoblasts in which tumour cells contain high levels of
● Soft-tissue lesions have been reported in the alkaline phosphate.
jaws and nasopharynx. When visible on radio- Radiographic features are divided into three stages:
graphs, they appear as smooth-bordered soft- i. Frankly osteolytic stage
tissue masses, possibly with underlying bone ii. Frankly mixed stage
destruction. iii. Frankly osteoblastic stage
Internal structure Frankly osteolytic stage
● No internal structure is radiographically visi- ● There is moth-eaten appearance, margins of the
ble. Occasionally islands of residual bone, yet lesions are unicentric and borders are ill-defined.
unaffected by tumour, give the appearance of Adjacent lamina dura may be destroyed
the presence of new trabecular bone within the ● Perforation and expansion of cortical margins by
mass. Very rarely the lesions appear radiopaque extension into subperiosteal bone.
internally. ● As sarcoma extends more deeply into the bone,
Effects on surrounding structures pathological bone fracture occurs.

● If a good deal of bone mineral is lost, teeth may ● Mandibular lesion may destroy the cortex of neuro-
appear to be ‘too opaque’ and may stand out con- vascular bundles.
spicuously from their osteopenic background. Frankly mixed stage
● Lamina dura and follicles of impacted teeth may ● There is evidence of bone formation as well as
lose their typical corticated surrounding bone in a destruction.

manner analogous to that seen in hyperparathy- ● Sarcoma with small amount of new bone formation
roidism. usually present margins, which are not well defined.

Cherubism ● The bone within the radiolucent area of destruction
● Cherubism is a rare inherited autosomal dominant may take the forms of strands, which may be few and
disease that causes bilateral enlargement of the intersecting or may produce more or less honeycomb
jaws, giving the child a cherubic facial appearance. appearance
● As children’s faces are rather chubby, mild cases ● If the maxillary sinus or nasal fossa is involved, they
may go undetected until the second decade. are invaginated rather than infiltrated, since there is a
● Profound swelling of the maxilla may result in complete bony covering over the tumour.
stretching of the skin of the cheeks, which depresses Frankly osteoblastic stage
the lower eyelids, exposing a thin line of sclera and ● Mixed lesions has ragged, ill-defined borders and its
causing an ‘eyes raised to heaven’ appearance. radiographic pattern is result of excessive bone pro-
● The mandible is the most common location. duction intermingled with radiolucent foci of bone
Radiographic features destruction.
● The lesion grows in an anterior direction and in ● Granular appearance – The sclerotic portion of mixed
severe cases can extend almost to the midline. and opaque lesions may show vertical obliteration of
● The periphery usually is well defined and in some trabeculae pattern by new bone, impairing dense
instances corticated. granular or sclerotic appearance.
● The internal structure resembles that of Central ● Sun-ray appearance – If the tumour has invaded
giant cell granuloma (CGCG), with fine, granular the periosteum, many thin irregular spicules of
bone and wispy trabeculae forming a prominent new bone are directed outwards and perpendicular
multilocular pattern. to the surface of the lesion producing a sun-ray
● Expansion of the cortical boundaries of the max- appearance.
illa and mandible by cherubism can result in se- ● Codman’s triangle – Sometimes two triangular radi-
vere enlargement of the jaws. Maxillary lesions opacities project from the cortex and mark the lateral
enlarge into the maxillary sinuses. extremities of the lesion referred to as Codman’s
● As the epicentre is in the posterior aspect of the triangle.
jaws, the teeth are displaced in an anterior direc- ● Onion-peel appearance – On rare occasions, subperi-
tion. The degree of displacement can be severe, and osteal bone lay down in layers and it may take form
with some lesions the tooth buds are destroyed. of onion-peel lamination.
Q.13. Radiographic appearance of Paget disease. ● The lamina dura may become less evident and hyper-
cementosis develops on a few or most of the teeth in
Ans.
the involved jaw. This hypercementosis may be exu-
● Paget disease is a skeletal disorder and essentially a berant and irregular, which is characteristic of Paget
disease involving osteoclasts, resulting in abnormal re- disease. The teeth may become spaced or displaced
sorption and apposition of osseous tissue in one or more in the enlarging jaw.
bones.
● The jaws also enlarge when affected. Separation and
Q.14. Describe the radiological appearance of fibrous
movement of teeth may occur, causing malocclusion. dysplasia.
Dentures may be tight or may fit poorly in edentulous Ans.
patients.
● Bone pain is an inconsistent symptom, most often di- ● Fibrous dysplasia results from a localized change in nor-
rected towards the weight-bearing bones. mal bone metabolism that results in the replacement of all
● Paget disease occurs most often in the pelvis, femur, the components of cancellous bone by fibrous tissue con-
skull and vertebrae and infrequently in the jaws. It af- taining varying amounts of abnormal-appearing bone.
fects the maxilla about twice as often as the mandible. ● The most common sites are the ribs, femur, tibia, maxilla
● Whenever the jaws are involved, it is important to note and mandible. Patients with jaw involvement first may
that the entire mandible or maxilla is affected. Although complain of unilateral facial swelling or an enlarging
this disease is bilateral, occasionally it affects only one deformity of the alveolar process. Pain and pathologic
maxilla or the involvement may be significantly greater fractures are rare. If extensive craniofacial lesions have
on one side. impinged on nerve foramina, neurologic symptoms such
● Generally, the appearance of the internal structure de- as anosmia, deafness or blindness may develop.
pends on the developmental stage of the disease. Radiographic features
Radiographic features ● Fibrous dysplasia involves the maxilla almost twice
● Paget disease has three radiographic stages, although as often as the mandible and occurs more frequently
they often overlap in the clinical setting: in the posterior aspect.
i. An early radiolucent resorptive stage ● Lesions more commonly are unilateral except for
ii. A granular or ground-glass appearing second stage very rare extensive lesions of the maxillofacial region
iii. A denser, more radiopaque appositional late stage that are bilateral.
These stages are less apparent in the jaws. Radiographic types
● The trabeculae are altered in number and shape. ● Obisesan et al. classified the lesions of fibrous dysplasia
Most often they increase in number, but in the early radiographically into six types:
stage they may decrease. i. Peau d’orange or orange-peel type
● The trabeculae may be long and may align them- ii. Whorled plaque-like type
selves in a linear pattern, which is more common in iii. Diffuse sclerotic type
the mandible. They may also be short, with random iv. Cyst-like type
orientation, and may have a granular pattern similar v. Pagetoid type
to that of fibrous dysplasia. vi. Chalky type
● A third pattern occurs when the trabeculae may be ● The periphery of fibrous dysplasia lesions most com-
organized into rounded, radiopaque patches of ab- monly is ill-defined, with a gradual blending of normal
normal bone, creating a cotton-wool appearance. trabecular bone into an abnormal trabecular pattern.
● The overall density of the jaws may decrease or Later on, as the lesion matures, a classical ‘ground-
increase, depending on the number of trabeculae. glass’ or ‘orange-peel’ or ‘pebbled’ appearance of bone
Effects on surrounding structures is observed in the radiographs.
● Paget disease always enlarges an affected bone to ● The internal aspect of bone may be more radiolucent,
some extent, even in the early stage. Prominent more radiopaque or a mixture of these two variations
pagetoid skull bones may swell to three or four compared with normal bone.
times their normal thickness. In enlarged jaws, the ● The internal density is more radiopaque in the max-
outer cortex may be thinned but remains intact. The illa and the base of the skull. Early lesions may be
outer cortex may appear to be laminated in occlusal more radiolucent than are mature lesions and in rare
projections. cases may appear to have granular internal septa,
● When the maxilla is involved, the disease invariably giving the internal aspect a multilocular appearance.
involves the sinus floor. Cortical boundaries such as ● The abnormal trabeculae usually are shorter, thinner,
the sinus floor may be more granular and less apparent irregularly shaped and more numerous than normal
as sharp boundaries. trabeculae creating a radiopaque pattern.
● It may have a granular appearance or ‘ground-glass’ SHORT NOTES:

appearance, resembling the small fragments of a shat-
Q.1. Cotton-wool appearance on radiograph.
tered windshield, a pattern resembling the surface of
an orange, a wispy arrangement (cotton wool) or an Ans.
amorphous, dense pattern.
● A distinctive characteristic is the organization of the
● Cotton-wool appearance results from the haphazard
abnormal trabeculae into a swirling pattern similar to deposition of sclerotic bone in the radiolucent areas.
● Conditions showing cotton-wool appearance on the ra-
a fingerprint.
● Occasionally, radiolucent regions resembling cysts
diographs are as follows:
may occur in mature lesions of fibrous dysplasia. i. Paget disease
Effects on surrounding structures ii. Fibrous dysplasia
● The effects on the involved bone may include expan-
iii. Odontogenic fibroma
● Cotton-wool appearance is the characteristic feature of
sion with maintenance of a thinned outer cortex.
Fibrous dysplasia may expand into the antrum by Paget disease. In the mature stage of Paget disease, the
displacing its cortical boundary and subsequently osteoblastic activity predominates and produces a gener-
occupying part or most of the maxillary sinus. alized cotton-wool appearance.
● Often the bone surrounding the teeth is altered with-
Q.2. Lamina dura.
out affecting the dentition, and a distinct lamina dura
disappears because this bone also is changed into the Ans.
abnormal bone pattern. In rare cases, some root re-
● The radiograph of sound teeth in a normal dental arch,
sorption may occur. Involved teeth may have hyper-
which demonstrates that the tooth socket is bound by a
cementosis.
thin radiopaque layer of dense bone.
● If the fibrous dysplasia increases the bone density,
● Its thickness and density varies according to amount of
the PDL space may appear to be very narrow. Fi-
occlusal stress to which tooth is subjected.
brous dysplasia can displace teeth or interfere with
● It is wider and denser in cases of heavy occlusion while
normal eruption.
thinner and less dense in teeth that are not subjected to
● Fibrous dysplasia appears to be unique in its ability
occlusal forces.
to displace the inferior alveolar nerve canal in a su-
● Discontinuity in periapical region suggestive of inflam-
perior direction.
matory lesion.
Q.15. Discuss any three multilocular lesions of the ● PDL space can be identified and analysed with the help
mandible. of lamina dura.
Ans. Q.3. Name the anatomical landmarks seen on upper

posterior periapical film.
[Same as SE Q.2]
Ans.
Q.16. Periapical radiopacities.
Upper posterior periapical film shows following
Ans. landmarks:
[Same as SE Q.7] Radiolucent areas
i. Maxillary sinus
Q.17. Differential diagnosis of periapical radiopacities. ii. Nasolacrimal duct
iii. Posterior palatine foramen
Ans.
Radiopaque areas
[Same as SE Q.7] i. Zygomatic process
ii. Zygomatic bone
Q.18. Discuss: (A) adenoameloblastoma and (B) amelo-
iii. Malar bone
blastoma.
iv. Coronoid process of mandible
Ans. ● Maxillary sinus appears as a dark shadow over
the posterior teeth from premolar to the tuberosity

[Same as SE Q.10]
region.
Q.19. Describe the radiological appearance of jaws in ● Nasolacrimal duct is round or oval-shaped radio-
osteogenic sarcoma. lucency over the roots of first molar.

● Posterior palatine foramen is rarely seen on peri-
Ans.
apical films. It is round or oval-shaped radiolu-
[Same as SE Q.12] cency over the roots of first molar.
● Zygomatic process appears as a U-shaped radi- ● Tyre track appearance or Herring bone effect is one of
opaque line with its open end directed superiorly. the errors in faulty radiograph that results from the pro-
● Malar bone appears as an irregular radiopaque jection error.
shadow covering the third molar apices, which ● It is caused when back side of the film with the lead foil
may extend up to the apices of second molars. is placed facing towards the cone.
● Coronoid process of mandible is a triangular ● It can be avoided by always taking care to place the
grey area of radiopacity seen on the radiograph pebbled or the front side of the film towards the cones.
of upper molars.
Q.8. Moth-eaten appearance.
Q.4. ‘Onion-peel’ appearances on a radiography.
Ans.
Ans.
Moth-eaten appearance is seen in the following conditions:
● Laminar periosteal new bone formation has been re- ● Squamous cell carcinoma
ported leading to onion-peel appearance on radiographs. ● Malignant lymphoma
● The conditions showing onion-peel/skin appearance on ● Chronic osteomyelitis
radiographs are as follows: ● Histiocytosis-X
i. Ewing sarcoma ● Degeneration of condyle
ii. Osteogenic sarcoma ● Eosinophilic granuloma
iii. Garre osteomyelitis
iv. Eosinophilic granuloma Q.9. Line of Ennis.
Q.5. Radiographic appearance of ameloblastoma. Ans.
Ans. ● Line of Ennis is the synonym of inverted Y of Ennis.

It is so called as it was reported by one of the senior
● Ameloblastoma is defined as benign tumour that is usu- researchers in oral radiology Dr Ennis.
ally unicystic, nonfunctional, intermittent in growth, ● In an IOPA radiograph of the periapical region of the
anatomically benign and clinically persistent. maxillary canine, the lateral wall of the nasal fossa
Radiographic features and the anterior border of the maxillary sinus form an
● In early stages, there is area of bone destruction which
inverted Y, which is termed as ‘inverted Y of Ennis’.
is well defined and is indicative of slow growth.
● Outline is smooth, scalloped, well defined and well Q.10. Radiographic appearance of compound composite
corrugated. odontomes.
● Usually it is multilocular but may be unilocular.
Ans.
Coarse or fine trabeculae may be present.
● There is presence of septa in the lesion and appears as [Ref SE Q.6]
honeycomb appearance or soap-bubble appearance.
Q.11. Radiopaque landmarks of maxilla.
Effect on surrounding structures
● Extensive root resorption, expansion of cortical Ans.
plates as well as perforation of bone are late features.
[Ref SE Q.1]
Q.6. Name four conditions showing soap-bubble appear-
ance on skull radiograph. Q.12. Radiographic appearance of dentigerous cyst.
Ans. Ans.
Soap-bubble appearance is seen in the following conditions: Radiographic appearance of dentigerous cyst
● Ameloblastoma ● Dentigerous cyst is also called as follicular cyst. It is
● Central haemangioma the most common type of odontogenic cyst, which

● Odontogenic myxoma encloses the crown of the unerupted tooth.
● Giant cell lesions ● Radiographically, it appears as well-defined radiolu-
● Odontogenic keratocyst cency usually associated with hyperostotic borders.

● Pindborg tumour ● Usually it is unilocular but sometimes may appear
● Aneurysmal bone cyst multilocular, due to ridges in the bony wall.

● It may envelop the crown symmetrically but may
Q.7. Herring bone pattern.
expand laterally from the crown.
Ans. There may be resorption of roots of adjacent teeth.
Radiological types of dentigerous cysts are as follows: Radiographically, chronic suppurative osteomyelitis
i. Central type: When the cystic cavity envelops the may present at least four different images:
crown of the impacted tooth symmetrically from a. A radiolucency in the bone with ragged borders.
all sides, it is called central type. b. A radiolucency with multiple radiopaque foci
ii. Lateral type: In this type, the cystic cavity is within it.
located on one side of the involved crown. c. A dense zone of radiopacity with faint radiolu-
iii. Circumferential type: When cystic cavity appears cency at the margin.
to enclose the entire tooth, it is called circumfer- d. A ‘salt and pepper’ radiographic effect in the bone.
ential type.
Q.16. Describe the radiographic appearance of myxoma.
Q.13. Radiographic appearance of hyperparathyroidism.
Ans.
Ans.
● The odontogenic myxoma is an infiltrative benign tumour
● Hyperparathyroidism is an endocrine disorder in which of bone that occurs almost exclusively in the jawbones.
there is an excess of circulating parathyroid hormone. ● Radiographically, the odontogenic myxoma may produce
Radiographic features several patterns: unicystic, multilocular, pericoronal (less

● Due to loss of central trabeculae and thinning of corti- often) and radiolucent–radiopaque.
cal tables, entire calvarium has granular appearance. ● Fine intralesional trabeculation occurs in most of the mul-
● Bone matrix contains less than normal amounts of cal- tilocular examples, as well as some of the unicystic types,
cium producing unusually radiolucent skeletal image. as a soap-bubble, honeycomb or tennis-racket pattern.
● Ground-glass appearance and moth-eaten appear- ● The unilocular variety tends to be small and is mostly
ance and pepper pot skull appearance. located in the anterior region and the multilocular type
● Teeth show loss of lamina dura; it may be complete in the posterior region.
or partial. ● Margins may be poorly or well defined, and border scle-
● Demineralization of inferior border of mandibular rosis has been observed in some cases. The tumour may
canal, thinning of outlines of the maxillary sinus. be scalloped between the roots of the teeth.
● The odontogenic myxoma expands the cortical plates,
Q.14. Name a few periapical radiopacities.
showing as a smooth enlargement of the alveolar and
Ans. basal bone. Sometimes, it perforates the cortical plate
and produces a bosselated surface
Various periapical radiopacities are as follows:
● Hypercementosis Q.17. Enumerate the landmarks seen on the intraoral
● Focal sclerosing osteitis periapical view of upper third molar region.
● Benign osteoblastoma
Ans.
● Benign cementoblastoma
● Idiopathic osteosclerosis [Same as SN Q.3]

● Periapical cemental dysplasia
Q.18. Onion-skin appearance.
Q.15. Discuss the radiological appearance of chronic
Ans.
osteomyelitis.
[Same as SN Q.4]
Ans.
Q.19. Soap-bubble appearance.
● Chronic osteomyelitis is a diffuse sclerosing osteomy-
elitis in which the balance in bone metabolism is tipped [Same as SN Q.6]
towards increased bone formation, producing a subse-
Q.20. Tyre track appearance.
quent sclerotic radiographic appearance.
Radiographic features of chronic suppurative osteomyelitis Ans.
● Radiographically, chronic suppurative osteomyelitis
[Same as SN Q.7]
presents a ‘moth-eaten’ radiolucent area in the bone
with poorly defined margins. Q.21. Radiographic features of chronic osteomyelitis.
● Within the radiolucent area, multiple radiopaque foci
Ans.
are evident which represent areas of sequestrations
formation. [Same as SN Q.15]
Section I

of Previous Years
PART I: ORAL AND MAXILLOFACIAL SURGERY

Topic 1 Introduction to Oral and Maxillofacial Surgery 545
Topic 2 General Principles of Surgery 554
Topic 3 Local Anaesthesia 563
Topic 4 Conscious Sedation and General Anaesthesia 580
Topic 5 Principles of Exodontia and Instrumentation 583
Topic 6 Impactions 594
Topic 7 Maxillofacial Trauma 606
Topic 8 Mandibular Fractures 621
Topic 9 Cysts of Orofacial Region 636
Topic 10
Benign Tumours of the Jaw 648
Topic 11
Diseases of TMJ 658
Topic 12
Diseases of Salivary Gland 668
Topic 13
Diseases of Maxillary Sinus 679
Topic 14
Inflammatory Lesions of Jaw and Orofacial Infections 689
Topic 15
Facial Neuropathology 706
Topic 16
Preprosthetic Surgery 714
Topic 17
Premalignant and Malignant Lesions 723
Topic 18
Management of Medically Compromised
Patients and Medical Emergencies 733
Topic 19 Minor Oral Surgical Procedures
and Orthognathic Surgery 749
Topic 20 Implantology and Miscellaneous 756
Section I

of Previous Years
Part I
Oral and Maxillofacial Surgery
Topic 1
Introduction to Oral and Maxillofacial Surgery
LONG ESSAYS:
1 . Discuss the use of various chemical agents for maintaining sterilization and asepsis in the dental clinic.
2. Define asepsis. What precaution would you take to maintain asepsis during a minor oral surgical procedure?
SHORT ESSAYS:
1 . Sterilization and disinfection in dental practice.
2. Hot air oven.
3. Cross-infection in dental office.
4. Physical methods of sterilization. [Same as SE Q.1]
5. Describe briefly about autoclave. [Same as SE Q.1]
SHORT NOTES:
1 . Define sterilization and disinfection. [Ref SE Q.1]
2. Principle of autoclave. [Ref SE Q.1]
3. Cidex.
4. List out few physical and chemical agents used for sterilization.
5. Define the terms ‘antiseptic’ and ‘disinfectant’.
6. Cold sterilization. [Same as SN Q.3]
545
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Discuss the use of various chemical agents for cells, including the tubercle bacillus, but it has no
maintaining sterilization and asepsis in the dental clinic. effect on spores.
l Usually 50%–80% alcohol solution is recommended
Ans.
because water prevents rapid evaporation, assists
● Sterilization is defined as a process by which an article, penetration into the tissues and speeds up the process
surface or medium is freed of all microbial forms such of protein denaturation.
as bacteria, viruses, fungi and spores. l A 10 min immersion in 70% ethyl alcohol is gener-
● Ideally, a sterile field means free of contaminants, ally sufficient to disinfect a thermometer or a delicate
which is difficult to attain. The goal is elimination of instrument.
infection, not sterility. l It denatures proteins and dissolves lipids, an action
● Chemical agents, rarely achieve sterilization. Instead, that may lead to cell membrane disintegration.
they are only expected to destroy the pathogenic organ- l Ethyl alcohol is used as a component in many popu-
isms in an object. lar hand sanitizers, as a preservative in cosmetics and
● The process of destroying pathogens is called disinfec- to treat skin before a venepuncture or injection.
tion, the object is said to be disinfected. l It mechanically removes bacteria from the skin and
● If the object is lifeless, such as a table top, the chemical dissolves lipids.
agent is known as a disinfectant. l Isopropyl alcohol (rubbing alcohol) has high bacteri-
● However, if the object is living, such as a tissue of the cidal activity in concentration as high as 99%.
human body, the chemical is an antiseptic. l Methyl alcohol is toxic to the tissues and is used
● Antiseptics and disinfectants are usually bactericidal, infrequently.
but occasionally they may be bacteriostatic. Advantages
● None of the chemicals used for cold sterilization satisfac- ● Rapid bactericidal action
torily meets all of the requirements for true sterilization. ● Economical
● Slightly irritating to tissues

Various chemical agents used for maintaining steriliza-
Disadvantages
tion and asepsis are as follows:
● Evaporates rapidly
● No sporicidal or virucidal action

Disinfectants
● Damage to rubber or plastic goods and to carbon
i. Alcohol, e.g. ethyl alcohol and isopropyl alcohol
ii. Aldehyde compounds, e.g. formaldehyde and glutaral- steel instruments
dehyde 2% ii. Aldehyde compounds
iii. Chlorines, e.g. sodium hypochlorite and calcium hypo- a. Formaldehyde
chlorite ● It exists as a gas at high temperatures and as a
iv. Quaternary ammonium compounds, e.g. benzalkonium solid at room temperatures.
chloride ● It is used as water-based solution called formalin,
v. Phenolic compounds, e.g. ortho-phenylphenol and ortho- which is prepared by suspending 37 g of the solid
benzyl-para-chlorophenol formaldehyde in 100 mL of water.
● In microbiology, formalin is utilized for inactivat-
Antiseptics
ing viruses in certain vaccines and producing
i. Alcohols
toxoids from toxins.
ii. Aqueous quaternary ammonium compounds
● In the gaseous form, formaldehyde is expelled
iii. Iodophor compounds
into a closed chamber where it is a sterilizing
iv. Chlorhexidine
agent for surgical equipment, hospital gowns and
v. Hexachlorophene compounds
medical instruments.
i. Alcohol ● However, penetration is poor, and the surface
l Ethyl alcohol (ethanol) and isopropyl alcohol are must be exposed to the gas for up to 12 h for ef-
water-soluble chemical substances. fective sterilization.
l Alcohols are effective skin antiseptics and valuable ● Instruments can be sterilized by placing them in a
disinfectants for medical instruments. 20% solution of formaldehyde in 70% alcohol for
l For practical clinical use, the preferred alcohol is 18 h. Formaldehyde, however, leaves a residue,
ethyl alcohol. It is active against vegetative bacterial and instruments must be rinsed before use.
● It is used to preserve anatomical specimens and ● They are used for ordinary environmental sanita-
for destroying anthrax spores in hair and wool. tion of surfaces like walls, floors and furnitures.
● Under properly controlled conditions, satisfactory ● They can be used as both antiseptics and disin-
disinfection of clothing, bedding, furniture and fectants.

books can be achieved. v. Phenolic compounds
● Its uses are limited due to irritating fumes and ● In case of hospital disinfection, phenols occupy a
pungent odour. prominent place.

b. Glutaraldehyde ● Most of phenolic germicides are used as surface dis-
● Glutaraldehyde is an alkylating agent usually em- infectants, e.g. bedside tables, bed rails and labora-
ployed as a 2% solution. tory surfaces.
● It is a high-level disinfectant with broad-spectrum ● They are low-level disinfectants and have corrosive
of activity and has sporicidal action at room property.

temperature. ● Examples: Ortho-phenylphenol and ortho-benzyl-
● It is one of the most effective chemicals used for para-chlorophenol.

sterilization purposes. It destroys vegetative cells
within 10–30 min and spores in 10 h. Antiseptics
● It is especially effective against tubercle bacilli, i. Alcohols
spores, fungi and viruses. These are effective skin antiseptics and a valuable dis-
● To use it for sterilization purposes, materials have infectant as already discussed earlier.
to be precleaned, immersed for 10 h, rinsed thor- ii. Quaternary ammonium compounds
oughly with sterile water, dried in a special cabi- These can be used as both antiseptics and disinfectants.
net with sterile air and stored in a sterile container. iii. Iodophor compounds
● It can be safely used to treat corrugated rubber an- ● For example: Povidone iodine
aesthetic tubes and facemasks, plastic endotracheal ● They have broad spectrum of antiseptic action.
tubes, metal instruments and polythene tubings. ● They are formulated as 1% iodine solution.
iii. Chlorines Halogens

● Chlorine is available in a gaseous form and as both ● The halogens are a group of highly reactive
organic and inorganic compounds. elements.

● They are widely used in municipal water supplies, ● Two halogens, chlorine and iodine, are com-
where they keep bacterial populations at low levels. monly used for disinfection.
● The chloramines, such as chloramine-T, are organic Iodine
compounds that contain chlorine. ● Iodine atom is slightly larger than the chlorine
● They are valuable for general wound antisepsis and atom, and is more reactive and more germicidal.
root canal therapy. Iodine acts by halogenating tyrosine portions of
● Chlorine is effective against a broad variety of organ- protein molecules.
isms, including most Gram-positive bacteria, Gram- ● Tincture of iodine, a commonly used antiseptic
negative bacteria, viruses, fungi and protozoa. for wounds, consists of 2% iodine and sodium
● However, they are not sporicidal. iodide dissolved in ethyl alcohol.
● In microorganisms, the halogen is believed to cause iv. Chlorhexidine
the release of atomic oxygen, which then combines ● It is active against a number of bacteria.
with and inactivates certain cytoplasmic proteins, ● It can be prepared in alcohol or with cetrimide 0.5%
such as enzymes. 1 70% of alcohol or chlorhexidine with cetrimide

● Another theory is that chlorine changes the structure or 4% solution with detergent can be used as preop-
of cell membranes, thus leading to leakage. erative scrub.
● Examples: Sodium hypochlorite and calcium hypo- v. Hexachlorophene compounds
chlorite. ● They are less effective against Gram-negative or-
iv. Quaternary ammonium compounds ganisms, viruses and spores.

● These are widely used as disinfectants and are good ● In patients, who are sensitive to iodine, they can be
cleansing agents. used as surgical site preparation solution.

● These compounds are bactericidal, virucidal and Hexachlorophene
fungicidal, but are not sporicidal. ● It is less effective against Gram-negative organisms.
● Example: Benzalkonium chloride. ● It can be used as valuable surgical preparation solu-
Uses tion in patients sensitive to iodine compounds.

● They are low-level disinfectants. ● It has toxic potential.
Formaldehyde gas It is the series of steps which are designed to prevent the
● Formaldehyde gas is widely employed for fumiga- introduction of infection into a wound at the time of opera-
tion of operation theatres and other rooms. tion or when wounds are dressed.
● The dose of formalin is decided based on the volume Precautions taken to maintain asepsis during a minor oral
of the room. surgical procedure are described under the following heads:
● After sealing the windows and other outlets, formal- i. Operating room procedures
dehyde gas is generated by adding 150 g of KMnO4 ii. Hand scrub techniques
to 280 mL of formalin for every 1000 cubic feet of iii. Preparation of the patient/surgical site preparation
room volume.
● The reaction produces considerable heat, and so i. Operating room procedures
heat-resistant vessels should be used. ● The primary goal of surgical team while in operating
● After starting generation of formaldehyde vapour, the room is preventing surgical site infection.
doors should be sealed and left unopened for 48 h. ● The operation theatre should provide an environment
● A fumigator may be used for this purpose, loaded free from bacterial contamination, as far as possible.
with water and about 40% formalin. ● The ceiling, walls and floor are regularly disinfected,
Beta-propiolactone (BPL) especially following a contaminated case. The oper-

● Beta-propiolactone is a condensation product of ke- ating rooms should have two sets of doors.
tone and formaldehyde with a boiling point of 163°C. ● The access to operation theatre and the recovery area
● It is said to be more efficient for fumigating purposes is restricted to operation theatre personnel, who are
than formaldehyde. required in the operating room.
● It has a rapid biocide action, but unfortunately has ● A surgical head cap is used to cover the hair com-
carcinogenic activity. pletely and a mask is placed and tied over the mouth.
Testing of disinfectant ● The people should not walk bare feet in the operating
Rideal–Walker test room. They should ware shoe covers or footwear

● In the Rideal–Walker test, suspensions containing made of conductive material to prevent static elec-
equal numbers of typhoid bacilli are submitted to tricity and also electrocution from various electrical
the action of varying concentrations of phenol and equipment present in operating room.
of the disinfectant to be tested. ● The various electrical devices in surrounding areas
● The dilution of the test disinfectant, which steril- attached to the patient in the operating room are the
izes the suspension in a given time, divided potential sources of electrical shock. Hence, they
by the corresponding dilution of phenol, is stated should be disinfected properly with care.
as the phenol coefficient (phenol 5 I) of the ● Once the patient is prepared and draped, only those
disinfectant. personnel, who have scrubbed, gowned and gloved,

● This test does not reflect natural conditions as the may work at the surgical site.
bacteria, and the disinfectant react directly with- ● The backs of those who are gowned are considered
out any organic matter being present. nonsterile, as also the areas below the waist. Hence,
● Modifications have therefore been suggested. one must be careful to keep the arms above the waist,
Chick–Martin test when not operating.
● In the Chick–Martin test, the disinfectant acts in ● Some of the hospitals have the detachable and steril-
the presence of organic matter. izable operating light handles, which can be adjusted
● Even this modification falls short of simulating by the surgeon.
natural conditions. ● In order to reduce bacterial counts in the air of the
● Various other modifications have been introduced, operating room, it may be sent through a filter or may
but no test is entirely satisfactory. be passed through UV radiation device.
Fumigation of operating room
Q.2. Define asepsis. What precaution would you take
● The operation theatres are disinfected by fumiga-
to maintain asepsis during a minor oral surgical
tion.
procedure?
● Fumigation can be achieved by the use of fumiga-
Ans. tors as well as potassium permanganate reaction

technique.
Asepsis is a term used to describe the methods which pre-
● Fumigation is initiated after setting up of the
vent contamination of wounds and other sites by ensuring
instrument (STERI TRAX) in place.
that only sterile things come in contact with them.
● The fumigator is loaded with water and 40%
Or formalin. Fumigator is set for 30 min.

Parameters playing role in effective fumigation are b. The second purpose is to reduce bacterial count
as follows: on the skin.
Relative humidity (RH) ● Many techniques of hand scrub have been
● Relative humidity plays a major role in fu- suggested.

migation. Higher the humidity, better is the ● The sink that is used for scrubbing should be a
disinfection. deep one and the taps are operated either with
● A minimum of about 70% is essential. a foot pedal or have a long handle which can
Temperature be operated with elbow.
● Evaporation of gaseous fumigant is more at ● All jewellery should be removed before wash-
the higher temperature. ing. The nails should be checked for cleanli-
● Optimum temperature at around 30–40°C is ness. All gross subnail contamination should
required. be removed.
Formaldehyde levels in the air in the operation theatre ● The scrubbing may be done with the help
● The dose of formalin is usually decided by the size of a brush and antiseptic solution. The scrub
of the room, e.g. as a general rule, about 180 mL brush may be available as a disposable single
is used for a room of the size 1000 cubic feet. use packed and impregnated with soap
Antiseptic environment solutions or can be reusable with a soap
● The principle is to minimize bacterial contamina- dispenser.
tion in the vicinity of operating table and the ● Nails should be scrubbed first thoroughly and
concept of zones is useful, and must be employed. the arms are wetted few inches above the
i. Outer or general access zone, e.g. patient elbows.
reception area and general office. ● The scrubbing begins first at the tip of the fin-
ii. Clean or limited access zone, e.g. the area gers and is continued along the skin surface of
between reception and general office, dis- fingers, and the interfinger webbing. Each
persal area, corridors and staff room. finger should be scrubbed separately on all
iii. Restricted access zone, e.g. for those prop- surfaces.
erly clothed personnel engaged in operation ● The scrubbing is continued until all the sur-
theatre activities, anaesthetic room, etc. faces of the hand are clean.
iv. Aseptic or operating zone, e.g. the opera- ● Then the hands are cleaned along the forearms
tion theatre. and scrubbing is progressed towards the elbow,

Airflow extending above the elbow. In the similar man-
● The air may be filtered, or allowed to flow past ner, the other hand is scrubbed.
an ultraviolet radiation device to reduce bacte- ● A scrubbed area should not be touched again
rial counts. because of the possibility of contamination

● The two types of airflow in operation theatres from an unsterile area.
are (i) conventional and (ii) unidirectional. ● After the scrubbing of both the arms, excess
● The normal turbulent airflow through theatre is of soap is rinsed with arms elevated above
necessary to maintain humidity, temperature the elbow height to enable the water to drain
and air circulation. from the fingers progressing down the arms
● Air is pumped into the room through filter and and the elbows. They are not rubbed during
passed out of vents in the periphery of operating the rinse.
room and does not return to operating room. ● The surgeon approaches the scrub nurse for the
ii. Hand scrub techniques drying towel.

● Hand scrub is the first step towards aseptic surgical ● The technique of drying begins at fingertips of
technique. The surgical team who participate in the one hand and progresses down then, with the
operative procedure needs to scrub and wear sterile opposite side of the towel. The other hand is
gowns. dried in a similar manner.
● It is the single most important and successful method Hand disinfectants
of controlling the spread of infection in hospital Certain proprietary preparations available for preop-
environment. erative washing of hands of surgeons and assistants,
● The purpose of hand scrub is two-fold: which have a bactericidal effect and do not cause
a. The first is to remove the superficial contaminants excessive drying of skin, are as follows:
and loose epithelium and is achieved by the i. Betadine scrub solution – contains 7.5% povi-
mechanical action of the brush. done-iodine.
ii. Hibiscrub and Phisiomed – contains 4% The single-use surgical blades and suture needles
●
chlorhexidinegluconate. are recommended.

iii. Soap containing disinfectants like hexachlo- Other precautions taken are
rophene. Preoperative gingival/periodontal care
iv. 70% Hibisol lotion (2.5% chlorhexidine in ● It is necessary that the patient should undergo
70% alcohol) may also be applied as extra preoperative scaling and the patient is given
precaution. oral hygiene instructions.
Gloving ● This helps in keeping the bacterial population
● Gloving is essential to protect both the surgeon to a minimum.

and the patient from blood-borne viruses and to Use of antimicrobial mouth rinse
prevent wound becoming contaminated with the ● The use of an antimicrobial mouth rinse preop-
surgeon’s skin flora. eratively reduces the number of bacteria con-

● Hand gloves help to protect the operator from in- siderably.
fection by bacteria and viruses from patient’s ● The action is a combination of mechanical
blood. removal and antisepsis.

● There are two types of gloves: ● The recommended rinse contains diguanides
i. Latex gloves like chlorhexidine.

They are clear and the most common type of Use of antibiotic prophylaxis
gloves. ● The clinician relies on the use of antibiotics
ii. Brown milled rubber gloves prophylactically to reduce the incidence of

These are thinner than latex gloves and pro- postoperative infection.
vide a better tactile sensation. However, they ● Antibiotics should be avoided when there is no
are more fragile and require more frequent real and specific indication as it causes bacte-
changes during the operation. rial resistance and superinfection.
The ‘hand-to-glove’ and ‘glove-to-glove’
techniques of donning the gloves should be
employed. Double gloving affords extra pro-
SHORT ESSAYS:
tection, but at the expense of reduced sensitiv- Q.1. Sterilization and disinfection in dental practice.
ity and dexterity, and possible discomfort.
Ans.
iii. Preparation of the surgical site
● Preferably just prior to scrubbing, the hair on the
skin in the area of surgical field is removed. {SN Q.1}

● A lubricating ointment should be applied to
patient’s eyes, and they are covered. Sterilization

● The external auditory meatus is plugged and Sterilization is defined as a process by which an article,
blocked, if bleeding in the vicinity is anticipated. surface or medium is freed of all living microorganisms
● The scrubbing should begin in the centre of the site including bacteria, fungi, spores and viruses. Steriliza-
to be prepared, and moved outwards concentrically, tion is the complete destruction of agents that are capa-
away from the site of operation. This avoids con- ble of causing infections, including spores.
tamination of already scrubbed site of surgery. Disinfection
Draping the patient ● It is a process that eliminates many or all pathogenic
● The purpose of draping a patient is to isolate the
microorganisms, except bacterial spores, on inani-
surgical site from other parts of body that have not mate objects.
been prepared for surgery, and also from nonster- ● Disinfection means the destruction or removal of all
ile equipment. pathogenic organisms except bacterial spores on in-
● The patient’s head.
animate objects by chemical disinfectants, e.g. alde-
Disposable items hydes, halogens, alcohols and surfactants. This is the
● Many disposable items are supplied in sterile packs
destruction of most microorganisms, but not all via-
by their respective manufacturing companies. ble organisms, particularly highly resistant spores.
● These are sterilized by methods such as gamma
radiation.
● The sterility of such products can be relied upon; Various physical methods used in sterilization are as
if the supplier is from a reputable manufacturer follows:
and the wrapper seal is not broken. ● Sunlight
Drying
● ● Autoclave should be loaded properly; other-
Dry heat
● wise, it may not be effective.
● Moist heat Effective sterilization in an autoclave depends upon
● Filtration ● Good cleaning of the instruments with soap and
● Radiation running water to remove all blood and debris

● Ultrasonic vibration ● Direct flow of steam to all parts of the sterilizer, and
Autoclave instruments should be in contact with the steam

Mode of action of an autoclave ● Periodic monitoring of the sterilizer to check its
effectiveness
Sterilization monitoring
{SN Q.2} ● The steam cycle is monitored by three meth-
● The use of saturated steam under pressure is consid- ods: physical, chemical and biological moni-
ered the most practical and effective method of ster- tors
ilization. Physical monitoring
● When steam comes in contact with the instrument to ● Routine observation of dials and gauges indi-
be sterilized, it condenses almost instantly and re- cating time, temperature and pressure
leases latent heat, which quickly denatures vital cell Chemical monitoring
proteins. ● By using Browns tubes; type I for autoclaves.
● The condensed water provides a moist environment The colour changes once the correct time and
for killing bacteria. temperature are reached.
● Saturated steam under pressure is even more efficient Biological monitoring
because increasing the pressure in a container of ● The effectiveness of steam sterilization is mon-
steam increases the boiling point of water, so that itored with a biological indicator containing
new steam entering a closed container gradually be- spores of Geobacillus stearothermophilus (for-
comes hotter. This is the principle of an autoclave. merly known as Bacillus stearothermophilus)
● Moist heat destroys microorganisms by the irrevers- and autoclave indicator tape.
ible coagulation and denaturation of enzymes and
structural proteins. The presence of moisture there- Q.2. Hot air oven.
fore significantly affects the coagulation temperature Ans.
of proteins and the temperature at which microorgan-
isms are destroyed. Hot air oven or dry heat sterilizers
● This method should be used only for materials that
might be damaged by moist heat or that are impenetra-

Uses ble to moist heat (e.g. powders, petroleum products and
● Steam sterilization should be used whenever sharp instruments).
possible on all critical and semicritical items ● Sterilization is for 12 min at 190°C.
that are heat- and moisture-resistant.
Advantages There are two types of dry heat sterilizers:
● This is the most effective form of destruction
a. The static-air type
● This is referred to as the oven-type sterilizer as heat-
of all forms of microbial life.
● It is nontoxic, microbicidal, sporicidal and
ing coils in the bottom of the unit cause the hot air to
rapidly heats and penetrates fabrics. rise inside the chamber via gravity convection.
● Time taken for sterilization is 60–120 min at a tem-
● Temperature can be accurately controlled.
● Short sterilizing time; heating and penetration

perature of 160°C.
of heat is rapid. b. The forced-air type
● Also called the mechanical convection sterilizer.
● Most economical sterilization technique.
● It is equipped with a motor-driven blower that circu-
● No remnants of any toxic residue on the instru-
ments after sterilization. lates heated air throughout the chamber at a high
Disadvantages velocity, permitting a more rapid transfer of energy
● Causes corrosion of delicate instruments.
from the air to the instruments.
● Unsuitable for sterilization of greases, oils or Another method of dry heat sterilization uses a heat transfer
powders. device.
● Rubber and plastic goods may get damaged or ● This is used for sterilizing endodontic instruments, e.g.
melt. glass bead sterilizer.
● Small diameter glass beads, salt or even molten metal Asymptomatic carriers
may be used as a head transfer device. ● These persons may have a subclinical infection
Advantages of dry heat sterilizers include and are unaware of it.

● It is nontoxic and does not harm the environment. ● They give no history of past infection, hence
● A dry heat cabinet is easy to install and has relatively cannot be diagnosed easily.
low operating costs. ● These individuals may carry infective organ-
● It is noncorrosive for metal and sharp instruments. isms in saliva and blood. The classic example
Disadvantages of dry heat sterilizers include is hepatitis B virus infection.
● Slow rate of heat penetration and microbial killing. ● Hepatitis B virus infection may manifest with
● Time-consuming method as the sterilization process or without symptoms, and the clinician may be
has to be followed by a cooling process. faced with either convalescent or asymptom-
● High temperatures are not suitable for most materials atic carriers of such infection.
like plastics and rubbers.
Routes of transmission
Transmission of infection within a dental clinic may
Q.3. Cross-infection in dental office
occur via several routes:
Ans. i. Direct contact of tissues with infective biological fluids
such as blood and oral secretions.
● Cross-infection is defined as the transmission of infec-
ii. Indirect contact with contaminated instruments, equip-
tious agents among patients and staff within a clinical
ment or environmental surfaces.
environment.
iii. Inhalation of aerosolized infective droplets/particles.
● In dentistry, the sources of infection may constitute:
iv. Direct inoculation into cuts and abrasions of unpro-
i. Patients suffering from infectious diseases
tected skin or mucosa via contaminated sharps or
ii. Patients, who are in the prodromal stage of certain
instruments.
infections
iii. Healthy carriers of pathogens Infection through any of these routes requires that all three
of the following conditions be present, ‘the chain of infec-
Pathways of cross-infection
tion’, i.e. pathogen, susceptible host and microorganism.
● There are six common pathways
Pathogen
i. Patient to practitioner
● Sufficient infectivity and sufficient dose
ii. Practitioner to patient
● Exposure portal through which the pathogen may
iii. Patient to patient
enter the host
iv. Clinic to community
Susceptible host
v. Clinic to practitioner’s family
● Dental patients and dental healthcare workers
vi. Community to patients
(DHCWs) may be exposed to a variety of microor-
The sources of infection are described in detail as ganisms via blood or oral or respiratory secretions.
follows: Microorganisms
Patients suffering from acute illnesses ● These microorganisms may include the following:
● The likely source of infection is usually a person, i. Bacteria: Staphylococci, Streptococci, M. tuber-
who is in the prodromal phase of an infection attend- culosis;
ing the clinic. ii. Viruses: Herpes simplex virus types 1 and 2, cy-
● The patient at this stage may appear healthy, but the tomegalovirus, hepatitis B virus (HBV); hepatitis
saliva and blood may be infectious. C virus (HCV), human immunodeficiency virus
● The diseases which can spread easily in this manner are (HIV)
viral infections, e.g. measles, mumps and chickenpox. iii. Other bacteria and viruses, specifically those as-
Healthy carriers sociated with upper respiratory tract infections.
● They are important factors in the transmission of
Q.4. Physical methods of sterilization.
disease and can be classified as follows:
a. Convalescent carriers Ans.
● In this stage, the patient suffers an acute illness
[Same as SE Q.1]
and apparently recovers.
● However, the blood and secretions serve as Q.5. Describe briefly about autoclave.
persistent reservoirs of the infective organisms.
Ans.
● Such individuals can be identified on the basis
of past history of infection. [Same as SE Q.1]

SHORT NOTES: iii. Dry heat

iv. Moist heat
Q.1. Define sterilization and disinfection. v. Filtration
Ans. vi. Radiation
vii. Ultrasonic vibration
[Ref SE Q.1] Chemical agents
Q.2. Principle of autoclave i. Acids
ii. Alkalis
Ans. iii. Salts
[Ref SE Q.1] iv. Halogens
v. Oxidizing agents
Q.3. Cidex vi. Reducing agents
Ans. vii. Formaldehyde
viii. Phenol, etc.
● The Cidex is gluteraldehyde 2% (C5H8O2) and it is a
high-level disinfectant. Q.5. Define the terms ‘antiseptic’ and ‘disinfectant’.
● It has broad-spectrum activity and is sporicidal.
Ans.
● It has a shelf life of 14 days.
● The articles to be sterilized are washed and dried and Antiseptic

placed in a tray totally submerged in the solution for ● Antiseptic is the chemical that is applied to living
minimum 6–8 h. tissues such as mucous membrane to reduce the

● Before using, instruments should be thoroughly washed number of microorganisms present, through inhibi-
with saline otherwise they will cause severe tissue reaction. tion of their activity or destruction. Antiseptics are
Advantages germicides applied to living tissue and skin; in gen-
● Long, activated shelf life of around 14 days. eral, antiseptics are used only on the skin and not for
● Noncorrosive. surface disinfection.
● It is also active in the presence of organic debris. Disinfectant
● Rubber and plastic goods may also be sterilized ● Disinfectant is a chemical used on nonvital, inani-
without any damage. mate objects to kill surface vegetative pathogenic

Disadvantages organisms, but not necessarily spore forms or
● Causes severe tissue irritation and is also allergenic. viruses.
● Solution needs to be changed frequently as its acti- ● Disinfectants are not used for skin antisepsis because
vated time is completed. they can injure skin and other tissues.
● Cannot be used as antiseptic. ● If the object is lifeless, such as a table top, the chem-
ical agent is known as a disinfectant.

Q.4. List out few physical and chemical agents used for ● However, if the object is living, such as a tissue of the
sterilization. human body, the chemical is an antiseptic. Antisep-
Ans. tics and disinfectants are usually bactericidal, but
occasionally they may be bacteriostatic.
Various physical and chemical agents used for sterilization
are as follows: Q.6. Cold sterilization.
Physical agents Ans.
i. Sunlight
ii. Drying [Same as SN Q.3]
Topic 2
General Principles of Surgery
LONG ESSAYS:
1 . Cephalometry used in oral surgery.
2. Describe the uses of lasers in maxillofacial surgery.
3. Explain suturing material for a facial wound and methods of suturing.
4. Suture techniques used in oral surgery. [Same as LE Q.3]
5. Suturing materials. [Same as LE Q.3]
SHORT ESSAYS:
1 . Indications of bone grafts in maxillofacial surgery.
2. Magnetic resonance imaging.
3. Cephalometry. [Ref LE Q.1]
4. Indications and techniques of needle biopsy.
5. Exfoliative cytology.
6. Needles used in suturing.
7. Define biopsy and name the various biopsy techniques. [Same as SE Q.4]
SHORT NOTES:
1 . Incisional biopsy.
2. Name few skin grafts.
3. Name the structures seen in IOPA (intraoral periapical X-ray).
4. Risdon’s incision.
5. What is the difference between ‘square knot’ and ‘surgeon’s knot’?
6. Catgut suture.
7. Name few indications of bone grafts.
8. Mention two LASER applications in oral surgery.
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Cephalometry used in oral surgery. Salzman (1964) has proved that cephalometrics can pro-
vide valuable information from both clinical and research
Ans.
bases by the following:
● Establishing two-dimensional relationships of craniofa-
[SE Q.3] cial components.
● {Clinical
assessment, dental model evaluation and ● Classifying skeletal and dental abnormalities with re-
cephalometric analysis must be used to establish an ac- spect to cranial base, skeletal pattern, interarch and
curate diagnosis of a dentofacial deformity. intra-arch dental relationships and soft tissue profile.
● Cephalometric analysis of the lateral radiograph is a ● Analysing growth and development responsible for den-
two-dimensional diagnostic aid. tofacial pattern, either for configuration of cranial base,
congenital abnormalities, pathologic conditions or Down’s, Steiner’s, Tweed’s, Jarabak’s, Ricketts and
facial asymmetry. so many others.
● For orthodontic treatment planning and/or treatment ● The proposed ‘10’ measurement analysis for orthog-
planning of surgical procedures. nathic surgery will give a quick assessment as the
● Analysing changes after treatment and effectiveness of points and measurements are also simple to locate,
different treatment modalities. identify and trace.
● Determining dentofacial growth changes following ● When the measurements are colour enhanced by
treatment. using different colour pens and pencils, it can also be

● Predicting hard and soft tissue contours before initiation easily understood by patients.
of treatment.
● Diagnostic cephalometric radiographs should be taken, Q.2. Describe uses of lasers in maxillofacial surgery.
after patient is placed in cephalometer with head ad-
Ans.
justed in natural head position, and sagittal plane of the
patient’s head should be parallel with film. ● The word LASER stands for ‘light amplification by
● Lips should be in repose and teeth should be placed in stimulated emission of radiation’.
centric occlusion. Soft tissues must be reproduced on ● Lasers deliver energy in the form of light, which can be
the cephalometric film without sacrificing details of os- either continuous or intermittent.
seous structures.} ● Lasers are very specific in regard to the wavelength
PA cephalometric analysis produced. No measurable effect is seen beyond the in-

● Posteroanterior (PA) cephalometric analysis is tended target site.
mainly used for assessing asymmetry of the facial ● The different types of lasers are the carbon dioxide la-
skeleton. ser, the Nd:YAG (neodymium or yttrium–aluminium–

● First, a vertical line is drawn joining the midline of garnet) laser and the argon laser. Each one works in a
the nose and the chin and the dental arch–midsagittal different manner and may be used for different treat-
line. ment options.
● On either side of midsagittal line, a second vertical Uses of lasers in maxillofacial surgery
line is drawn passing through the zygomatic arch. ● The therapeutic lasers offer improved possibilities in
● A third vertical line is drawn passing through the the treatment planning of wound healing, inflamma-
angle of the mandible on either side of midsagittal tion and oedema.
line. ● Patients undergoing radiotherapy and/or chemora-
● These lines will help to evaluate deviation, asymme- diotherapy suffer gravely from the mucositis induced
try or disproportion of facial skeleton, and compari- by the therapy. Nutrition is troublesome and therapy
son can be made with the normal side measurements. regimen may have to be suboptimal for this reason.
● Horizontal lines are drawn along zygomatic plane, ● Laser therapy can be even used to reduce mucositis
occlusal plane, infraorbital plane, plane of the lower by mucosal irradiation prior to radiotherapy/chemo-
border of the mandible and so on, to assess deviation therapy.
in relation to horizontal plane. ● Pain is the most frequent complaint among pa-
‘Quick Ceph’ dentofacial planner for orthognathic tients. Laser therapy can reduce or eliminate pain
surgery of various origins.
● Cephalometrics is still imperfectly understood as a ● Following surgery postoperatively, discomfort can be
clinical tool. substantially reduced by irradiating the operated area

● Since proper pretreatment assessment can mean the before anaesthesia wears off.
difference between successful and unsuccessful ● Laser therapy has been used to eliminate or reduce
treatments. paraesthesia that may occur as a result of the surgery,

● This ‘Quick Ceph’ measurement analysis will give particularly in the mandibular region. Any such com-
the most valuable diagnostic, treatment and follow- plications can be reduced or eliminated by laser
up information in a matter of minutes for evaluating therapy.
an orthognathic case. ● Many cases of sinusitis are ‘dental origin’. A great
● The entire generation of orthognathic, oral and max- number of patients arrive in the dental office with
illofacial surgeons and plastic surgeons have been sinusitis of a viral or a bacterial background. In most
fed on a surplus of cephalometrics, right from its in- cases, laser therapy will lead to a fast reduction of the
vention by Broadbent. symptoms making the scheduled treatment easier.
● Many a times, a clinically useful information may be ● For Temporomandibular joint (TMJ) arthritic cases,
hidden in a maze of cephalometric analysis like the treatment is concentrated to the joint area’; and in
myogenic cases, the muscular insertions and trigger ii. Synthetic, e.g. polyglycolic acid
points are treated. In such cases, laser therapy should iii. Metallic, e.g. stainless steel
be used always in combination with conventional Both absorbable and nonabsorbable materials may
treatment to improve the outcome of the treatment. be derived from natural or synthetic sources

● The patients suffering from Meniere disease (tinnitus/ C. Based on the number of filaments in the suture
vertigo) have a significantly increased prevalence of material
problems in the masticatory, neck and trapezius i. Monofilament
muscles; in addition, problems in the cervical spine, ii. Multifilament
particularly in the transverse processes of the atlas iii. Pseudomonofilament
and the axis.
i. Monofilament suture materials

● Laser therapy can be successfully used to promote
● These materials are made of a single strand.
muscular relaxation and pain relief in these cases.
● They have the advantage of least capillary ef-

● Relaxation of the tension in these muscles as well as
fect, thereby they do not absorb tissue fluids
occlusal stabilization procedures will reduce or elim-
and thus do not swell. This decreases the
inate the symptoms of tinnitus and vertigo in this
chances of infection.
group of patients.
Example: Absorbable: Monocryl

● It can also be used in periodontal surgical procedures
Nonabsorbable: Polyamide, polyester, etc.
like recontouring or reshaping gums, removing the
Disadvantages
bacteria in periodontal pockets to promote healing,
● Main disadvantage of this material is its ‘mem-
to excise tumours, to help prevent blood loss by seal-
ory effect’ due to which the material tends to
ing small blood vessels and to treat some skin condi-
come back to its original position. This prop-
tions like removal or improve warts, moles, tattoos,
erty tends to loosen the knot. Multiple throws
birthmarks, scars and wrinkles.
may be required to stabilize the knot.
Q.3. Explain suturing material for a facial wound and ii. Multifilament suture materials
methods of suturing. l These materials are made of multiple thin strands
of the suture material which are either rolled,

Ans.
twisted or braided together to form a uniform
Suture materials are classified as follows: strand of thread.
A. Based on the degradation of the material within the ● These materials are usually easier to handle and
tissues have good knot tying properties.

i. Absorbable ● The knot once placed usually does not slip.
ii. Nonabsorbable ● They are preferred for use in those areas where
good strength is required to hold the wound

i. Absorbable suture materials
edges together.
Examples: Catgut, polyglycolic acid (dexon) and so on
● As the materials are multifilamentous, they have
● Lose their strength within the tissues and usu-
more capillary action, whereby tissue fluids and
ally degrade within 60 days. This usually coin-
inflammatory exudates seep through these mul-
cides with the approximate time taken for
tiple filaments harbouring more microorganisms
complete wound maturation.
and forming a source of infection.
● They undergo enzymatic degradation by natu-
Example: Black braided silk.
ral enzymes present within the body.
iii. Pseudomonofilament suture materials
Uses
● These materials are microscopically made of
● Deeper layer suturing and suturing of wounds
numerous strands of fibre which have been pro-
in patients, who are unable to come for suture
cessed by twisting, grinding and finally polish-
removal.
ing, to give them a monofilamentous appearance.
ii. Nonabsorbable suture materials
Example: Catgut.
Examples: Silk, nylon, etc.
● These materials are usually not degraded by Sizes of suture materials
the body ● Based on the diameter of the thread in cross-section,
● Suture removal is required at the end of suture materials are labelled from 1-0 to 10-0.
the healing phase, i.e. usually between 5 and ● With an increase in the number of zeros, the diameter of
7 days the material reduces. Therefore, the diameter of an 8-0
B. Based on the source of the materials material is less than the diameter of a 3-0 material.
i. Natural, e.g. silk ● 10-0: Is generally used for microsurgery repair.
● 5-0, 6-0: Is used for suturing of skin on the face. ● If one of the sutures gets loose, it does not affect
● 4-0, 5-0: Is used for suturing in the extremities. the remaining sutures. It can be replaced sepa-
● 3-0: Is used in scalp sutures. rately.
● 3-0, 4-0: Is most commonly used in most oral surgical ● In case of oedema or haematoma after a surgical
procedures. procedure, if the tension on the wound edges is

too much, one or two sutures may be removed
Techniques of suturing without disturbing the other sutures.
i. Simple interrupted sutures Disadvantage of interrupted sutures
● This is the most common and universally used type ● Time-consuming
of suturing technique. ii. Continuous sutures

Indications This type of suture may be of two types:
● Closure of oral mucosal incisions/lacerations. a. Continuous sutures without locking
● Closure of skin wounds. b. Continuous sutures with locking (blanket stitch)
Technique
● The needle is held at two-third the distance from a. Continuous sutures without locking
the tip of the needle with a needle holder and Indications
passed through one side of the flap perpendicular ● Where large wounds require to be sutured
to the tissues and brought out along the curvature ● Intraorally when full quadrant alveoloplasty is
of the needle. done

● It is then passed through the other flap at the same Technique
distance from the edge of the flap and also at the ● First, suture should be placed like an inter-
same depth. rupted suture. But, while cutting the suture

● It is brought out of the flap along with the suture ends, only the free ends are cut leaving the
material, till about 3–4 cm of the free end of the suture material with the needle behind.
suture material is left. ● The needle is then passed through the flaps of
● The needle end of the material is kept longer than the wound alternately to get continuous
the free end. oblique sutures all along the length of the
● The needle is held in the left hand and wound wound.
around the needle holder once or twice depending ● At the end of the wound, the knot is placed.
on the type of knot. Advantages

● The free end of the suture material is grasped with ● Even distribution of tension along the wound
the beaks of the needle holder. margin.

● The material that is wound around the needle ● Enables water-tight closure of the wound.
holder is made to slip over the beaks by slowly ● It is a much faster technique than interrupted
pulling on the needle end of the suture material. sutures.

● The free end of the suture material is pulled mini- Disadvantages
mally as it will result in wastage of the suture ● If one suture gets loose, all the other sutures
material. also get loose.

● The knot is stabilized such that it comes to one ● It is not possible to remove individual sutures
side of the flap. It should not rest along the edges as in case of oedema/haematoma release.
of the wound. b. Continuous sutures with locking
● To complete the knot, the needle is held in the left Indications
hand and the suture material is rolled around the ● In case of large wounds to be sutured
beaks of the needle holder in the opposite direc- ● In case of full quadrant alveoloplasty
tion. Again, the free end of the suture material is Technique

grasped and the suture material is glided over this ● First, a simple interrupted suture is placed.
free end to stabilize the knot. This may be done Then similar to the suturing technique de-
one more time to get a stable knot. scribed above, it is passed through both the
● Both the free end and the needle end of the suture flaps. The needle is then passed through the
material are held tight, so that the assistant trims loop made by the suture material.
it with a scissors leaving about 3–4 mm. ● The assistant is made to follow the suture by
Advantages of interrupted sutures holding the suture material close to the tis-
● Allows equal distribution of tension along the sues where the needle last passed through the
wound. loop.
● Each time the needle is made to pass through ● It is then passed through the first flap at the
the flaps and under the suture loop, the assistant same vertical level as the last bite.
should hold the suture material tightly close to ● In this way, the needle comes back through
the tissues to prevent the suture material from the same flap where it started at a distance of
slipping and becoming loose. 3–4 mm from the entry point.
● At the end of the suture line, the knot is made ● The knot is placed and stabilized on that side.
with the suture loop and the needle end of the Disadvantages
suture material. ● Since it runs parallel to the flap edges, it is
Advantages likely to compromise the blood supply of the

● Even distribution of tension along wound wound edges.
margins. ● Be careful not to tighten the knot too much or
● Good water-tight closure, especially for intra- there may be necrosis of the wound edges.
oral wounds. Advantages
Disadvantages ● It causes eversion of the wound edges and it al-
● Cumbersome technique lows more amount of raw tissue to be in contact.

● Requires assistance ● It causes even distribution of tension along the
● Not possible to remove individual sutures wound.

iii. Mattress sutures b. Vertical mattress suture
● This type of suturing technique provides wound Indications
edge eversion. It is observed that wounds tend to ● Used for the closure of skin wounds
contract as they heal, so the edges are everted during ● In those areas where the skin edges tend to in-
closure, and they approximate with less prominent vert

scarring. Technique
● These are of two types: ● It is used by the ‘far–far, near–near’ system,
a. Horizontal mattress where the needle is first passed far away from
b. Vertical mattress the wound edges and then nearer or at a more
Indications superficial level.
● In wounds, where wound eversion is desirable ● The needle is passed through one wound edge
during closure taking a deep bite of tissue almost 4–8 mm from

● Wounds on the abdomen, hip and sometimes the wound edge. This type of suturing requires
neck incisions that the wound edges are well undermined
● Where wounds are under tension and need to prior to suturing.
be brought together over a distance ● It is then passed through to the other edge at
● Closure in those areas where the wound edges the same depth and brought out. A knot is not
tend to roll inwards placed as yet.
a. Horizontal mattress sutures ● The needle is then turned around and passed
Indications backward through the second flap at a level
● Used specifically in those areas, where there more superficial, i.e. closer to the wound edges
is an underlying bony defect or a deficiency (1–2 mm away).
Examples: ● The needle is then passed through the first flap
● Closure of oroantral fistula at the same superficial level and brought out. In
● Closure of mucosa over a cystic cavity after this way, both edges’ suture materials are on
enucleation the same side.
● Used for closure over an extraction wound ● The knot is then placed and stabilized on the
● Closure of scalp wound side where the suturing first began.

Technique Advantages
● The needle is first passed through one flap and ● It causes good eversion of the wound margins
then at the same vertical level through the other bringing greater amount of raw tissue surface
flap similar to the placing of an interrupted su- into approximation.
ture, but the knot is not placed. The needle is then ● Since, it runs vertical to the blood supply of the
passed at a distance 3–4 mm parallel horizontally wound edges, suturing in this manner is not
to where the needle was passed through the likely to compromise the vascularity of the
second flap. wound edges.
Q.4. Suture techniques used in oral surgery. ● For magnetic resonance imaging (MRI), the patient is
placed in a machine which is basically a large magnet,
Ans.
the protons then act as small bar magnets and point up
[Same as LE Q.3] or down with a slightly greater number pointing up.
● Across the magnetic field, when a radiofrequency pulse is
Q.5. Suturing materials.
directed, the protons flip and align themselves along it. When
Ans. the pulse ceases, the protons relax and they realign them-
selves along the main magnetic field, thus emitting a signal.
[Same as LE Q.3]
● The hydrogen atom is commonly used as it is abun-
dantly found in the body.

● The values known as Tl and T2 are used to measure the
SHORT ESSAYS: time taken for these protons to relax.
Q.1. Indications of bone grafts in maxillofacial surgery. ● A variety of pulse sequences can be used to give differ-
ent information about the tissues.

Ans.
● MRI gives very accurate soft tissue details.
Autografts and processed homografts have been used ● It is not very useful to study bony details, as the protons
extensively in oral surgery. are held firmly within the bone.

Indications of bone grafts in maxillofacial surgery ● Bone outline is clearly visible. Imaging of TMJ and
i. To fill the defective bony cavities following the facial soft tissues can best be done with an MRI.
enucleation of large cysts of the jaws, where the General uses of MRI in maxillofacial region
bony cavities are unable to heal by regeneration. ● It is used when more clarity is required for soft tissue
Autogenous and inorganic bone grafts are used. lesions.

ii. Similarly, alveolar bone grafting in alveolar clefts is ● It is useful in case of internal derangement of TMJ,
also widely practiced. where the position of the disc and condyle can be
iii. In preprosthetic procedures, to obtain an absolute visualized in open mouth and close mouth position.
increase in the height of the alveolar ridge. ● Intracranial lesions can be seen clearly.
iv. To treat nonunited fractures, the bone ends are fresh-

Q.3. Cephalometry.
ened. In the process, the consequent bony deficiency is
filled by placing the bone graft, so that it will restore Ans.
the continuity of bone and will hasten the bony union.
[Ref LE Q.1]
v. In cases of neoplasms, resection of the pathology
results in a defect. Bone graft is utilized to replace Q.4. Indications and techniques of needle biopsy.
the excised segments of bone, thereby restoring the
Ans.
continuity of the jaw bone.
vi. In osteotomy procedures, to correct the jaw deformi- ● Biopsy can be defined as a diagnostic procedure which
ties, e.g. hypoplasia, the interfragmentary gap can be is done by removing a sample of tissue from patient.
bridged by the bone graft. Various types of biopsy
vii. In reconstructive surgery of the facial bony defor- i. Aspiration biopsy
mities, the bone grafts can be used as onlay ii. Cone biopsy
grafts to recontour the bone. Another example is iii. Core needle biopsy
reconstruction of the floor of the orbit in blowout iv. Endoscopic method of biopsy
fractures. v. Suction-assisted core biopsy
viii. In case of ankylosis of the temporomandibular joint, vi. Punch biopsy
surgery is performed to release the ankylosis and the vii. Surface biopsy
joint can be reconstructed by providing a costochon- viii. Excisional biopsy
dral graft to serve as a condyle. Indications
The success of bone grafting depend on ● For assessment of any unexplained oral mucosal
● Choice of the graft abnormalities that persist despite treatment or the

● Infection removal of local irritants.
● Recipient site ● Lesions that interfere with oral function such as
● Contact between the graft and recipient bone ends fibrous hyperplasia and osseous lumps.
● Lesions of unclear aetiology, particularly when
Q.2. Magnetic resonance imaging.
associated with pain, paraesthesia or anaesthesia.
Ans. ● Radiolucent or radiopaque osseous lesions.
Technique diagnosis. The cells display wider atypia that may

● First, the site from where the biopsy sample is to be suggestive of cancer, but are not clear-cut and
be collected should be cleansed and then anesthe- may represent precancerous lesion or carcinoma in
tized with local anaesthesia. situ. Biopsy is recommended.
● The needle is passed into the region of abnormal- iv. Class IV (suggestive of cancer): A few cells with
ity, e.g. a cyst or a tumour and a vacuum is created malignant characteristic. Biopsy is mandatory.
with the syringe and multiple in and out needle v. Class V (positive for cancer): Cells that are obvi-
motions are performed. ously malignant. Biopsy is mandatory.
● The cells to be sampled are sucked into the sy-
Q.6. Needles used in suturing.
ringe through the fine needle. Usually three or
four samples are collected. Ans.
● Prior to microscopic examination, the sample of Suturing needles are made of either stainless steel or
fluid and cells is centrifuged at high speed and carbon steel.
then a small amount is placed on a slide and cov- Classification of suturing needles
ered with a plastic slip. i. Based on design
● A smear is prepared by spreading samples of fluid ● Straight
and cells onto glass slides. The specimens are ● Curved
then fixed and stained to improve viewing. ii. Based on cross section
● The preservation is often performed by heating ● Round body (tapering)
the slide with a Bunsen burner. ● Cutting edge: Conventional cutting or reverse cutting
Q.5. Exfoliative cytology. iii. Based on how material connects to needle

● Eyed needle
Ans.
● Swaged needle
● Exfoliative cytology is the study of cells which exfoliate i. Based on the needle design
or abrade from the body surfaces. Straight needles
● Exfoliative cytology is used for the diagnosis of the oral ● These can be either round bodied (tapered) or
mucosal lesion. cutting needles.

Technique Uses
● Clean the surface of the oral lesion of debris and ● Used for suturing in the abdominal region.
mucin, and then vigorously scraping the entire sur- ● In the maxillofacial region, its use is limited.
face of the lesion several times with a metal cement ● In the absence of an awl, it may be used for cir-
spatula, a moistened tongue blade or a cytobrush. cummandibular wiring.

● The collected material is then quickly spread evenly ● It can also be used for placing a cheek stitch for
over a microscopic slide and fixed immediately be- the stabilization of a cheek retractor for intraoral
fore the smear dries. surgical procedures.
● The fixative may be either commercial preparations Curved needles
such as Spray-cyte, 95% alcohol or equal parts of ● Most commonly used in the maxillofacial region.
alcohol and ether. ● These can further be classified based on the cur-
● After the slide is flooded with fixative, it should be vature into one-fourth circle, three-fourth circle,
allowed to stand for 30 min to air-dry. three-eighth circle and one-half circle (most
● Slides are never flame-fixed as bacteriologic smears. commonly used in oral surgery).
● It is essential that the procedure is repeated and a Use
second smear be prepared for submission to the ● This type of needle may be used for suturing
cytologist. extraoral incisions on the skin and intraoral mu-

● In preparing duplicate slide, separate scraping should cosal incisions/lacerations.
be done. ii. Based on the cross section
The report by the cytologists will fall in following five Round bodied needle
classes: ● The cross section of this type of needle is round.
i. Class I (normal): Indicates that only normal cells It slowly tapers to a point and so it is called a
were observed. tapered needle.
ii. Class II (atypical): Indicates the presence of minor Use
atypia, but no evidence of malignant changes. ● A round body needle is generally preferred for the
iii. Class III (indeterminate): This is an in-between closure of all intraoral mucosal wounds as it is
cytology that separate cancer from noncancer gentle on thin and fragile mucosal tissues.
● It is also used for the suturing of fascia and muscle, Disadvantage

which may tear through if a cutting needle is used. ● Needle and material to be discarded after each use.
Disadvantage
Q.7. Define biopsy and name the various biopsy tech-
● Due to its design, it is more difficult to use.
niques.
Cutting needle
● In cross section, this type of needle has a triangu- Ans.
lar body.
[Same as SE Q.4]
● Based on the position of the apex of the triangle,
it is further classified into:

● Conventional cutting needle SHORT NOTES:
● Reverse cutting needle
Q.1. Incisional biopsy.
Conventional cutting needle
● This type of needle has the apex facing towards Ans.
the inner aspect of the curvature of the needle. ● Some lesions are too large to excise initially without
Disadvantage having established a diagnosis, or are of such a nature
● It may cut through if used on fragile tissue such as
that excision would be inadvisable. In such instance, a
mucosa. small piece is removed for examination. This is termed
Reverse cutting needle as an incisional or diagnostic biopsy.
● In this type of needle, the apex is towards the
● It is most useful in dealing with large lesions in which
outer aspect of the curvature with the inner part of the operator suspects may be treated by some methods
the needle being flat. other than surgery once the diagnosis is made, or the
Uses diagnosis will determine whether the treatment should
● It is used in the suturing of skin wounds and in
be conservative or radical.
subcuticular suturing. ● The biopsy should include surrounding normal tissue
iii. Based on how the suture material connects to the with adequate depth of underlying connective tissue.
needle
● Eyed needle Q.2. Name few skin grafts.
● Swaged needle
Ans.
Eyed needle
● It is also called as traumatic needle. It has a hole Following are the skin grafts used for various recon-
or eye which may be round, oval or square at the structions:
broader end of the needle. ● Deltopectoral flap: Used for reconstruction of full thick-
● The suture material is threaded into this hole of ness cheek defect.
the needle. Such needles can be sterilized and re- ● Sternomastoid myocutaneous flap for face reconstruction.
used a few times till they lose their sharpness. ● Temporal flap: Used in reconstruction of full thickness
They are thus a cheaper alternative. cheek defects.

Disadvantages Q.3. Name the structures seen in IOPA (intraoral peri-
● Multiple uses make it blunt and traumatic to the apical X-ray).
tissues. Ans.
● Chances of infection, if not adequately sterilized.
● Traumatic entry through the tissues as two strands The structures seen in an IOPA (intraoral periapical
of thread have to go through it. radiograph) are:
● Chances of slipping out of the thread from the ● The tooth
needle during suturing. ● The periapical structures
Swaged needle ● Lamina dura
● It is also called atraumatic needle. ● The alveolar bone surrounding the tooth
● It is available in ready-made sterile packs, where ● Inferior dental canal
the manufacturer attaches the suture material into ● Maxillary antrum outline in relation to upper molars
the hollow of the needle body. This type of needle ● Outline of nasal cavity
has no eye. Q.4. Risdon’s incision.

Advantages
Ans.
● Atraumatic.
● Sterile needle for each procedure. ● The incision is taken about 1 cm below the angle of the
● Single-use sharp needle for each procedure. mandible.
● It extends forward, parallel to the lower border of the ● It is commercially supplied as a package soaked in iso-
mandible and curves backward slightly behind the propyl alcohol, which acts as a preservative.
angle. ● Resorption is by enzymatic degradation by proteolytic
● Approach to neck of condyle and ramus is achieved by enzymes and phagocytosis.

sharply incising through the pterygomasseteric sling ● When placed inside the tissues, it loses most of its
and reflecting the masseter muscle laterally, to expose tensile strength within 10–15 days and is resorbed by
the neck of the condyle and sigmoid notch. 2–3 months.
Disadvantage ● Disadvantages of plain surgical gut suture are
● Poor access to the condylar head region. l It is allowed to dry during suturing, it becomes stiff
and it is difficult to handle.

Q.5. What is the difference between ‘square knot’ and
l Since it is degraded by enzymatic action, there is an
‘surgeon’s knot’?
intense inflammatory reaction during this process.
Ans. l It also allows more bacterial adhesion when com-
pared to nylon or polypropylene.

Square knot
l It has poor tensile strength and rapidly loses strength
● After the needle is passed through both wound
when placed in the tissues.
edges, the needle end is held in the left hand and
rotated around the beaks of the needle holder one Q.7. Name few indications of bone grafts.
time (clockwise direction), and the free end of the
Ans.
suture material is held and the knot stabilized on the
tissues. Autografts and processed homografts have been used
● The suture material is then rotated around the needle extensively in oral surgery.
holder once in the opposite direction (anticlockwise Indications
direction) and then tightened. ● To fill the defective bony cavities following the enu-
● A third tie is also recommended in the same direction cleation of large cysts of the jaws, where the bony
as the first tie and then stabilized. This ensures com- cavities are unable to heal by regeneration. In such
plete stability of the knot. cases, autogenous and inorganic bone grafts are
Surgeon’s knot used.
● The suture material is rotated around the needle ● Similarly, alveolar bone grafting in alveolar clefts is
holder two times in a single direction (clockwise) also widely practiced.

and the knot is placed. ● To obtain an absolute increase in the height of the
● For the second tie, the suture material is rotated in alveolar ridge as a preprosthetic procedure.
the opposite direction (anticlockwise) and then stabi-
Q.8. Mention two LASER applications in oral surgery.
lized.
Advantage Ans.
● Since the first tie is more stable, it does not slip away
Applications of LASER in oral surgery
easily while placing the second tie.
i. Mucositis
Q.6. Catgut suture. Laser therapy can be used to reduce the postirradiation
mucositis.
Ans.
ii. Pain
● Catgut was the first absorbable suture material available. Pain of various origins can be reduced or eliminated
● It is derived from a natural source, which may be puri- with laser therapy.
fied connective tissue (mostly collagen) derived from iii. Paraesthesia
either serosal layer of cow’s intestine (bovine source) or Laser therapy eliminates or reduces complications of
submucosal fibrous layer of sheep intestines. paraesthesia following various surgical procedures.
Topic 3
Local Anaesthesia

LONG ESSAYS:
1 . Describe in detail about the extracranial course of trigeminal nerve.
2. Define local anaesthesia and classify it. What is the composition of local anaesthesia (LA) solution and describe
the function of each component? Discuss contraindications of local anaesthesia and explain the ideal require-
ment of LA. Explain the mode of action of LA.
3. Describe the complications of LA and its management.
4. Give boundaries of pterygomandibular space. Describe the technique of inferior alveolar nerve block and the
complications associated with it and briefly discuss the management of each.
5. What is trismus? Mention various conditions resulting in trismus with treatment of each in brief.
6. Complications due to LA solution. Classify and explain the same. [Same as LE Q.3]
SHORT ESSAYS:
1. Theories on the mechanism of local anaesthetic action.
2. Mechanism of action of local anaesthesia. [Ref LE Q.2]
3. Contents of local anaesthetic (LA) solutions and properties of LA. [Ref LE Q.2]
4. Define syncope and its management.
5. Electrophysiology of nerve conduction.
6. Local anaesthetic agent pharmacology.
7. Infraorbital nerve block.
8. Inferior alveolar nerve block. [Ref LE Q.4]
9. Posterior superior alveolar nerve block anaesthesia.
10. Gow-Gates technique.
11. Role of vasoconstrictor in local anaesthesia solution.
12. Local anaesthesia toxicity.
13. Lignocaine hydrochloride.
14. Discuss in brief the mode of action of local anaesthesia. [Same as SE Q.2]
15. Pharmacokinetics of local anaesthetics. [Same as SE Q.6]
16. Gow-Gates nerve block. [Same as SE Q.10]
17. Toxicity. [Same as SE Q.12]
SHORT NOTES:
1 . EMLA.
2. Ideal local anaesthetic drug.
3. Name the branches of the inferior alveolar nerve. [Ref LE Q.1]
4. Define nerve block.
5. Failure of local anaesthesia – causes.
6. Action of vasoconstrictors in local anaesthesia.
7. Intraligamentary anaesthesia.
8. Composition of local anaesthesia. [Ref LE Q.2]
9. Clinical applications of vasoconstrictor agents.
1 0. Give the order of anaesthetizing various nerves in direct pterygomandibular block technique.
11. Landmarks for extraoral maxillary nerve block.
12. Mental nerve block.
13. Complications of broken needle in the pterygomandibular space and their prevention.
14. Vazirani-Akinosi technique.
15. Specific receptor theory.
16. Define pain. Enumerate methods of pain control.
17. Haematoma. [Ref LE Q.3]
18. Anaphylaxis.
19. Contraindications for regional analgesia.
20. Reasons for failure of local anaesthesia. [Same as SN Q.5]
21. Adrenaline. [Same as SN Q.19]
22. Epinephrine. [Same as SN Q.9]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Describe in detail about the extracranial course of ● Sensory from the medial part of the upper and
trigeminal nerve. the lower eyelid, medial part of the forehead;
Ans. sensory from the conjunctiva of the upper eyelid.
ii. Supraorbital nerve
● The trigeminal nerve is the largest, mixed cranial nerve ● Sensory from the skin of the upper eyelid and
that contains both sensory and motor fibres. the skin of the forehead and scalp as back as the
● The trigeminal nerve is attached to the lateral part of the vertex of the skull; sensory from the lining of the
pons by its two roots, motor and sensory. The two roots frontal sinus.
enter the middle cranial fossa. iii. Lacrimal nerve
● Sensory branch from the skin of the upper eyelid
Divisions of the trigeminal nerve
A. Ophthalmic nerve V1 and lateral part of the eyebrow region and as well
● The ophthalmic nerve is the first division of the tri-
sensory branch from the conjunctiva of the lat-
geminal nerve and it is a sensory nerve. eral part of the upper eyelid.
● Among the three divisions, it is the smallest and it
iv. Nasociliary nerve
● Long ciliary branch
passes forward and enters the orbit through the supe-
● Sensory from the eyeball and ciliary ganglion.
rior orbital fissure.
● Infratrochlear
B. Maxillary nerve V2
● Supplies to the side of the nose; sensory from
● The maxillary nerve is the second division of the
trigeminal nerve and it is a sensory nerve. conjunctiva and lacrimal sac.

● Ethmoid branches
● It begins at the middle of the semilunar ganglion and
leaves the skull through the foramen rotundum. a. Anterior ethmoid branch – Sensory from the
C. Mandibular nerve V3 lining of the frontal sinus and of the anterior
● This is the largest among the three divisions of the
ethmoid cells.
trigeminal nerve. b. Posterior ethmoid branch – Sensory from the
● It consists of two roots:
lining of the posterior ethmoid cells and sphe-
a. Largest sensory root arises from the semilunar noid sinus.
● Internal branches
ganglion.
● Sensory from the anterior portion of the sep-
b. Smaller motor root passes beneath the ganglion to
unite the sensory root just after it emerges through tum and lateral walls of the nasal cavity.
● External nasal branch
the foramen ovale.
● Sensory from the tip of the nose.
● These three large nerves proceed from the convex
border of the semilunar ganglion. B. Maxillary division – Middle meningeal branch

A. Ophthalmic division ● In the cranial cavity, the maxillary division sends a
i. Supratrochlear nerve sensory branch to the dura.
● In the pterygopalatine fossa, this division gives off ● Sensory from the skin of the lower
two branches. eyelid
a. Zygomatic nerve and branches b. Lateral nasal branches
i. Zygomaticofacial branch ● Sensory from the skin of the lateral
● Sensory from the skin over the promi- side of the nose
nence of zygomatic bone c. Superior labial branches
ii. Zygomaticotemporal branch ● Sensory from the upper lip (skin)
● Sensory from the skin of the side of the C. Mandibular division

forehead and of the anterior part of the i. Nervus tentorii
temporal fossa region ● Sensory from the dural layer of the posterior
b. Sphenopalatine nerves (pterygopalatine) cranial fossa and from the lining of the mastoid
i. Orbital branches cells
● Sensory from the periosteum of the orbit ii. Buccal (long buccal) nerve
and from the lining of the sphenoid sinus ● Sensory from the mucosal layer and the skin of
and posterior ethmoid cells the cheek region; sensory from buccal gingivae
ii. Greater palatine branch (anterior palatine) of the mandibular molar region
● Sensory from the mucous membrane of iii. Auriculotemporal nerve
the major part of the hard palate and adja- ● Sensory from the skin over the areas supplied by
cent part of the soft palate the branches of the facial (VII) nerve, that is,
iii. Lesser palatine branches zygomatic, buccal and mandibular areas
● Sensory from the mucous membrane of ● Sensory from the parotid gland by means of the
the soft palate and tonsil area parotid branch

iv. Posterior lateral nasal branches ● Sensory from the temporomandibular articulation
● Sensory over the nasal conches ● Sensory from the skin lining the external audi-
v. Nasopalatine branches tory meatus and from the later surface of the
● Sensory from the mucous membrane layer tympanic membrane
of the lower and the posterior part of the ● Sensory from the skin and scalp over the upper
nasal septum and from the premaxillary part of the external ear and the side of the head
part of the hard palate up to the vertex of the skull
vi. Pharyngeal branch iv. Lingual nerve
● Sensory from the auditory tube ● Sensory from the mucosal layer covering the
c. Posterior superior alveolar nerve anterior two-thirds of the tongue; sensory from
i. Gingival branches the mucous membrane of the floor of the mouth
● Sensory from the buccal gingivae of the and of the lingual side of the mandibular gingi-
upper molar region and from the mucosal vae and sensory from the submandibular and
layer of part of the cheek. sublingual glands and their ducts
ii. Alveolar branches
● Sensory from the maxillary molars, ex-
cept the mesiobuccal root of maxillary {SN Q.3}

first molar and the mucous membrane of
v. Inferior alveolar nerve
the maxillary sinus
a. Dental branches: Sensory from all of the lower
iii. In the infraorbital canal region
molar and bicuspid (mandibular) teeth and
a. Middle superior alveolar nerve
their periodontal membranes
● Sensory from the maxillary bicuspids
b. Mental nerve: Sensory from the lower lip
and the mesiobuccal root of the first
(skin) and chin regions and from the mucous
molar; sensory from the lining of the
membrane lining the lower lip region
maxillary sinus.
c. Incisive nerve: Sensory from incisors, cuspid
b. Anterior superior alveolar nerve
teeth and their periodontal membranes
● Sensory from the maxillary incisors
and cuspids and from the lining of the

maxillary sinus.
iv. Terminal branches on the face (infraor- Q.2. Define local anaesthesia and classify it. What is
bital branches) the composition of local anaesthesia (LA) solution and
a. Inferior palpebral branches describe the function of each component? Discuss
contraindications of local anaesthesia and explain the ideal Chlorprocaine

requirement of LA. Explain the mode of action of LA. Tetracaine
Benzocaine
Ans.
C. Classification according to the biological site and
mode of action
[SE Q.3] i. Class A agents acting at the receptor site on the
{Local anaesthesia is defined as a loss of sensation in a external surface of nerve membrane.
circumscribed area of the body, caused by a depression of ii. Class B agents acting at receptor sites on the inter-
excitation in nerve endings or an inhibition of the conduc- nal surface of the nerve membrane.
tion process in peripheral nerves.} iii. Class C agents acting by a receptor-independent
physico-chemical mechanism.
(SE Q.3 and SN Q.8) iv. Class D agents acting by combination of receptor
{(Composition of LA and receptor-independent mechanisms.
i. 2% lidocaine hydrochloride – Local anaesthetic agent [SE Q.3]
ii. 1:80,000–1:100,000 – Vasoconstrictor prolongs the
action of local anaesthetic {Properties of an ideal anaesthetic
iii. Sodium metabisulphite – Oxidizing agent It has reversible action.
●
iv. Methyl paraben – Preservative It is nonirritating to the tissues and produces no sec-
●
v. Thymol – Antifungal ondary local reaction.

vi. Distilled water – Solvent)} ● It has a low degree of systemic toxicity.
● It has a rapid onset and is of sufficient duration to be

Classification of LA
advantageous.
A. Based on duration of action of LA
● It has potency sufficient to give complete anaes-
1. Injectable
thesia without the use of harmful concentrated
a. Low potency and short duration
solutions.
Procaine
● It has sufficient penetrating properties to be effective
Chlorprocaine
as a topical anaesthetic.
b. Intermediate potency and long duration
● It is relatively free from producing allergic reaction.
Lidocaine
● It is stable in solution and undergoes biotransforma-
Prilocaine
tion readily within the body.
c. High potency and long duration
● It is either sterile or is capable of being sterilized by
Tetracaine
heat without deterioration.}
Bupivacaine
Contraindications
Ropivacaine
Absolute contraindications to LA
Dibucaine
● Myocardial infarction within 6 months
2. Surface anaesthetics
● Recent hepatitis A or hepatitis B
a. Soluble compounds
● Jaundice
Cocaine
● Local infection or sepsis
Lidocaine
● Hypersensitivity to lidocaine
Tetracaine
Relative contraindications to LA
b. Insoluble compounds
● Chronic renal failure
Benzocaine
● Hyperthyroidism
Butylaminobenzoate
● Atypical plasma cholinesterase
Oxethazaine
● Pregnancy (during first trimester)
B. Based on amide- and ester-linked
● Hypertension
Amide-linked local anaesthetics
● Malignant hypothermia
Lidocaine
● Congenital methaemoglobinaemia
Prilocaine
Bupivacaine [SE Q.2]
Dibucaine
Ropivacaine {Mechanism of action of LA
Ester-linked local anaesthetics ● In producing a conduction block, the primary action of
Cocaine LA is to decrease the permeability of the ion channels
Procaine to sodium ions (Na1).
● Displacement of calcium ions from the sodium ● Berman’s locator to locate needles,
channel receptor site permits binding of the LA ● Surgical removal
molecule to this receptor site, and this produces ii. Persistent nerve paralysis
blockade of the sodium channel. ● Persistent anaesthesia beyond expectation or
● Local anaesthetic molecules may act by competitive altered sensation

antagonism with calcium for same site on the nerve ● Numbness, swelling, tingling and itching after
membrane. injection
● Decrease in sodium conductance leads to depression Causes
of the rate of electrical depolarization; and failure to ● Trauma to nerve, injection of LA containing
achieve the threshold potential level along with a alcohol or sterilizing solution leads to irrita-
lack of development of propagated action potentials tion, oedema and paraesthesia.
is known as conduction blockade. ● Trauma to the nerve sheath during injection,
● The nerve membrane remains in a polarized state, electric shock-like feeling.

because the membrane’s electrical potential remains ● Haemorrhage around nerve sheath, increasing
unchanged, local currents do not develop and the pressure.

self-perpetuating mechanism of impulse propagation ● Local anaesthetic solution itself may cause
is stalled. damage to the nerve.

● An impulse that arrives at a blocked nerve segment is Problems
stopped, because it is unable to release the energy ● Self-inflicted injuries, biting, thermal/chemi-
necessary for its continued propagation. cal insult, etc.

● Hence, nerve block produced by LA is called a non- ● In lingual nerve involvement and taste alteration
depolarizing nerve block.} ● Hyperaesthesia and dysaesthesia (painful
response)
Q.3. Describe the complications of LA and its man-
Management
agement.
● Resolve within 8 weeks or else can remain
Ans. permanent.
● Reassure patient and examine for degree and
Complications due to LA are classified as:
extent of paraesthesia.
A. Local complications
● Tincture of time is recommended medicine.
B. Systemic complications
● Consult a neurologist in persistent cases.
A. Local complications iii. Facial nerve paralysis
i. Needle breakage ● Paralysis of 7th nerve with loss of motor function
Needle breakage is rare nowadays because of the use of Causes
disposable needles. ● Injection of LA into capsule of parotid gland,
Causes during over insertion in inferior alveolar nerve
● Primary cause of needle breakage is weaken- block (IANB) or Vazirani technique.
ing of the dental needle by bending it before its ● Infraorbital nerve block or infiltration to max-
insertion into the patient’s mouth. illary canine.
● Sudden unexpected movement by the patient Features
as the needle penetrates muscle or contacts ● Usually transient with minimal or no sensory
periosteum can also lead to breakage of needle. loss.
● Smaller needles are more likely to break than ● Unable to use muscles of facial expression,
larger needles. face is lopsided and eye on affected side is
● Needles that have previously been bent are closed.
more likely to break than unbent needles. ● Protective lid reflex of eye with wrinkling and
● If a broken needle can be retrieved without blinking abolished.
surgical intervention, no emergency exists. Prevention
● A Magill intubation forceps or haemostat can be ● Strict adhering to protocol of IANB and Vazi-
used to grasp the visible proximal end of the nee- rani block
dle fragment and remove it from the soft tissue. ● Needle tip contact with bone in IANB
Management Management
● Carry calm attitude and inform the patient. ● Reassure the patient not to panic
● Removal of needle with Magill intubation for- ● Eye patch, artificial tears and so on
ceps or small haemostat, ● Follow-up of case
iv. Trismus ● Petroleum jelly to cover lesion and minimize

● Trismus occurs due to spasm of jaw muscles, irritation
which causes the normal opening of mouth
restricted. {SN Q.17}
Causes
● Trauma to blood vessels or muscles in infra-
vi. Haematoma
● Effusion of blood into extravascular spaces during
temporal fossa.
● Local anaesthetic with alcohol or cold steril-
injection of LA
● Tissue-density determining factor
ization solution diffuses into tissues, causing
irritation. Causes
● IANB or PSA block due to nicking of an
● Intramuscular or supramuscular injection has
mycotoxic properties. artery or vein

● Excessive volumes of LA in a restricted area
with distension of tissue, after multiple IANBs. ● Haematoma caused by IANBs are intraoral,
Problems while PSA are extraoral usually
● Chronic hypomobility with limitation of in- Problem
terincisal opening. ● Bruise, trismus, pain and inconvenience to
● Acute phase – Haemorrhage, pain and muscle patient
spasm. Prevention
● Haematoma with fibrosis and scar contracture. ● Proper knowledge of anatomy with minimum
Prevention trauma to tissue
● Sharp, sterile and disposable needle ● Minimal tissue insertion and using short nee-
● Aseptic, atraumatic with minimum effective dle for PSA block
volume of LA
● Avoid repeated and multiple insertion on nee-
dle while block {SN Q.17}

Management Management
● Analgesics: Aspirin 325 mg; muscle relaxants Immediate
and heat therapy, i.e. warm saline gargles. ● Direct pressure application not less than
● Codeine in rare cases: 30–60 mg/6 h. 2 min, stop bleeding
● Diazepam: 10 mg BD or benzodiazepines can Subsequent
be used. ● Ice application
● Physiotherapy: Opening and closing mouth ● Soreness and limitation of movement – no
exercises. heat application in the first 4–6 h, can be
● Ultrasound therapy: Antibiotics can be given. applied next day as it has analgesic and va-
● TMJ infection is rare. Vazirani-Akinosi block sodilating effect
in severe pain cases. ● With 12–14 days resolution occurs
v. Soft tissue injury ● No treatment during this period is advised
● Self-inflicted injury to lips and tongue
Cause
● Young children, mentally or physically disabled vii. Pain on injection
child and adult Causes
Problems ● Careless injection technique
● Swelling and significant pain ● Rapid deposition of solution, needle with
● Behavioural problem barbs

Prevention Problems
● Local anaesthetic of appropriate volume should ● Increased patient’s anxiety and unexpected
be used. movements
● Warn the patient and guardian about anaes- Prevention
thetic effect. ● Proper technique of injection with sharp nee-
Management dle use

Symptomatic ● Use topical LA
● Analgesic, antibiotic, lukewarm saline rinse, ● Using sterile LA with slow injection in tissues
etc. ● Temperature of solution to be corrected

viii. Burning on injection xi. Sloughing of tissue

Causes Causes
● pH of the solution deposited in soft tissues ● Epithelial desquamation – long topical LA
● Rapid injection of LA application

● Contamination of LA cartridge with sterilizing ● Sterile abscess due to prolonged ischaemia
solution Problem
● Solution warmed to body temperature ● Severe pain and infection rarely
Problems Prevention
● Usually transient indicates tissue irritation ● Topical anaesthesia is used as recommended
● Can lead to oedema, paraesthesia or possible (1–2 min)

trismus ● Not to use over-concentrated solution of vaso-
Prevention constrictor
● Slow rate of LA administration, 1 mL/min to Management
1.8 mL/min Symptomatic
● Alkaline LA solution with storage of solution ● For pain, analgesics like aspirin or codeine or
at room temperature topical ointment – Orabase to minimize irritation.

Management B. Systemic complications
● Symptomatic management of specific prob- i. On cardiovascular system
lems ● Local anaesthetic decreases electrical excitabil-
ix. Infection ity of the myocardium, conduction rate and force

Causes of contraction.
● Improper technique and poor handling ● All these factors together result in myocardial
● Contamination of needle before entering oral depression at a dose of 1.5–5 mcg/mL of lido-
cavity caine, has antiarrhythmic action.
Problem ● It can be used as a potent drug for ventricular tachy-
● Low-grade infection and trismus cardia, ventricular premature contractions and in

Prevention cardiac arrest caused by ventricular fibrillation.
● Proper handling and preparation of tissue ii. On blood vessels
before penetration ● Local anaesthetics cause vasodilatation of the
● Proper handle and care for needle and car- blood vessels except for cocaine, which pro-
tridge duces vasoconstriction.
Management ● It primarily produces hypotension at a level ap-
● Pain and dysfunction treated with heat and proaching overdose due to depression of the
analgesic or muscle relaxant or physiotherapy myocardium and smooth muscle relaxation of
● Trismus with antibiotics and analgesics the vessel wall.
x. Oedema ● At lethal levels it causes cardiovascular collapse.
● It is swelling of tissue – Not a syndrome but iii. On central nervous system
a sign. ● At low level there is no significant effect.
Causes ● Lidocaine causes CNS depression at toxic levels.
● Trauma, infection, haemorrhage, allergy, in- ● At 0.5–4 mcg/mL – anticonvulsive action.
jecting irritating solution, etc. ● Due to their depressant action on the CNS, local
Problems anaesthetics raise the seizure threshold by de-

● Pain, dysfunction and embarrassing to patient creasing the hyperexcitability of the cortical
● Angioneurotic oedema neurons site from where the convulsive episodes
Prevention originate.
● Atraumatic injection protocol ● At 4.5–7 mcg/mL – preseizure signs and symp-
Management toms occur.

● Reduction of swelling earliest with solution ● Preseizure signs and symptoms include slurred
of cause speech, shivering, tremor, warm flushed feeling of

● Allergy induced oedema with blockers and the skin, light headedness, dizziness, drowsiness,
consultation with physician visual disturbance, auditory disturbance, etc.
● Antibiotic therapy in infection-induced ● At .7.5 mcg/mL – convulsive action results and
oedema at this dose, lidocaine causes tonic-clonic seizure.

● Seizure continues as long as the drug is present ● When buccal or lingual soft tissue anaesthesia
in the blood. (anterior to first molar) is necessary
● The duration of presence of local anaesthesia in Contraindication
blood is further increased by the increased blood ● Infection or acute inflammation in the area of in-
flow to brain. jection (rare)

● Increased cerebral metabolism also leads to pro- ● Patients who has the habit of biting either the lip
gressive metabolic acidosis which prolongs the or the tongue, for instance, a very young child or a
seizure activity. physically or mentally handicapped adult or child
● Further increase in the dose causes CNS depres- Advantages
sion and respiratory arrest as a result of respira- ● One injection provides a wide area of anaesthesia,
tory depression. useful for quadrant dentistry.

iv. On respiratory system Disadvantages
● At nonoverdose levels, it has a relaxant effect on ● Not necessary for localized procedures.
bronchial smooth muscles. ● Among all intraoral injection techniques, positive
● Overdose leads to respiratory arrest as a conse- aspiration (10%–15%) is highest.

quence of respiratory centre depression (CNS ● Anaesthesia of lower lip and tongue is discom-
depression). fortable to many patients and possibly dangerous

for certain individuals.
Q.4. Give boundaries of pterygomandibular space. De-
Technique
scribe the technique of inferior alveolar nerve block and
● The patient should be positioned with the mouth
the complications associated with it and briefly discuss
open and the lower border of body of the mandi-
the management of each.
ble parallel to the floor.
Ans. ● The operator should stand to the right front side of
the patient and with the left index finger or thumb

Boundaries of pterygomandibular space
palpating the mucobuccal fold.
Anteriorly: Buccal space
● The finger is then moved posteriorly until contact
Posteriorly: Parotid gland with lateral pharyngeal space
is made with the external oblique ridge and the
Superiorly: Lateral pterygoid muscle
anterior border of the ramus of the mandible.
Inferiorly: Inferior border of mandible
● When the finger or thumb contacts the ramus of
Medially: Lateral surface of medial pterygoid muscle
the mandible, it is moved up and down until the
Laterally: Medial surface of ramus of the mandible
greatest depth of the anterior border of the ramus
is identified.
[SE Q.8]
● The palpating finger is moved lingually across the
{Inferior alveolar nerve block retromolar triangle and onto the oblique ridge.
Nerves anaesthetized ● Keeping the finger or thumb, still in line with the
● Inferior alveolar nerve and its subdivision coronoid notch and in contact with the internal
● Lingual (commonly) oblique ridge, it is moved to the buccal side, tak-
● Incisive nerve ing with it the buccal sucking pad.
● Mental nerve 5
● A syringe with a 1 /8-inch length and 25-gauge
● Buccinator nerves and branch of mandibular nerve needle is then inserted parallel to the occlusal
Areas anaesthetized plane of the mandibular teeth from the opposite
● Mandibular teeth upon one half of the mandible side of the mouth, at a level bisecting the finger or
(till midline) thumbnail, penetrating the tissue of the pterygo-
● Body of the mandible, lower or inferior portion temporal depression and entering the pterygo-
ramus of mandible mandibular space while the patient is asked to
● Buccal mucoperiosteum, mucous membrane ante- keep the mouth wide open.}
rior to the mandibular first molar Common complications associated with IANB
● Tongue (anterior two thirds) and floor of the oral i. Haematoma
cavity (lingual nerve) ii. Trismus
● Lingual soft tissues and periosteum (lingual iii. Transient facial paralysis
nerve) i. Haematoma
Indications ● Effusion of blood into extravascular spaces during
● All surgical procedures on multiple mandibular injection of LA
teeth in one quadrant ● Tissue-density determining factor
Causes Various conditions resulting in trismus are as follows:

● IANB or PSA block due to nicking of an artery or i. Infections
vein ● Odontogenic acute infections like pericoronitis,
● IANBs are intraoral, while PSA are extraoral usually Ludwig’s angina, submasseteric, infratemporal
Management abscess and so on.
Immediate ● Chronic infections can also cause trismus like
● Direct pressure application for not less than tuberculous osteomyelitis of ramus, body of man-
2 min, stops the bleeding dible and so on.
Subsequent ii. Trauma
● Ice application ● Fracture of zygomatic arch may impinge on the
● Soreness and limitation of movement – no heat coronoid process and restrict the oral opening.
application in the first 4–6 h, can be applied ● Fracture of mandible can cause trismus, because
next day as has analgesic and vasodialating of pain and tenderness or muscle spasm.
effect iii. Inflammation
● Within 12–14 days resolution occurs ● Myositis or muscular atrophy can bring about
● No treatment during this period is advised trismus.

ii. Trismus iv. Myositis ossificans
● Muscle soreness or limited movements ● Following trauma, a haematoma can be formed
Causes within the fibres of masticatory group of muscle,

● Trauma to blood vessels or muscles in infratem- especially masseter, which can progress into os-
poral fossa sification and muscle stiffness.
● LA with alcohol or cold sterilization solution dif- v. Tetany
fuses into tissue, causes irritation ● Typical carpopedal spasm along with trismus can
● Intramuscular or supramuscular injection has my- be seen.

cotoxic properties vi. Tetanus
● Excessive volumes of LA in a restricted area with ● Following acute infection such as Clostridium
distension of tissue, after multiple IANBs tetani, typical lockjaw symptoms can be seen due
Management to hypocalcaemia.
● Analgesics like aspirin 325 mg; muscle relaxants vii. Neurological disorder
and heat therapy, i.e. warm saline gargles ● Epilepsy, brain tumour, bulbar paralysis and em-
● Codeine in rare cases: 30–60 mg/6h bolic haemorrhage in medulla oblongata can
● Diazepam: 10 mg BD or benzodiazepines can be bring about trismus.
used viii. Psycosomatic trismus
● Physiotherapy: Opening and closing mouth exercises ● It is also known as trismus hystericus. It is due to
● Ultrasound therapy: Antibiotics can be given fear and anxiety associated with hysterical fits.
● TMJ infection is rare. Vazirani-Akinosi block in ix. Drug-induced trismus
severe pain cases ● Strychnine poisoning can bring about spasms
iii. Transient facial paralysis leading to trismus.

● Produced by deposition of local anaesthetic into the x. Mechanical blockade
body of the parotid gland ● Elongation, exostosis, osteoma and osteochon-
Sign and symptoms droma of coronoid process will cause mechanical

● Inability to close the lower eyelid and drooping of blockade and can interfere with mandibular
the upper lip on the affected side movements.
Management xi. Extra-articular fibrosis
● Reassure the patient not to panic ● Chronic cervicofacial sepsis, irradiation therapy,
● Eye patch, artificial tears, etc. ossification of sphenomandibular ligament, bands

● Follow-up of case of scars and burns of the face and neck region and
oral submucous fibrosis will lead towards pro-
Q.5. What is trismus? Mention various conditions regressive trismus.
sulting in trismus with treatment of each in brief. Management
● Analgesics like aspirin 325 mg; muscle relaxants and
Ans.
heat therapy, i.e. warm saline gargles.
● Muscle spasm resulting in defective mouth opening is ● Codeine in rare cases: 30–60 mg/6 h.
known as trismus. ● Diazepam: 10 mg BD or benzodiazepines can be used.

● Physiotherapy: Opening and closing mouth exer- ● The local anaesthetic receptor is located at or near
cises. the sodium channel in the nerve membrane, either
● Ultrasound therapy: Antibiotics can be given. on its external surface or on the internal axoplasmic
● TMJ infection is rare. Vazirani-Akinosi block in surface.
severe pain cases. ● Once the receptors access is gained, sodium ion
permeability is decreased or eliminated, and nerve

Q.6. Complications due to LA solution. Classify and
conduction interrupted.
explain the same.
Q.2. Mechanism of action of local anaesthesia.
Ans.
Ans.
[Same as LE Q.3]
[Ref LE Q.2]
SHORT ESSAYS: Q.3. Contents of local anaesthetic (LA) solutions and
properties of LA.
Q.1. Theories on the mechanism of local anaesthetic
action. Ans.
Ans. [Ref LE Q.2]
Theories for mode of action of local anaesthetics Q.4. Define syncope and its management.
i. Acetylcholine theory
Ans.
● Acetylcholine is involved in nerve conduction to-
gether with its role as a neurotransmitter at nerve ● A transient loss of consciousness due to cerebral isch-
synapses. aemia caused by a reduction in blood supply to the brain
● But, there is no evidence of involvement of acetyl- is known as vasovagal syncope.
choline in neural transmission along the body of the ● Vasodilatation causes slowing of the heart, which causes
neuron. a dramatic fall in blood pressure.

ii. Calcium displacement theory Signs and symptoms
● Displacement of calcium from certain membrane ● Nausea
sites that controls the permeability to sodium. ● Light-headedness
● Altering the concentration of calcium ions has no ● Pale grey appearance
effect on local anaesthetic policy. ● Thready, slow pulse
iii. Surface charge theory ● Hypotension
● Local anaesthetics bind to the nerve membrane and ● Confusion
change the electrical potential at its surface. ● Weakness
● LA molecules carrying net positive charge make the ● Sweating
electrical potential at the surface of nerve membrane Causes

more positive, thereby increasing the threshold ● Psychologic factor – pain or fear
potential. ● Postural changes
● Recent evidence shows that there is no alteration in ● Anoxia
the resting potential by local anaesthetic and they ● Carotid sinus syndrome
act within the nerve membrane channels rather than Pathophysiology of vasovagal syncope
at the surface. ● Anxiety causes increased release of catecholamines,
iv. Membrane expansion theory which cause decreased peripheral vascular resis-
● Local anaesthetic diffuses to hydrophobic regions tance, resulting in pooling of blood in the peripheries
and expands the membrane preventing the sodium and fall in arterial blood pressure.
permeability. ● Compensatory mechanisms come into play and
● Lipid-soluble molecules alter the lipoprotein matrix cause increased heart rate, rapid breathing, pallor and
of the nerve membrane and decrease the diameter of perspiration.
sodium channels. ● Decompensation soon occurs and eventually syn-
● There is no direct evidence to support this theory. cope.

v. Specific receptor hypothesis Dental consideration
● Specific receptor hypothesis is the most favoured Anxiety reduction protocol, adequate postoperative pain
theory. and anxiety control techniques are followed.
● Local anaesthetics act by attaching themselves to ● Premedicate the patient with hypnotics, for a re-
specific receptor in the nerve membrane. laxed sleep, the night before the surgery.
Premedicate the patient with sedatives on the day

● Step 2
of surgery. After these steps of depolarization, repolarization
● Schedule the surgery in the morning. occurs.
● Minimize the patient’s waiting time, i.e. reduce ● The electrical potential gradually becomes
the length of appointment. more negative inside the nerve cell relative to
● Consider psychosedation during surgery. outside until the original resting potential of
● Administer adequate pain control during surgery. 270 mV is again achieved.
● Avoid any anxiety during surgery using relaxing ● The entire process requires 1 ms, depolarization
background music. takes 0.3 ms and repolarization takes 0.7 ms

● Follow-up postoperative pain and anxiety control.
● Effective postoperative analgesics. Q.6. Local anaesthetic agent pharmacology.

● Telephone highly anxious or fearful patients on
Ans.
the same day the treatment was delivered.
Management Pharmacokinetics of local anaesthetics is as follows:
● Stop all the treatments, make the patient lie flat with Uptake
legs raised and place a cool towel on his/her forehead. ● When injected into soft tissues, the local anaesthetics
● Give supplemental oxygen. exert a pharmacological action on the blood vessels

● Monitor vital signs and check for breathing. in the area.
● Perform basic life support (BLS) if breathing is ● Almost all local anaesthetics possess a degree of va-
absent and summon for medical assistance. soactivity, producing dilation of the vascular bed into
● If breathing is present hold some ammonia salts which they are deposited. Although, the degree of
under the patient’s nose to revive consciousness. vasodilation may vary and some may produce vaso-
● Have the patient escorted home. constriction.
● Ester local anaesthetics are also potent vasodilating
Q.5. Electrophysiology of nerve conduction. drugs.

● Procaine is the most potent vasodilator used clini-
Ans.
cally for vasodilation when peripheral blood flow has
The electrical events that occur within a nerve during the been compromised because of (accidental) intra-
conduction of an impulse are: arterial (IA) injection of a drug (e.g. thiopental).
● A nerve possesses a resting potential. This is a nerve ● IA administration of an irritating drug such as thio-
electrical potential of 270 mV that exists across the pental may produce arteriospasm with an attendant
nerve membrane, produced by differing concentrations decrease in tissue perfusion, that if prolonged could
of ions on either side of the membrane. lead to tissue death, gangrene and loss of total limb.
● The interior of the nerve is negative relative to the ● In this situation, procaine is administered IA in an
exterior. attempt to break the arteriospasm and re-establish

Step 1 blood flow to the affected limb.
A stimulus excites the nerve, leading to the following ● Tetracaine, chloroprocaine and propoxycaine also
sequence of events: possess vasodilating properties to varying degrees,

● Initial phase includes slow depolarization of but not to the degree of procaine.
nerve. ● The only local anaesthetic consistently producing
● The electrical potential becomes slightly less vasoconstriction is cocaine.

negative within the nerve. ● Cocaine initially produces vasodilation, followed by
● When the falling electrical potential reaches a an intense and prolonged vasoconstriction.
critical level, and extremely rapid phase of ● It is produced by inhibition of the uptake of catechol-
depolarization results. amines (especially norepinephrine) into tissue bind-

● This is termed threshold potential or firing ing sites.
threshold. ● This results in an excess of free norepinephrine, lead-
● Across the nerve membrane, a reversal of the ing to a prolonged and intense state of vasoconstric-
electrical potential occurs in the phase of rapid tion.
depolarization. ● This inhibition of the reuptake of norepinephrine has
● The interior of the nerve is now electrically not been demonstrated with other local anaesthetics,
positive in relation to the exterior. e.g. lidocaine and bupivacaine.
● An electrical potential of 140 mV exists on ● The significant clinical effect of vasodilation is an in-
the interior of the nerve cell. crease in the rate of absorption of the local anaesthetic
into the blood, thus decreasing its duration and quality ● Patient position should be in such a way that his/
(e.g. depth) of pain control while increasing the con- her maxillary occlusal plane is at an angle of 45°
centration of anaesthetic in blood (or plasma) and the to the floor.
potential for overdose (toxic reaction). ● The target is determined by palpating the supraor-
● The rates at which local anaesthetics are absorbed bital and infraorbital notches.
into the bloodstream and reach their peak blood level ● A vertical imaginary line is drawn through these
vary according to their route of administration. landmarks which will pass through pupil of the
Distribution eye, infraorbital foramen, bicuspid teeth and men-
● In certain ‘target’ organs, the plasma concentration tal foramen.
of a local anaesthetic has a significant bearing on the ● After palpating the infraorbital margin, the finger
potential toxicity of the drug. is moved downwards from it where a concavity

● The following factors influence the blood levels of will be felt.
the local anaesthetic: ● This is the infraorbital depression and the infraor-
i. Rate of absorption of the drug into the cardiovas- bital foramen is in its deepest part.
cular system. ● Maintaining the thumb on this foramen extremely,
ii. Rate at which drug is distributed from the vascu- retract the lip using the index finger to expose the
lar compartment to the tissues (more rapid in mucobuccal fold.
healthy patients than in those who are medically i. Biscupid approach
compromised). ● In this approach, the needle is held parallel to the
iii. Elimination of the drug either through metabolic biscuspid teeth.

or excretory pathways in order to decrease the ● The puncture is made at a point about 5 mm
blood level of the local anaesthetic. from the mucobuccal fold which allows the
Metabolism needle to be advanced between the levator labii
● Metabolism (or biotransformation) of local anaes- superioris above, and the levator anguli oris
thetics is important as the entire toxicity of a drug below.
depends on a balance between its rate of absorption ● Maximum penetration of the needle should be
into the bloodstream at the site of injection and its about 2 cm; 1 mL of the solution should be depos-
rate of removal from the blood through the processes ited, and the overlying tissue gently massaged to
of tissue uptake and metabolism. aid penetration of the solution into canal.
Q.7. Infraorbital nerve block. ii. Central incisor approach
● In the central incisor approach, the needle is di-
Ans.
rected such that it bisects the crown of the central
Infraorbital nerve block is also known as anterior and incisors of the same side to the mesioincisal angle
middle superior alveolar nerve block. to the distoincisal angle.
Area anaesthetized ● The needle is inserted for about 5 mm from the
● Area supplied by the anterior superior alveolar nerve, mucobuccal fold and 1 mL of anaesthetic solution
middle superior alveolar nerve and inferior palpebral is deposited.
nerve.
The effectiveness of block is checked by subjective and
● Infraorbital nerve along with its branches, lateral
objective symptoms.
nasal and superior labial nerve are anaesthetized.
● Area of maxillary central incisor, canine teeth, pre- Q.8. Inferior alveolar nerve block.
molar and mesiobuccal root of maxillary first molar
on injected side; buccal periodontium, bone of the Ans.
same teeth and anaesthesia of lower eyelid along
[Ref LE Q.4]
with lateral aspect of nose and upper lip.
Landmarks Q.9. Posterior superior alveolar nerve block anaesthesia.
● Supraorbital notch
Ans.
● Infraorbital notch
● Pupil of eye Posterior superior alveolar nerve block

● Infraorbital foramen Nerve anaesthetized
● Mental foramen ● Posterior superior alveolar nerve
Procedure Area anaesthetized
Basically two techniques: Bicuspid approach and cen- ● The maxillary molars except the mesiobuccal root of
tral incisor approach. first molar

The buccal alveolar process of the maxillary molars,

● Nerves anaesthetized
including structures overlying it – periosteum, con- ● Inferior alveolar nerve, mental nerve, incisive nerve,
nective tissue and mucous membrane lingual nerve, mylohyoid nerve, auriculotemporal
Anatomical landmarks nerve and buccal nerve.
● Mucobuccal fold and its concavity Areas anaesthetized
● Zygomatic process of the maxilla ● Mandibular teeth of one side up to the midline.
● Infratemporal surface of the maxilla ● Body of the mandible and inferior portion ramus.
● Anterior border and coronoid process of the ramus of ● Buccal mucoperiosteum, mucous membrane anterior
the mandible to the mandibular first molar (mental nerve).

● Tuberosity of the maxilla ● Anterior two thirds of the tongue and floor of the
Technique for right side cavity (lingual nerve).

● The operator should stand on the right side of ● Lingual soft tissues and periosteum (lingual nerve).
the patient and the patient is positioned, so that the ● Skin over zygoma.
maxillary occlusal plane is at a 45° angle to the ● Posterior portion of cheek and temporal regions.
floor. ● Target area: Lateral region of condyle neck, just be-
● The operator should move the left forefinger over the low the insertion of lateral pterygoid muscle.
mucobuccal fold in a posterior direction from the Landmarks
bicuspid area until the zygomatic process of the max- Extraoral
illa is reached. Lower border of tragus of ear corresponds to the
● The fingertip will rest in a concavity in the mucobuc- centre of external auditory meatus and corner of the
cal fold at its posterior surface. patient’s mouth.
● At this particular point, the left forefinger should be Intraoral
rotated so that the fingernail is adjacent to the mu- Tip of the needle is placed just below mesiolingual
cosa and its bulbous portion is still in contact with cusp of maxillary second molar.
the posterior surface of the zygomatic process. Procedure
● Then the hand is lowered, keeping the bulbous por- ● Patient is positioned in supine posture with neck ex-
tion of the finger still in contact with the zygomatic tended and mouth wide open.
process, so that the finger is in a plane at right angles ● This position facilitates the injection by moving the
to the occlusal surfaces of the maxillary teeth, and at condyle anteriorly.

a 45° angle to the patient’s sagittal plane. ● Palpating the anterior border of the ramus of the
● The index finger should be pointing in the exact di- mandible and identify the tendon of temporalis mus-
rection the needle is to follow. cle, the needle is penetrated into tissues just distal to
● The insertion is made for a distance of about 1/2 to maxillary second molar tooth at the height of mesio-
3/4 inch, going upward, inward and backward. lingual cusp of second molar.
● After aspirating and making certain that the needle ● The needle should be inserted just medial to the tem-
point is not within a vessel, the operator slowly in- poral tendon and directed in the direction parallel to
jects the contents. an imaginary line drawn from the corner of the
● It will not include the mesiobuccal root of the first mouth to the intertragic notch of the ear and ad-
maxillary molar, which is innervated by branches of vanced until the fovea region of the condylar neck is
the middle superior alveolar nerve. contracted.
● This root and supporting tissues can be anaesthetized ● With negative aspiration, deposit 1.8 mL of solution
by infiltrating bucally, the involved root. over 60–90 s.

Symptoms of anaesthesia ● The patient is asked to keep the mouth wide open for
● Subjective symptoms – None. 20–30 s after the injection, to allow bathing of the
● Objective symptoms – Instrumentation is necessary nerve within the solution.
to demonstrate presence of pain sensation.
Q.11. Role of vasoconstrictor in local anaesthesia solu-
Q.10. Gow-Gates technique. tion.
Ans. Ans.
● Dr George Gow-Gates, a general practitioner of den- ● The drugs that constrict blood vessels and thereby con-
tistry in Australia in 1973, devised the technique. trol tissue perfusion are called vasoconstrictors.
● This technique has an advantage of higher success rate ● To oppose the vasodialatory actions of the local anaes-
than inferior alveolar nerve block. thetic solutions, they are added to them.
● Vasoconstrictors are important additions to a local an- Q.13. Lignocaine hydrochloride.

aesthetic solution for the following reasons:
Ans.
i. By constricting blood vessels, vasoconstrictors de-
crease blood flow (perfusion) to the site of adminis- Chemistry
tration. ● Lidocaine (diethylamino-2,6-dimethylacetanilide) is
ii. Absorption of the local anaesthetic into the cardio- the first nonester type of local anaesthetic compound
vascular system is slowed, resulting in lower anaes- to be used in dentistry.
thetic blood levels. ● It is a white crystalline power with a melting point of
iii. Local anaesthetic blood levels are lowered, thereby 69°C and is used as the hydrochloride salt.
minimizing the risk of local anaesthetic toxicity. ● The drug is compatible with all vasoconstrictors and
iv. Increased amounts of the local anaesthetic remain withstands boiling and autoclaving.
in and around the nerve for longer periods, thereby ● Lidocaine base is only slightly water-soluble, but the
increasing the duration of action of most local an- hydrochloride salt is readily soluble in water.
aesthetics. Pharmacology
v. Vasoconstrictors decrease bleeding at the site of ad- ● In dentistry, lidocaine is the first nonester compound
ministration; they are useful when increased bleed- to be used as a local anaesthetic.
ing is anticipated (e.g. during a surgical procedure). ● Lidocaine diffuses readily through interstitial tissues
vi. The vasoconstrictors are chemically identical or and into the lipid-rich nerve, giving a rapid onset of
similar to the sympathetic nervous system media- anaesthesia.
tors, epinephrine and norepinephrine. ● It has an onset time of about 2 to 3 min.
vii. The actions of the vasoconstrictors so resemble the ● Duration of action depends on the type of injection,
response of adrenergic nerve to stimulation that e.g. nerve block will have longer duration than infil-
they are classified as sympathomimetic or adrener- tration and the amount of vasoconstrictor included in
gic drugs. the solution.
Systemic effects
Q.12. Local anaesthesia toxicity.
i. Nervous system
Ans. ● Lidocaine, in toxic doses, first produces stimu-
lation then depression of the central nervous

● Signs and symptoms of minimal to moderate overdose
system.
levels of local anaesthetic toxicity are as follows:
● The patient at times becomes lethargic and sleepy
● Apprehension
from systemic absorption of the drug.
● Restlessness and nervousness
● Convulsions may be induced.
● Excitability and talkativeness
ii. Cardiovascular system
● Slurred speech
● The effect of lidocaine on the vasculature is
● Euphoria
vasodilatation produced by the direct relaxing
l Generalized stutter, leading to muscular twitching
effects on the smooth muscle of the vessel
and tremor in the face and distal extremities
walls.
● Dysarthria
● In toxic doses this action contributes to hypoten-
● Nystagmus
sion and cardiovascular collapse.
● Failure to follow commands or be reasoned with
iii. Respiratory system
● Elevated blood pressure and respiratory rate
● Small doses of lidocaine have a mild bronchodi-
● Light-headedness and dizziness
lating effect on the respiratory system.
● Vomiting
● Respiratory arrest (apnea) is one of the most
● Sensation of twitching before actual twitching is
common causes of death related to the overdose
observed
of a local anaesthetic.
● Metallic taste
● In the majority of cases respiratory arrest pre-
● Visual disturbances (inability to focus) and auditory
cedes cardiac arrest in toxic overdose.
disturbances (tinnitus)
Biotransformation
● Drowsiness and disorientation
● Lidocaine undergoes biotransformation in the
● Loss of consciousness
liver rather than hydrolysis in the plasma.
Moderate-to-high overdose levels causes the following: ● Lidocaine and its various breakdown products
Tonic-clonic seizures followed by: are excreted in the urine to some extent, with
● Generalized depression of central nervous system 4-hydroxy-2,6-dimethylaniline being the major
● Depressed blood pressure, heart rate and respiratory rate urinary metabolite.
Q.14. Discuss in brief the mode of action of local anaes- ● Nonirritating to the tissues and produce no secondary
thesia. local reaction.
● Consisting of a low degree of systemic toxicity.
Ans.
● Having a rapid onset and sufficient duration of action.
[Same as SE Q.2] ● Having potency sufficient to give complete anaesthesia
without the use of harmful concentrated solutions.

Q.15. Pharmacokinetics of local anaesthetics.
● Relatively free from producing allergic reactions.
Ans. ● Stable in solution and undergo biotransformation read-
ily within the body.

[Same as SE Q.6]
● Either sterile or should be capable of being sterilized by
Q.16. Gow-Gates nerve block. heat without deterioration.

Ans. Q.3. Name the branches of the inferior alveolar nerve.
Q.17. Toxicity. [Ref LE Q.1]
Ans.
Q.4. Define nerve block.
[Same as SE Q.12]
Ans.
The nerve block method of securing regional analgesia
SHORT NOTES: ●
consists of depositing a suitable local anaesthetic solu-

Q.1. EMLA. tion within close proximity to a main trunk, and thus
preventing afferent impulses from travelling centrally
Ans.
beyond that point.
● EMLA means eutectic mixture of local anaesthetics.
● The development of an oil-in-water emulsion contain- Q.5. Failure of local anaesthesia – causes.
ing high concentrations of lidocaine and prilocaine in Ans.
base form resulted in EMLA, which has been shown to
provide anaesthesia of intact skin, profound enough to The failure of local anaesthesia can occur due to:
permit venipuncture to be performed painlessly. i. Improper technique used for giving local anaesthesia.
● EMLA consists of 5% cream containing 25 mg/g each ii. Inadequate knowledge of practitioner.
of lidocaine and prilocaine. iii. Severe infection can be one reason not to achieve
● It is applied to the skin for at least 1 h before the antici- proper anaesthesia.
pated procedure. iv. Uncooperative patient.
● The cream is covered with an occlusal dressing.
● It is used in paediatrics in many ways, including veni- Q.6. Action of vasoconstrictors in local anaesthesia.
puncture, vaccination, suture removal, minor otological Ans.
surgery, lumbar puncture, minor gynecological and uro-
logical procedures and dermatological surgery, includ- Vasoconstrictors are important additions to a local anaes-
ing split-thickness skin graft harvesting, argon laser thetic solution for the following reasons:
treatments, postherpetic neuralgia, debridement of in- i. They reduce blood flow (perfusion) to the site of ad-
fected ulcers and inhibition of itching and burning in ministration.
adults. ii. Absorption of the local anaesthetic into the blood ves-
● Use of EMLA in infants under 6 months of age is con- sels is lowered, thereby minimizing the risk of local
traindicated because of the possibility of a metabolite of anaesthetic toxicity.
prilocaine inducing methaemoglobinaemia. iii. Increased amounts of the local anaesthetic remain in
Adverse responses and around the nerve for longer periods. This increases
● Transient and mild skin blanching and erythema. the duration of action of most local anaesthetics.
Q.2. Ideal local anaesthetic drug. Q.7. Intraligamentary anaesthesia.

Ans. Ans.
The ideal anaesthetic drug should be: ● Intraligamentary anaesthesia technique provides single
● Having reversible action. tooth anaesthesia.
● This consists of forcing the anaesthetic solution under Anatomical landmarks

pressure into the periodontal membrane space of maxil- ● Mandibular bicuspids, since the mental foramen usu-
lary or mandibular teeth. ally lies at the apex and just anterior to the second
● It is, in effect, a type of infiltration technique. bicuspid root.
Indication
Q.8. Composition of local anaesthesia.
● For surgery on the lower lip or mucous membrane in
Ans. the mucolabial fold anterior to the mental foramen.

Technique
[Ref LE Q.2]
● The apices of the bicuspid teeth should be estimated.
Q.9. Clinical applications of vasoconstrictor agents. ● A 25-gauge needle with length of 1 inch should be
inserted into the mucolabial fold after retracting the

Ans. cheek.
Mode of action of adrenaline ● The needle is penetrated until the periosteum of the
● Epinehrine acts directly on both alpha- and beta- mandible is gently contacted slightly anterior to the
adrenergic receptors, beta effects predominate. apex of the second bicuspid and anaesthetic solution
Clinical applications of adrenaline of 0.5–1 mL is slowly deposited in this area.
● Management of acute allergic reactions, broncho- Symptoms of anaesthesia
spasm and cardiac arrest. ● Tingling and numbness of the lower lip on the in-
● As a vasoconstrictor for haemostasis and in local jected side is seen.

anaesthetic solutions to decrease absorption into car- Q.13. Complications of broken needle in the pterygo-
diovascular system. mandibular space and their prevention.
● As a vasoconstrictor in local anaesthetic, to increase
depth of anaesthesia and duration of action of anaes- Ans.

thesia. Complications due to broken needle are as follows:
● To produce mydriasis.
i. Haematoma
Q.10. Give the order of anaesthetizing various nerves in ii. Trismus
direct pterygomandibular block technique. iii. Infection, etc.
Prevention
Ans. ● Older needle should not be used.
Order of anaesthetizing pterygomandibular nerve ● Thin needles should not be used in thick bone.
● Inferior alveolar nerve ● Lateral pressure on the shaft or the needle should be
● Lingual nerve avoided.

● Long buccal nerve
Q.14. Vazirani-Akinosi technique.
Q.11. Landmarks for extraoral maxillary nerve Ans.
block.
Vazirani-Akinosi technique is also known as closed mouth
Ans. technique.
Infraorbital block landmarks Nerves anaesthetized
● Inferior alveolar nerve, mental nerve and incisive nerve.
● Pupil of the eye
● Lingual nerve, buccinator nerve and mylohyoid nerve.
● Infraorbital notch
● Infraorbital ridge Landmarks

● Mucogingival junction of maxillary third or second
● Side of nose
● Lower eyelid molar.

● Maxillary tuberosity.
Q.12. Mental nerve block. ● Coronoid notch on ramus of mandible.
Procedure
Ans.
● Patient is placed in supine position with teeth oc-
Nerve anaesthetized cluded.

● Mental nerve ● Lip is retracted to expose maxillary and mandibular
Areas anaesthetized teeth.

● Lower lip ● At the level of mucogingival junction of maxillary
● Mucous membrane in the mucolabial fold anterior to molars, the syringe is directed parallel to the occlusal
the mental foramen and sagittal planes.
● Penetrate the needle just medial to the ramus of man- Urticaria may develop rapidly.
●
dible 25–30 mm into the tissues. Death may occur within a few minutes or several
●
● Now the tip of the needle lies in midportion of ptery- hours later.
gomandibular space close to the branches of man- Treatment
dibular nerve. ● Immediate application of a tourniquet above the site
● About 1.5–1.8 mL of anaesthetic solution is deposited. of injection.

● Epinephrine is the drug of choice because of its va-
Q.15. Specific receptor theory.
sopressor, bronchodilator and antihistaminic action.
Ans. ● Dose for adult is 0.3–1 mg subcutaneously or intra-
muscularly.
● Specific receptor hypothesis is the most favoured
● If possible, an intravenous route of drug administra-
theory of local anaesthesia.
tion can be started.
● The local anaesthetic receptor is located at or near
● Oxygen under pressure should be given with assisted
the sodium channel in the nerve membrane either on
respiration.
its external surface or on the internal axoplasmic
● Antihistamines such as diphenhydramine 50 mg are
surface.
given IV or IM.
● Once the receptors access is gained, sodium ion per-
● Corticosteroids such as hydrocortisone 100 mg IV or
meability is decreased or eliminated and nerve con-
IM are given for peripheral vascular effects.
duction interrupted.
● Local anaesthetics act by attaching themselves to Q.19. Contraindications for regional analgesia.
specific receptor in the nerve membrane.
Ans.
Q.16. Define pain. Enumerate methods of pain control.
● If patient refuses regional analgesia because of fear or
Ans. apprehension.
● Infection rules out the use of regional anaesthetics.
Pain is defined as an unpleasant emotional experience, usu-
● Patient is allergic to various local anaesthetics.
ally initiated by a noxious stimulus and transmitted over a
● Patient is below the age of reason.
specialized neural network to the central nervous system,
● Patient is unable to cooperate because of mental defi-
where it is interpreted as such.
ciencies.
Following are the methods of pain control:
● Major oral surgery makes regional analgesia unfeasible.
● Removing the cause
● Anomalies make regional analgesics difficult or impos-
● Blocking the pathway of painful impulses
sible.
● Raising the pain threshold
● Preventing pain reaction by cortical depression Q.20. Reasons for failure of local anaesthesia.
● Using psychosomatic methods
Ans.
● The first two methods affect pain perception, the last
two affect pain reaction and the third may affect both [Same as SN Q.5]
aspects
Q.21. Adrenaline.
Q.17. Haematoma.
Ans.
Ans.
[Same as SN Q.9]
[Ref LE Q.3]
Q.22. Epinephrine.
Q.18. Anaphylaxis.
Ans.
Ans.
[Same as SN Q.1]
● Anaphylactic reactions is a prototype example of a type I
Q.23. Kazanjian’s technique.
hypersensitivity immunologic reaction which is IgE-
mediated. Ans.
Signs and symptoms
[Same as SN Q.14]
● Patient becomes extremely apprehensive, intensive
itching occurs and asthmatic breathing develops.

Topic 4
Conscious Sedation and General Anaesthesia
LONG ESSAYS:
1 . Mention the indications for general anaesthesia in dental setting. Describe the stages of general anaesthesia.
2. Preanaesthetic evaluation of patient undergoing general anaesthesia and explain assessment of physical status
of the patient.
SHORT ESSAYS:
1 . General anaesthesia.
2. Stages of general anaesthesia. [Ref LE Q.1]
3. General anaesthesia versus conscious sedation.
4. Preanaesthetic evaluation of patient undergoing general anaesthesia. [Same as LEQ2]
5. Postoperative care of patient treated under general anaesthesia.
6. Nitrous oxide.
SHORT NOTES:
1 . Conscious sedation.
2. Intravenous anaesthetic thiopentone sodium in oral surgery.
3. Name few gaseous anaesthetic agents.
4. Name the stages of general anaesthesia.
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Mention the indications for general anaesthesia in ● Reflexes and respiration remain normal.
dental setting. Describe the stages of general anaesthesia. ● Though minor surgical procedures can be carried out
in this stage, it is difficult to maintain.
Ans.
Stage II: Stage of delirium
Indications for general anaesthesia in a dental setting ● This stage extends from the loss of consciousness till
● In uncooperative patients, if multiple procedures are the beginning of regular respiration.
required like extractions, root canal treatment and so on, ● Excitement in the form of violent movements of
then they may be done in one sitting. limbs, vomiting and muscle contractions; patient
● Apprehensive patients. may hold his breath or have irregular respiration,
● Patients allergic to the contents of a local anaesthetic incoherent speech, etc.
solution. ● Raised BP and tachycardia.
● Dilated pupils.
[SE Q.2]
● Surgeries should not be performed at this stage.
{Stages of general anaesthesia ● With newer drugs used for anaesthesia, this stage is
Stage I: Analgesia bypassed nowadays.

● This stage extends from the beginning of induction Stage III: Stage of surgical anaesthesia
to the loss of consciousness. ● This stage extends from the beginning of regular
● There is progressive abolition of pain. spontaneous respiration until complete cessation of

● Patient is conscious but in a dream-like state. The spontaneous respiration. This can be divided into
patient can hear and see. four planes.
Plane 1 ● This is useful in determining the surgical and anaes-

● Regular spontaneous respiration and eyelid reflex thetic risk prior to the procedure.
is lost ASA I
● Vigorous uncoordinated eyeball movements ● The patient has no organic, physiological, bio-
● Loss of pharyngeal reflex chemical or psychiatric disturbance.

● Loss of conjunctival reflex at the end of plane I ● The pathological process for which the operation
Plane 2 is being conducted is localized and does not entail

● Centrally fixed eyes, decreased size of pupil, loss any systemic disturbance.
of muscle tone, loss of laryngeal reflex and loss of ASA II
corneal reflex ● Mild-to-moderate systemic disturbances caused
Plane 3 either by the condition to be treated surgically or

● Pupillary light reflex is lost. Intercostal muscle by other pathophysiological process
paralysis occurs. Respiration is diaphragmatic ● Mild organic heart disease, diabetes, hyperten-
and there is complete muscle relaxation. sion, anaemia, old age, etc
Plane 4 ASA III
● Respiration is gradually depressed and there is ● Limitation of lifestyle due to disease
progressive diaphragmatic paralysis. ● Severe systemic disturbances or diseases, e.g.
Stage IV: Stage of medullary paralysis angina, history of MI, diabetes, etc
● In this stage, respiratory arrest and vasomotor col- ASA IV
lapse take place. ● Life-threatening severe systemic disorder
● Pupils are widely dilated. ASA V

● Skin is cold and ashen. ● A morbid-end patient not expected to survive
● Pulse is feeble and BP is low. more than 24 h with or without operation

● Respiration finally ceases.} ASA VI
● Emergency operation of any variety
Q.2. Preanaesthetic evaluation of patient undergoing
Drugs used for premedication
general anaesthesia and explain assessment of physical
i. Opioids such as morphine or pethidine
status of the patient.
ii. Benzodiazepines such as diazepam and medazolam
Ans. iii. Anticholinergics such as atropine
iv. Histamine receptor blockers such as cimetidine and
Preanaesthetic evaluation is mandatory for all patients un-
ranitidine
dergoing surgical procedures under general anaesthesia.
The purpose of premedication
● The patient who is to undergo any surgical procedure
● To reduce anxiety of the patient.
under general anaesthesia should be assessed thor-
● To produce amnesia.
oughly by the anaesthetist prior to the surgery.
● To reduce salivary and bronchial secretions.
● Thorough evaluation of medical history should be done.
● To suppress coughing and vomiting.
● Any previous history of exposure to anaesthesia (how
● To reduce use of GA drugs by providing synergistic
long back, any side effects of that procedure) should be
effect.
found out.
● Current physical status, use of medications, if any.
● Presence of loose teeth, dentures, crown and bridge on SHORT ESSAYS:

anterior teeth, etc.
Q.1. General anaesthesia.
● An informed consent form should be signed by the patient.
● The patient should be explained about the endotracheal Ans.

tube, masks, IV lines, etc. The patient should also be told
Depending on the route of administration of the drug, in-
that these may be present when he recovers from anaes-
duction of general anaesthesia (GA) may be by two means:
thesia. It should not be new and frightening to the patient.
i. Inhalation induction
● Any questions and doubts should be answered in detail.
ii. Intravenous induction
● Appropriate laboratory findings should be checked and
also the availability of cross matched blood, if required.

Inhalational induction
A well-prepared patient is usually very cooperative. ● Gaseous agents used are nitrous oxide or anaesthetic
Assessment of the physical status of the patient vapours such as halothane or isoflurane.
● The American Society of Anaesthesiologists adopted ● Induction by this method is a slow process and is
the ASA physical status classification. usually used for maintenance of anaesthesia.
Intravenous induction Q.4. Preanaesthetic evaluation of patient undergoing

● Drugs such as thiopentone sodium are injected intra- general anaesthesia.
venously for induction of GA.
Ans.
● Induction of anaesthesia is usually done using intra-
venous drugs. [Ref LE Q.2]

● This produces smooth and easier induction and is
Q.5. Postoperative care of patient treated under general
much faster so that the classical stages of anaesthesia
anaesthesia.
as described by Guedel are not seen as the patient is
taken into the stage III rapidly. Ans.
Endotracheal intubation
Postoperative care of patients treated under general
● This procedure secures the airway by placing a tube
anaesthesia
into the trachea either via the nose, mouth or a tra-
● Postoperatively, the patient should be looked after in
cheostomy.
an intensive care unit for first 24–48 h.
● This tube has an inflatable cuff.
● Airway should be maintained properly with nasotra-
● Once the tube is placed into the trachea, the cuff is
cheal or nasopharyngeal tube.
inflated. This prevents aspiration of debris.
● Patient’s vital signs should be maintained.
● This tube is connected to the anaesthetic machine to
● Care should be taken to reduce the risk of vomiting and
allow the delivery of oxygen, nitrous oxide and an
excessive restlessness as a result of pain or hypoxia.
inhalational anaesthetic.
● Airway complication may occur, so all the necessary
● A throat pack is used as a supplement to the cuff to
instruments should be kept near by the bed.
prevent aspiration of blood, saliva and debris.
● Patient’s blood pressure should be monitored at regu-
Drugs used for premedication
lar time intervals.
● Opioids such as morphine or pethidine
● Fluid and electrolyte balance should be maintained.
● Benzodiazepines such as diazepam and medazolam
● Anticholinergics such as atropine Q.6. Nitrous oxide.

● Histamine receptor blocker such as cimetidine and
Ans.
ranitidine
● Nitrous oxide is the most commonly used inhalational
Q.2. Stages of general anaesthesia. anaesthetic.
● It is an inert and colourless inorganic gas.
Ans.
● It produces different levels of effect depending on the
[Ref LE Q.1] percentage of exposure.

● 10%–15% causes numbness and tingling of extremities,
Q.3. General anaesthesia versus conscious sedation. and some sedation. 35%–40% causes increased sedation
and mild analgesia.
Ans.
● Patient has the sensation of floating, and noises around
him may appear dull and distant.
● There is significant numbness and tingling felt in the
General anaesthesia Conscious sedation
hands, feet and circumoral areas.
Single sitting i.e. once in a At several visits, the treatment ● The patient may have a feeling of warmth.
lifetime procedure procedures may be performed
Indications
Used for uncooperative Patient is cooperative, but anx- ● Mildly apprehensive and uncooperative adult pa-
patients ious and fearful tients and uncooperative children.
Basic investigation, premedi- No extensive investigation ● Patients who have a severe gag reflex.
cation and NPO is strictly and no premedication are ● Medically compromised patients such as those with
required required; no NPO required
cardiovascular disorders, asthma, etc., who cannot
Ventilation is required Airway is maintained as undergo stressful procedures.
patient is conscious Contraindications
99% success rate reported No mortality ● Patients with upper respiratory tract infection.
● Pregnant patients, especially first trimester of pregnancy.

Time-consuming procedure Recovery operation period is
1–2 min ● Mentally retarded patients and patients who are ex-
tremely anxious.
Patient cannot control the Patient feels he is in control of
● Such patients are more suitable for procedures
situation the situation
under GA.
SHORT NOTES: ● It acts rapidly and can produce unconsciousness within

20 s.
Q.1. Conscious sedation. ● It is given in a dose of 4–8 mg/kg.
Ans. ● Extravasation of the intravenous injection is highly
irritating and may produce severe pain.

● A minimally depressed level of consciousness that re- ● It is a weak muscle relaxant and poor analgesic.
tains the patient’s ability to maintain an airway indepen- ● This is the most commonly used inducing agent.
dently and continuously, and respond appropriately to
physical stimulation and verbal command is known as Q.3. Name few gaseous anaesthetic agents.
conscious sedation. Ans.
Indications for conscious sedation
● Uncooperative children and adults Commonly used gaseous anaesthetic agents
● Patients with phobia for dental treatments ● Nitrous oxide
● Small children requiring multiple dental procedures ● Halothane
● Some medically compromised patients who cannot ● Enflurane
tolerate stress in the dental procedure ● Isofluroane
Objectives of conscious sedation Q.4. Name the stages of general anaesthesia.

● Mood alteration: Patients who are generally psycho-
logically apprehensive. Ans.

● Elevation of pain threshold: The patient’s pain
Stages of general anaesthesia
threshold is elevated by the use of certain drugs. Stage I: Analgesia
● Amnesia.
Stage II: Stage of delirium
Q.2. Intravenous anaesthetic thiopentone sodium in oral Stage III: Stage of surgical anaesthesia
surgery. Stage IV: Stage of medullary paralysis
Ans.
● Thiopentone sodium is an ultrashort acting barbiturate
with a half-life of 6–8 h.
Topic 5
Principles of Exodontia and Instrumentation
LONG ESSAYS:
1 . Discuss the indications, contraindications and complications of dental extractions.
2. How would you do an open method of tooth extraction?
3. Classify the instruments used in dental extraction. Explain in detail elevators used in extraction.
4. Describe the principles of elevators used in oral surgery.
5.
Enumerate the various causes for postextraction bleeding and discuss the various methods available to control
bleeding from socket.
6 . Discuss in detail indications, contraindications and principles followed in dental extraction of teeth. Add a note
on its complications. [Same as LE Q.1]
7. What are the complications of extraction of teeth? How would you avoid them? Describe in detail the treatment
of anyone? [Same as LE Q.1]
8. Enumerate the causes for postextraction bleeding. How do you diagnose and manage postextraction bleeding?
[Same as LE Q.5]
SHORT ESSAYS:
1. Dry socket.
2. Describe control of haemorrhage during minor surgical procedures.
3. Elevators – principles and use. [Ref LE Q.4]
4. Surgical extraction. [Ref LE Q.2]
5. Contraindications of extraction of teeth. [Ref LE Q.1]
6. Principle of forceps design.
7. Tooth extraction in a patient who is under anticoagulant therapy.
8. Dry socket and its management. [Same as SE Q.1]
9. Nonhealing socket (dry socket). [Same as SE Q.1]
10. Treatment of dry socket. [Same as SE Q.1]
11. Describe mode of action of various agents used to achieve local haemostasis following extraction. [Same as SE Q.2]
12. Principles of elevators. [Same as SE Q.3]
13. Mechanical principles of using the elevators in extraction of teeth. [Same as SE Q.3]
14. Transalveolar extraction. [Same as SE Q.4]
15. Control of bleeding through extraction socket. [Same as SE Q.2]
SHORT NOTES:
1. Extraction in pregnancy.
2. Chisel and mallet in dentistry.
3. Elevators.
4. Elevator principles. [Ref LE Q.4]
5. Enumerate any two complications of the use of elevators during exodontias.
6. Contraindications for extraction. [Ref LE Q.1]
7. Forceps in extraction.
8. Dry socket.
9. Complications of extraction. [Ref LE Q.1]
10. Wound healing.
11. Haemostatic agents.
12. Mention four bleeding control measures in postextraction bleeding.
13. Whitehead’s varnish.
14. Bone wax.
15. Trismus.
16. Name the principles of elevators. [Same as SN Q.4]
17. Healing of extraction wound. [Same as SN Q.11]
18. Control of haemorrhage by local measures. [Same as SN Q.13]
19. List five causes of trismus. [Same as SN Q.16]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Discuss the indications, contraindications and com- ● Pulp pathology: Studied in cases where endodontic
plications of dental extractions. treatment is not possible
● Apical pathology: Studied in cases of apical pathology,
Ans.
where it can widen and involve the adjacent teeth.
The indications of dental extractions are as follows: ● Periodontal disturbances
● Dental caries ● Depending on the
a. If all the conservative procedures have failed a. Success of the periodontal therapy
b. The sharp margins of the teeth repeatedly ulcerate b. Patient’s attitude towards the concept of conserving
the mucosa such teeth
c. Leading to deteriorating oral hygiene c. Economic and time factors
● Orthodontic reasons
Other systemic and local contraindications are
a. Therapeutic extractions – to gain space
● Diabetes and hypertension: A sure way of pre-
b. Malposed teeth – to realign them
venting any potential complication is by carry-
c. Serial extraction – extraction of a few deciduous
ing out extraction only in patients with con-
teeth in chronological order to prevent malocclusion
trolled diabetes and hypertension.
as the child grows
● Patients on steroid therapy: To prevent adrenal
Extractions of teeth for orthodontic reasons should be
crisis due to stress, the steroid dose should be
based on orthodontic assessment, genetic evaluation
doubled 1 or 2 days prior to extraction; and,
and evaluation of the soft tissues, lips and tongue.
should be continued 1 or 2 days postopera-
● Prosthetic considerations
tively after which the dose can be slowly ta-
a. To provide efficient dental prosthesis.
pered.
b. To remove remaining few teeth for purpose of com-
● Pregnancy: Extraction should be carried out
plete dentures.
only with the obstetrician’s consent in the first
● Impactions
and third trimester.
Removal of impacted tooth for purpose of facial
● Bleeding disorders: Consent from the haema-
pain, periodontal disturbances of the adjoining teeth,
tologist is necessary for an uncomplicated ex-
Temporomandibular joint (TMJ) problems, bony pa-
traction. Patients on anticoagulant therapy re-
thology like cysts and pathological fractures of the jaws
quire physician’s/cardiologist’s advice.
as well as overcrowding of anterior teeth.
● Medically compromised patients: Failure to
● Supernumerary teeth
evaluate the patient preoperatively may pose as
It may predispose to malocclusion, periodontal distur-
a systemic complication that can lead to drug
bances, facial pain, bony pathology or aesthetic problems.
interactions.
● Tooth in the line of fractures
● Local contraindications: It is preferable to
The tooth is extracted if:
avoid any kind of infection by carrying out
a. It is a source of infection at the site of the fracture.
extractions under antibiotic therapy.
b. The tooth itself is fractured.
● Extraction of teeth in recently irradiated pa-
c. The retention may interfere with fracture reduc-
tients: Irradiation in jaws will reduce the blood
tion.
supply due to fibrosis. Therefore, extraction is
● Teeth in relation to bony pathology
avoided to prevent osteoradionecrosis.)}
If are involved in cyst formations, neoplasms or osteo-
myelitis.
● Root fragments
If they lead to painful ulceration that becomes neoplas- {SN Q.9}

tic, bony pathology like osteomyelitis, cyst or neoplasm Complications
and facial pain or numbness. The possible complications of tooth extraction are as
● Teeth prior to irradiation
follows:
It is indicated only if oral hygiene cannot be maintained ● Failure to secure anaesthesia
in a sound condition. ● To remove the tooth with either forceps or ele-
● Focal sepsis
vators
● Doubtful teeth with foci of infection are extracted
● Fracture of crown of tooth being extracted
● Aesthetics
● Roots of tooth being extracted
In cases where conservative, orthodontic or surgical ● Alveolar bone
means cannot be used. ● Maxillary tuberosity
● Economic consideration
● Adjacent or opposing tooth
● Mandible
(SE Q.5 and SN Q.6)
● Dislocation of adjacent tooth
● TMJ
{(Contraindications ● Displacement of root into the soft tissues
It is better to avoid extraction in cases of absolute ● Into the maxillary antrum
contraindications such as: ● Excessive haemorrhage during tooth removal
● Congestive cardiac failure ● On completion of extraction
● Leukaemia ● Postoperatively
● Uraemia ● Damage to adjacent structures
● Cirrhosis of liver ● Gums
● Terminal stages of malignancy ● Lips
is required for application of forceps or elevator and to

● Lingual nerve displace the tooth. All the sharp edges and bony projec-
● Tongue and floor of the mouth tions should be removed.
● Postoperative pain due to damage to hard and ● A dental bur, chisel or gouge with hand or mallet pres-
soft tissues sure are usually used for bone removal. The burs com-
● Dry socket monly used are round- or rose-head bur and ash surgical
● Acute osteomyelitis of mandible bur usually size 8.
● The elevated flap is to be held with a flat bladed retrac-
tor. Constant sterile saline should be used to prevent
●
Syncope heat, clogging and to remove debris.
●
Respiratory arrest ● A row of small holes are made which are then con-
●
Cardiac arrest nected either with the bur or the chisel.
●
Postoperatively ● The tooth is dislocated with forceps in case of firm tooth
● Swelling due to oedema or haematoma forma- or with elevators. In cases of multirooted teeth, the bi-
tion furcation is used to separate the two roots from below
● Infection upwards followed by dislocation of individual roots.
● Trismus This can be done either with a bur or an osteotome.
Q.2. How would you do an open method of tooth ● Any bony defects are planed with rongeur forceps or
extraction? bone files. Once the bony edges are smooth, the wound
Ans. is irrigated with saline and all bone debris and infected
granulation tissues are removed.
● Open method of extraction is also known as ‘transalveo- ● The mucoperiosteal flap is replaced back in position and
lar extraction’ or ‘surgical extraction’. sutured to minimize wound contamination with debris
This method of extraction is indicated if: and haemorrhage. A simple interrupted or interrupted
i. A tooth resists intra-alveolar form of extraction. horizontal suture is used to close the wound.}
ii. When the retained roots are difficult to grasp with for-
ceps especially when they are in close approximation Q.3. Classify the instruments used in dental extraction.
to the maxillary antrum. Explain in detail elevators used in extraction.
iii. A heavily restored, root filled or pulpless tooth.
iv. Ankylosed or hypercementosed tooth. Ans.
v. Geminated or dilacerated tooth. The instruments used for closed extraction method are
vi. Teeth showing complicated root patterns radiographi- as follows:
cally. a. The elevators used in dental extraction
vii. When denture has to be inserted immediately. According to form
● Straight
[SE Q.4]
● Angular
● {After securing adequate anaesthesia it is important to ● Crossbar
design the mucoperiosteal flap to facilitate the tooth, Commonly used elevators
root and bone removal. ● Periosteal elevators
● The mucoperiosteal flap should be large anteroposteri- ● Apexo elevators
orly to provide adequate visual and mechanical access. ● Crossbar elevators
The base of the flap should be broader when compared b. The forceps used for extraction of teeth
to the free end, as this provides a rich blood supply for ● Upper anterior forceps
efficient healing. ● Bayonet forceps
● The incision should be made with a scalpel through the ● Upper molar forceps
mucous and periosteal layer of the gingiva at right angle ● Upper root forceps
to the bone. It should avoid the mental nerve and the ● Lower anterior forceps
greater palatine artery. The flap can be buccal, lingual or ● Lower molar forceps
palatal. It should involve the dental papilla and should lie The instruments used for open extraction as per steps
on sound bone structure. involved are
● The mucoperiosteal flap is elevated with the help of a ● Incision – Scalpel blade
sharp periosteal elevator to expose the underlying bone. ● Elevation of mucoperiosteal flap – Nonbladed
The alveolar bone removal is limited to only as much as retractor
● Bone cutting – Bur, chisel or osteotome

ii. Wedge principle
● Tooth separation – Bur or osteotome
iii. Wheel and axle principle)}
● Displacement of tooth – Elevators or forceps
● Flap closure – Suturing material
Elevators are described in detail below: (SE Q.3)

● Elevators are the instruments used to elevate the
{i. Lever principle
tooth or root from the alveolar socket. ● It has three basic components: Fulcrum, effort and
● It has the handle, shaft and blade. Its effectiveness
load.
depends on the design of the handle and its effi- ● It is a lever of first class with the fulcrum in between
ciency on the design of the blade. the effort and the load.
a. Straight elevator ● In this principle, to gain a mechanical advantage the
● In straight elevator, the handle, the shaft and the
effort arm on one side of the fulcrum should be
blade all are in the same plane. longer than the load arm on the other side of the
● It is used to:
fulcrum.
l Luxate the last tooth in the dental arch
● The force is transmitted at the long effort arm and a
l Luxate the tooth during extractions
mechanical advantage is gained at the short load arm.
l Elevate the mandibular third molars
Area of usage:
b. Winter’s crossbar elevators ● This principle is not of much advantage in forceps
● These elevators form a pair. They are indicated in
if used alone, but if used in combination with
the removal of mandibular root when the other wheel and axle it proves useful.
root is already removed. ● The hinge of the forceps acts as a fulcrum, while the
● The tip of the elevator is introduced in empty
two arms represent each component of the lever.
socket with concave surface facing the root to be ● The length of the handle compared to the blade
removed. The elevator is then rotated by the represents the mechanical advantage. To gain a
wheel and axle principle. mechanical advantage, the grip should be farther
● Hence the same elevator can be used on the distal
from the fulcrum and the blade should be shorter.
root of the right side and the mesial root of the left ● This principle is used in elevators, wherein the
side. handle of the elevator represents the effort, and
● When both the roots are intact, tip of the elevator
the working-end which engages the tooth repre-
can be applied at the bifurcation from the buccal sents the load.
side and force is applied using lever principle and ii. Wedge principle
wheel and axle principle to elevate the roots. ● The wedge consists of two movable inclined planes
c. Cryer’s elevator with a base on one end and a blade on the other end,
● It is a useful instrument used to luxate the maxil-
which overcomes a large resistance at right angles to
lary teeth or roots. the applied force.
● Elevators have the handle at an angle to the shaft,
● The effort is applied to the base of the plane and the
e.g. Cryer’s elevator. resistance has its effect on the slant side.
● It is used to remove erupted maxillary III molars
Area of usage:
and maxillary root fragments. ● Wedge principle can be used alone in extracting a
e. Apexo elevators tooth. However, it is very often used with lever
● They are used for removal of fractured root,
principle.
impacted maxillary third molars and impacted ● According to this principle, a wedge can be used
cuspids. to split, expand or displace the portion of the sub-
● They are available in various numbers.
stance that receives it.
● Applied to elevators:
Q.4. Describe the principles of elevators used in oral
Elevators can also be used to luxate a tooth from
surgery.
its socket, e.g. a straight elevator is applied be-
Ans. tween the tooth and the bone to separate the at-
tachment of the periodontal ligament from the
(SE Q.3 and SN Q.4) bone as described previously.
● Applied to forceps:
{(Principles of elevators used for extraction are as For carrying out extraction, the tip of the forceps is
follows: inserted in between the mucoperiosteum and sur-
i. Lever principle of first order face of the tooth. To displace the mucoperiosteum,
the bony sockets are expanded which results in
slow separation of the periodontal ligament from order to control it, the patient will inevitably bleed
the bone. into the tissue planes of the neck and this results in
iii. Wheel and axle principle an unsightly ecchymosis, or there may be haema-
● Wheel and axle is a simple machine and is a modi- toma formation of considerable dimensions.
fied form of lever. The effort is applied to the circum- ● In extreme case, this could result in fatal pressure on
ference of wheel, which will turn the axle so as to the trachea.

raise the weight. II. Factors restarting haemorrhage
● Greater the diameter of the wheel the more is the During first few hours after operation, haemostasis in
mechanical advantage. the smaller vessels is largely due to contraction of the
Area of usage: vessel and platelet thrombus.
Applied to elevator Blood clots too not yet matured and contracted.
● Crossbar elevators are used for removing the ● Mechanical injury of the wound
mandibular roots by engaging the working ● Application of heat to wound including local
point of the elevator deep into the space be- hyperaemia

tween the tooth root and the bone, and the ● Reactive hyperaemia resulting as the effect of
handle is rotated. adrenalin wears off

● The root is removed from its socket by moving ● Violent exercise of general peripheral vasodilata-
about a circumference of the circle which the tion and raise in B.P.
roots would have made if they continued on ● The consumption of a number of alcoholic drinks
around.} perhaps for their analysis or euphoric effect

Applied to forceps again of general peripheral vasodilatation. All
● To remove a tooth, the beaks of the forceps are may trigger such a haemorrhage.
applied firmly on either side of the tooth and ● A fit of coughing in response to a small trickle of
force is applied in the form of an arc. This re- blood or saliva may produce venous congestion and
sults in a bodily rotation of the tooth in the restart substandard haemorrhage from the wound.
socket which is ultimately delivered out. ● The classic reactionary haemorrhage is that
● To gain a mechanical advantage, always hold which supervenes the high B.P. during the initial
the forceps handle as farther away as possible recovery from a severe operation.
to increase the effort arm. However, the peri- III. Infection at the wound site
odontal attachment gets ruptured due to the ● Secondary haemorrhage is usually due to partial di-
bodily rotation of the tooth. vision of blood vessels in combination of sepsis.

● This principle can be used separately or in ● The carotid vessels are stripped clean of tissue on
conjunction with wedge or lever principle in their superficial aspect. If triradiate part of suture
removing the teeth. line lies over these vessels and wound dehiscence
occurs, then there is considerable risk of ulceration
Q.5. Enumerate the various causes for postextraction
and rupture of a carotid.
bleeding and discuss the various methods available to
Management of postoperative haemorrhage
control bleeding from socket.
● Determine the site and amount of haemorrhage.
Ans. ● The blood clot should be grasped in a piece of
gauze and removed.

Causes of postoperative haemorrhage are categorized
● A firm gauze pack should be placed firmly over
as follows:
the socket and patient is instructed to bite on it.
I. Failure to control haemorrhage at the conclusion of the
● Tannic acid powder is placed around the pack to
operation
arrest haemorrhage.
II. A factor restarting haemorrhage in the early postopera-
● Interrupted horizontal mattress suture across the
tive period
socket is advisable in areas of themucoperios-
III. Infection at the wound site leading to secondary haem-
teum under local anaesthesia to arrest bleeding.
orrhage
● The mucoperiosteum is tensed over the underly-
I. Failure to effect haemostasis ing socket to make it ischaemic.

● It comes under negligence of operator. ● Ask the patient to bite on a gauze pack following
● No wound should ever be sutured until adequate a suture.

haemostasis has been achieved. ● If the above measures fail, a gelatin or fibrin
● Even though the haemorrhage may not be suffi- foam pack is tucked into the socket and composi-
ciently severe to necessitate reopening the wound, in tion block moulded over the area.
● The patient should be referred to nearest hospital ● The pain radiates to the ear and the same side of the head.
for further treatment. ● There is an absence of postextraction blood clot in
● The patient should avoid repeated rinsing of the socket.
mouth as this promotes bleeding. The oral cavity ● Sometimes early clot formation in the socket is fol-
should be cleaned with a gauze and cold water. lowed by premature clot necrosis or loss, accompa-
nied by pain and fetor oris.
Q.6. Discuss in detail indications, contraindications and
Preventive measures
principles followed in dental extraction of teeth. Add a
● Preoperative oral hygiene measures should be taken
note on its complications.
to reduce plaque levels.
Ans. ● An elective transalveolar approach whenever neces-
sary in case of difficult extractions.

[Same as LE Q.1]
● All extractions should be completed with the mini-
Q.7. What are the complications of extraction of teeth? mum amount of trauma and maximum care and as
How would you avoid them? Describe in detail the treat- rapidly as possible depending upon the experience of
ment of anyone? the operator.
● In the presence of active infection or ulcerative gin-
Ans.
givitis, avoid extraction of lower third molars.
[Same as LE Q.1] ● Patient having smoking habits should be advised to
stop smoking preoperatively and for at least two

Q.8. Enumerate the causes for postextraction bleeding.
weeks postoperatively until the socket heals.
How do you diagnose and manage postextraction
● Extractions should be performed during 23rd to 28th
bleeding?
day of the tablet cycle in female patients using oral
Ans. contraceptives.
● During first 24 h of postextraction period, avoid vig-
[Same as LE Q.5]
orous mouth rinsing.
● A radiograph should be taken to exclude the possibil-
SHORT ESSAYS: ity of retained fragments of tooth or foreign body.

● The affected socket must be gently irrigated with
Q.1. Dry socket. 0.12% warm chlorhexidine and all debris dislodged
and aspirated.
Ans.
● Intra-alveolar pastes consisting of zinc oxide euge-
● Dry socket is also known as alveolar osteitis. nol, anaesthetic and antibiotic (metronidazole) can
● It has been defined as a postoperative pain in and be placed. Locally, this increases the drug concentra-
around the alveolar socket of tooth, which increases in tion, diminishes their secondary effects and protects
severity at some moment between the first and the the underlying socket and alveolus. Appropriate an-
third day after a dental extraction, accompanied by algesics should be prescribed.
partial or total disintegration of the intra-alveolar clot
with a foul smell. Q.2. Describe control of haemorrhage during minor
Causes of dry socket surgical procedures.
● Difficult or traumatic extraction
Ans.
● Patients on oral contraceptives
● Female sex Control of haemorrhage during the operation

● Tobacco i. Incision planning
● Inadequate irrigation intraoperatively ● Underlying large blood vessels are not severed.
● Advanced age ● Haemorrhage may be profuse if the area to be incised
Clinical features is inflamed as a result of local infection.
● Pain typically appears on the second or third day fol- ● Once the wound has been opened further dissection
lowing the extraction, and it usually lasts for about should be conducted in such a manner that sizeable
10 or 15 days. blood vessels are identified and dealt in a systematic
● Pain is localized to the extraction socket sensitive to fashion.
even gentle probing. ii. The securing of blood vessels with haemostats
● A persistent sharp excruciating pain that increases ● Most effective haemostats for use in oral surgery –
with suction or mastication and lasts several days. curved or straight Halsted’s and mosquito artery
● Halitosis. forceps.
● No incision should ever be made through skin, un- ribbon guaze soaked in whitehead’s varnish should
less an adequate number of haemostats are available be packed into the wound.
for immediate use. Whitehead’s varnish – Benzoin – 10 parts
● Intraorally, the use of haemostats is limited. Storax – 7.5 parts
● It is impractical to clamp the inferior dental artery in Balsam of Tolu – 5 parts
the bone and the use of haemostats on the lingual Iodoform – 10 parts
aspect of mandibular lower third molar area, as this Solvent ether – 100 parts
could lead to a protracted anaesthesia of the anterior ● The pack should be sewn into position to prevent
two-third of tongue. its subsequent displacement and this precaution is

● Haemostats should be applied above and below the especially important if patient is being operated
point at which they are to be incised before dividing under GA.
the vessels. Such packs will always control a persistent haemor-
● The tips of the curved haemostats should be applied, rhage and should be removed in 48 h.
so that the curve of the instrument causes the tips of iv. The use of haemostatic agents
the blades to face upwards and out of the wound, so Example: Turpentine or tannic acid – Frankly dan-
that each severed end of the vessel can be properly gerous causes second-degree burns at angle of mouth
exposed by the assistant in order to facilitate the ty- and on the lips, where material has leaked over the
ing off of the vessel with catgut. face.
● Size 3.0 (metric size 2.5) of catgut is satisfactory for ● Commercial preparations – Dubious efficacy and
most purposes in oral surgery. more costly.

● Many small vessels do not require tying and if the ● Thrombin and Russell viper venom – Precipitate
end of the haemostat is trusted a couple of times clot formation when applied on pledget of cotton.
before removing it, the haemorrhage will usually ● Both are expensive.
cease. ● Oxidized regenerated cellulose (Surgicel) – One
● Small vessels can also be sealed by briefly touching of the best commercially absorbable haemostatic
the haemostat of a diathermy set for coagulation agents.
before removing it from the vessel. ● As it is absorbable it can be safely buried in the
iii. Haemostasis through the application of pressure tissues.

with swabs ● Nevertheless, since low pH thrombin solutions
● The most effective method for almost all intra- should not be used to the guaze, the activity of
wounds. thrombin will be rapidly destroyed.
● Pressure is a simple, but most effective method of ● Bone wax (Horsley’s) – Purely mechanically act-
controlling haemorrhage. ing haemostatic agent.

● Dry guaze swab is packed into wound, over the ● This substance is packed into bleeding bone-ends
bleeding area and digital pressure is maintained over to control the haemorrhage.
the swab for 2½ min. ● Appreciable quantities result in formation of wax
● The normal coagulation time is just over 2 min and granulomas.
it is useless to control haemorrhage from wound by ● Composition: Bees wax (yellow) – 7 parts by
pressure of swab for a shorter period than this. weight

● If there is large raw area which is oozing blood. Olive oil – 2 parts
● Some operators prefer to use a hot, wet swab to Phenol – 1 part
control the haemorrhage. The swab is soaked in hot v. Hypotensive anaesthesia and vasoconstriction
normal saline solution (temperature 48.8°C, 120°F) ● Hypotensive anaesthesia can be employed when
and it is well wrung out before applying it to the working under GA to reduce operative haemorrhage
wound. The delicate tissues of the floor of mouth to a minimum.
may be scalded, especially if there is any excess ● Technique: BP is lowered by use of hypotensive
fluid in the swab. agents like arfonad and bleeding is greatly reduced.
● When an artery such as inferior alveolar in its canal Disadvantages
is incompletely severed and ends are unable to con- i. During the operation, sizeable vessels may be cut
tract, haemorrhage persists even after pressure of a without any obvious bleeding. If overlooked, they
dry swab for an adequate period of time. are not then tied off with catgut; however, when
● In such circumstances a pack can be left in the operation is over and the patient’s BP is allowed
wound. To reduce any risk of infection, ½ inch to return to normal, such damaged vessels bleed
profusely and patient may have to be returned to upper forceps, beaks are in the same line as handles or
theatre for haemostasis to be effected. parallel to it.
ii. There is risk of encouraging thromboses, espe- i. Upper anterior forceps (Ash no. 1)
cially in elderly patients, when the BP is lowered a. Used for extracting upper incisors and canines.
to such an extent and the method itself is not out b. Beaks are symmetrical, shorter and placed in the
of risk. same line as the handles, so that the load arm is
iii. Hypotensive anaesthesia should not be reserved shorter than the working arm.
for operations, where excessive haemorrhage due ii. Bayonet forceps (Ash no. 101-A)
to oozing can be anticipated, or where visibility is a. Used for removing premolars and rarely for the up-
of utmost importance and a dry field cannot be per roots.
obtained by other methods. In such cases, it is of b. Beaks are asymmetrical, placed parallel to the
considerable value. handles to help the beaks to be placed more poste-
Use of vasoconstrictors riorly.
● Vasoconstrictors prolong the analgesic effect c. One end of the handle is concave to provide better
of LA. They are used to reduce capillary and secured grip for the operator’s fingers.
haemorrhage. iii. Upper molar forceps (Ash no. 94 and 95)
Example: Adrenalin – 1/80,000 in ligocaine; a. These forceps have asymmetrical, broader beaks.
1/300,000 in prilocaine b. The cross section of the beaks is concave/convex,
● As the effect of adrenalin passes off, a reactive so that concave surface is meant for application
hyperaemia occurs. This potentially can result against the crown/root surface.
in postoperative haemorrhage and haematoma c. One beak is pointed so that it can engage the bifur-
formation. cation of the tooth. The other beak is rounded, so
● According to Shanks, octapressin (Felypres- that it adapts around the palatal root. Based on the
sin) does not produce such undesirable se- position of the pointed beak, the forceps can be
quelae during halothane anaesthesia and used identified as right and left.
in concentration of 0.03 IU/mL with prilocaine iv. Upper root forceps
3%, and a satisfactory degree of vasoconstric- a. Designed for removing maxillary roots.
tion is obtained at the same risk of postopera- b. Beaks are symmetrical and closely approximate to
tive haemorrhage. each other.
● Felypressin solutions and prilocaine are not c. The beaks are narrower and slightly curved to fit to
generally available and have not so far been the circumference of the root.
widely used as surgical vasoconstrictor. Not v. Lower anterior forceps (Ash no. 74)
.8–10 mL of 0.03 IU/mL solution should be a. They are narrower than the lower molar forceps and
injected into an adult at one time. at right angles to the handles.
b. These forceps can also be used as lower root
Q.3. Elevators – principles and use.
forceps.
Ans. vi. Lower molar forceps (Ash no. 73)
[Ref LE Q.4] a. Beaks are symmetrical and at right angles to the
handles.
Q.4. Surgical extraction. b. They have sharp pointed tips that can engage
Ans. the bifurcation, both at the buccal and the lingual
surfaces.
[Ref LE Q.2]
c. Beaks are broader and stout.
Q.5. Contraindications of extraction of teeth. These are the minimum instruments required for ex-
tracting the teeth. All these forceps are designed in such a
Ans.
way that they are applied with the beaks parallel to the long
[Ref LE Q.1] axis of the tooth. Failure to secure the grip in this way will
result in the application of the force, leading to the fracture
Q.6. Principle of forceps design.
of the tooth.
Ans.
Q.7. Tooth extraction in a patient who is under antico-
Every forceps has a pair of handles, a pair of beaks agulant therapy.
and a hinge. In the lower forceps, beaks are at right
angles to the long axis of the handles, while in the Ans.
Tooth extraction in patients on anticoagulant therapy Q.9. Nonhealing socket (dry socket).
● Anticoagulant therapy predisposes the patient to pro-
Ans.
longed bleeding during any surgical procedure.
● This condition poses a problem as it cannot be con- [Same as SE Q.1]
trolled by routine haemostasis.
Q.10. Treatment of dry socket.
l Following intubation, sometimes it may cause severe
internal bleeding due to blunt injury and rarely can Ans.

pose a life-threatening complication.
[Same as SE Q.1]
● Wound healing is delayed.
Required preoperative investigations Q.11. Describe mode of action of various agents used to
Routine blood tests achieve local haemostasis following extraction.
i. Complete blood count
Ans.
ii. Bleeding and clotting time
iii. Platelet count [Same as SE Q.2]
iv. Haemoglobin
Q.12. Principles of elevators.
v. Prothrombin time
vi. Partial thromboplastin time Ans.
vii. Assay of coagulation factor levels
[Same as SE Q.3]
● With consent of the physician 4–5 days prior
to the surgical procedure, the anticoagulant Q.13. Mechanical principles of using the elevators in
therapy should be stopped. extraction of teeth.
● If oral anticoagulant therapy cannot be dis-
Ans.
continued, then the patient has to be shifted
to intravenous anticoagulant therapy like [Same as SE Q.3]
heparin. Once the blood levels are normal,
Q.14. Transalveolar extraction.
the patient can be treated as a normal patient
with regards to surgical bleeding. Ans.
● Pre- and postoperatively, the patient should
[Same as SE Q.4]
be covered with broad-spectrum antibiotics.
Intra and postoperative management Q.15. Control of bleeding through extraction socket.
● Avoid undue trauma to surrounding tissues to
Ans.
prevent internal bleeding during any surgical pro-
cedure. [Same as SE Q.7]
● Intraoperative transfusion of blood/blood prod-
ucts, if found necessary. SHORT NOTES:

● Monitor haemoglobin, complete blood counts in-
Q.1. Extraction in pregnancy.
tra- and postoperatively.
● Maintain adequate blood volume and control hae- Ans.
mostasis prior to wound closure.
● If the procedures are elective, then the treatment can be
● Monitor the vital parameters for any changes in
carried out in the second trimester.
the fluid volume indicated by the pulse and blood
● Local anaesthetics such as ligocaine, bupivacaine and
pressure.
codeine are considered least harmful to the foetus.
● Postoperatively, the patient may be maintained
● Emergencies of pain, infection or acute problems can be
on systemic oral coagulants like vitamin K for
combated with general anaesthesia.
3–5 days.
● Drugs such as aspirin, morphine and carbamazepine
● Cover the patient with adequate broad-spectrum
should be avoided.
antibiotics.
● Avoid medications that can exacerbate the under- Q.2. Chisel and mallet in dentistry.
lying condition
Ans.
Q.8. Dry socket and its management. Chisel
● It is a mono-bevelled instrument used for removal of
Ans.
bone.
[Same as SE Q.1] ● It has a heavy cylindrical handle.
The bevel has to be sharp.

● Q.8. Dry socket.
For cutting, the bevel has to be placed away from the
●
Ans.
bone, and for chipping it has to be towards the bone.
Mallet ● Dry socket is also known as alveolar osteitis.
● It can be made of wood, rubber, nylon or stainless steel. ● Caused due to loss of clot from the socket.
● Stainless steel mallets are preferred, as it can be ster- Clinical features
ilized and can be used for long time. ● Usually on the second or third day after the extrac-
● Mallet is used to deliver controlled force on the tion pain appears and it usually lasts for about 10 or
chisel and osteotome. 15 days.
● Halitosis.
Q.3. Elevators. Treatment
Ans. ● Gentle irrigation of socket should be done with
0.12% warm chlorhexidine and all debris needs to be

● Elevators are instruments used to elevate the tooth or dislodged and aspirated.
root from the alveolar socket. ● Intra-alveolar pastes consisting of zinc oxide eugenol,
● Its effectiveness depends on the design of the handle
anaesthetic and antibiotic (metronidazole) can be placed.
and its efficiency on the design of the blade. ● Increased concentration of the drug locally dimin-
● It has the handle, the shaft and the blade.
ishes their secondary effects and protects the under-
● Various elevators used in oral surgery are:
lying socket.
a. Straight elevator ● Appropriate analgesics should be prescribed for pain
b. Winter’s crossbar elevators relief.
c. Cryer’s elevator
d. Periosteal elevators Q.9. Complications of extraction.
e. Apexo elevators Ans.
Q.4. Elevator principles. [Ref LE Q.1]
Ans. Q.10. Wound healing.
[Ref LE Q.4] Ans.
Q.5. Enumerate any two complications of the use of ● While epithelium covers the clot, the angioblastic ingrowth
elevators during exodontias. occurs into the clot and fibroplasia then ensures into the
Ans. clot with cellular elimination of fibrin and blood debris.
● There is production of variable amount of osteoid in-
● Luxate the adjacent tooth. duced by mesenchymal cells.
● Cause perforation of blood vessels, if it slips. ● Woven bone is formed following osteoblastic and osteo-
● Fails to control the force applied. This cause fracture of clastic activity that ends in mature bone, often with
maxilla or mandible. some loss of total bone volume.
● Cause forcing of tooth into antrum, if proper force is not
applied. Q.11. Haemostatic agents.

Ans.
Q.6. Contraindications for extraction.
Commonly used haemostatic agents are
Ans.
Example:
[Ref LE Q.1] ● Turpentine or tannic acid – Frankly dangerous and
causes second-degree burns, where material has leaked

Q.7. Forceps in extraction.
over the face.
Ans. ● Thrombin and Russell viper venom – Precipitate clot
formation when applied on pledget of cotton.

Various forceps used in extraction are
● Oxidized regenerated cellulose.
● Upper anterior forceps
● Bayonet forceps Q.12. Mention four bleeding control measures in postex-

● Upper molar forceps traction bleeding.
● Upper root forceps
Ans.
● Lower anterior forceps
● Lower molar forceps ● Application of pressure

● Use of vasoconstrictors ● Inability to open the mouth is known as Trismus.

● Hypotensive anaesthesia ● Trismus indicates muscle spasm.
● Use of haemostatic agent
Causes
Q.13. Whitehead’s varnish.
i. Odontogenic ● Infective
Ans. ii. Traumatic a. Periodontitis
iii. Neoplastic b. Pericoronitis
● Whitehead’s varnish is the only solution which remains iv. Neurotoxic c. Space infections
uninfected till the stabilization process is complete. v. Psychogenic ● Fractured teeth and jaws
● It consists of aromatic resins which are broken down to ● Tumours eroding the mus-
produce benzoic acid. It is a waterproof solution. cles of mastication

● Tentanus
Whitehead’s varnish contains:
● Hysteria
● Benzoin 10 g
● Iodoform 10 g
● Storax 7.5 g
Q.16. Name the principles of elevators.
● Tolu balsam 5 g Ans.
● Ether 100 mL
[Same as SN Q.4]
Q.14. Bone wax.
Q.17. Healing of extraction wound.
Ans.
Ans.
● Bone wax is a local mechanical haemostatic agent in
case of bone bleeding. [Same as SN Q.10]
● Composition of bone wax: Q.18. Control of haemorrhage by local measures.
Bees wax 7 parts
Olive oil 2 parts Ans.
Phenol 1 part [Same as SN Q.13]
● However, bone wax acts as a foreign object and can lead
to formation of wax granuloma. Q.19. List five causes of trismus.
Q.15. Trismus. Ans.
Topic 6
Impactions
LONG ESSAYS:
1. What are the indications for removal of an impacted tooth? Describe the technique of removal of a mesioangu-
lar impacted lower third molar.
2. Describe the classification of impacted lower third molar. What are its complications?
3. Describe anyone classification for impacted mandibular third molar. Discuss radiological assessment of im-
pacted mandibular third molar.
4. Classify maxillary canine impactions. How do you manage a case of bilaterally impacted upper canine teeth?
5. Describe the various surgical steps involved in the removal of mesioangular impacted lower third molar.
[Same as LE Q.1]
6. Classify impacted mandibular third molar. Write in detail the steps in surgical removal of impacted mandibu-
lar left third molar. [Same as LE Q.1]
7. Describe in detail surgical procedure for removal of mesioangular impacted mandibular third molar. [Same as LE Q.1]
8. Classify impacted mandibular third molars. Enumerate the complications likely to be encountered during and
after surgical removal of impacted lower right third molar teeth. [Same as LE Q.2]
9. Classify impacted mandibular third molars. Enumerate the complications likely to be encountered during and
after surgical removal of horizontally impacted lower right third molar teeth? [Same as LE Q.2]
10. How would you extract an impacted canine from the palate surgically? Give the preoperative and postoperative
management in detail. [Same as LE Q.4]
SHORT ESSAYS:
1 . Radiological examination of lower third molar. [Ref LE Q.3]
2. Winter’s lines and their clinical significance.
3. Classification of impacted maxillary third molar.
4. Wharf’s assessment of mandibular third molar.
5. Early and late complications of impacted third molar surgeries.
6. Localization of impacted maxillary canine.
7. Lingual spilt bone technique.
8. WAR lines. [Same as SE Q.2]
9. Intraoperative complications of surgical removal of impacted mandibular third molar. [Same as SE Q.5]
SHORT NOTES:
1. Winter’s imaginary lines. [Ref SE Q.2]
2. Classify impacted maxillary third molars, based on relative depth of the impacted maxillary third molar in
bone? [Ref SE Q.3]
3. Which teeth are commonly impacted? Mention four complications of prolonged retention of impacted teeth.
4. Name four incisions for removal of impacted mandibular third molar.
5. Mention four steps in exposure of unerupted incisor.
6. Classification of impacted upper canine. [Ref LE Q.4]
7. Impacted tooth.
8. Postoperative complications of removal of impacted mandibular third molar.
9. Pericoronitis.
10. Radiographs used in the assessment of lower third molars.
11. Mention Winter’s lines with significance of each. [Same as SN Q.1]
12. WAR lines in impaction. [Same as SN Q.1]
13. George Winter’s/WAR lines. [Same as SN Q.1]
14. Classify impacted maxillary third molars – any one classification. [Same as SN Q.2]
15. Define impaction of tooth. [Same as SN Q.7]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. What are the indications for removal of an im- Indications for removal of impacted teeth
pacted tooth? Describe the technique of removal of a i. Adults with partially or completely impacted teeth
mesioangular impacted lower third molar. develop pericoronitis.
ii. The need and the urgency for its removal depend on
Ans. whether tooth is asymptomatic or not, as well as its
A tooth which is completely or partially unerupted and is effects on health.
positioned against another tooth bone or soft tissue, so that iii. Second molars are mostly involved with caries or
its further eruption is unlikely described according to its periodontal problems. Root resorption may be due to
anatomic position. the pressure effect.
iv. Pericoronitis may predispose to temporomandibular ● After satisfactory anaesthesia is obtained, the
joint problems. operating field is prepared with the usual
v. Removal of third molars as a preventive measure is methods.
advised in young patients, as young patients tolerate Instruments
the surgery very well; hence complications are few. ● Cartridge syringe with anaesthesia
vi. Pain or paraesthesia may be relieved on removal of ● BP knife
impacted tooth. ● Periosteal elevator
vii. These teeth may become foci of infection leading to ● Chisel and mallet (burs)
the development of premalignant and malignant le- ● Elevators
sions of oral mucosa. ● Tooth forceps
viii. Malocclusion and anterior overcrowding may de- ● Bone file
velop due to pressure on the distal end. ● Haemostats
ix. Impacted teeth are associated with cystic patholo- ● Artery forceps
gies that can lead to fracture of the jaw bone. ● Needle holders
x. Autotransplantation to replace the lost first molar ● Needle and suture material
and removal of mandibular third molar tooth before Surgical procedure

root formation is indicated. Incision
xi. For prosthetic reasons, a third molar may have to be ● The incision for the soft tissue flap is started just
removed to avoid ulcerations under the denture. Par- to the lingual side of the external oblique ridge of
tially erupted ones may be retained to serve as abut- ramus of mandible at a distance of ¾ inch distally
ments for constructing fixed bridge prosthesis. from lower second molar; directed anteriorly until
Method for removal of mesioangular third molar it contacts the midpoint of the distal surface of the
Surgical technique second molar; the incision is continued buccally
Once the assessment has been made, the operation can around the neck of the second molar to the inter-
be planned. It is considered under the following head- proximal space between first and second molars
ings. If necessary, the plan is modified to meet unex- and then it is extended down towards the muco-
pected conditions. buccal fold at 45° angle.
1. Selection of anaesthesia ● It is important to keep this incision to the buccal
2. Instruments side in order that postoperative infection and tri-

3. Incision and refection of the flap (flap design) mus may be kept at a minimum.
4. Bone removal ● Incisions are not made along the internal oblique
5. Luxation and delivery of the tooth ridge of the ramus of mandible, because of the
6. Debridement of the wound proximity of the lingual nerve to lingual cortical
7. Securing haemostasis and closure of the wound plate.
8. Postoperative instructions and care ● To prevent surgical trauma to this nerve, we make
Selection of anaesthesia our incisor from midpoint of the distal surface of

Choice of anaesthesia for the removal of impacted lower second molar distally and buccally.
third molar is influenced by the following factors: ● The incisions that are directly carried posteriorly,
● Available facilities shortly pass off the osseous structures because the
● Operator’s choice ramus flares out laterally at this point and open
● Temperament of the patient into pterygomandibular space.
● Associated diseases ● The buccal flap should meet the basic require-
● Type of the case ments:

● If local anaesthesia is selected for the lower i. It should provide adequate exposure of the
third molar, then an inferior dental nerve block, operative site.
lingual nerve block and long buccal nerve ii. It should have a wide base to ensure good
block is given. blood supply to the soft tissue.
● It is normal to remove the teeth on one side at iii. It should be large enough, so that the soft tis-
a time under local anaesthesia, but in suitable sue over the operative site is not traumatized
patients, experienced operator can remove all during the operation, and so that when flap is
four wisdom teeth during same visit. replaced, the edge rest on a wide shelf of bone.
● Without sedation, around 45 min of surgery Reflection of flap
under local anaesthesia is as much as most ● With a help of periosteal elevator, the mucoperi-
patients find it tolerable. osteum should be reflected by introducing at the

anterior end of the incision and slipped firmly back to its original position it should not rest on
downwards making certain that the periosteum is dead space.
stripped back with the oral mucosa. Postoperative care and instructions
Bone removal i. Proper antibiotics, anti-inflammatory drugs, analge-
● Bone should be removed in order to secure a sics and supportive therapy like B complex are given.
sound fulcrum for an elevator to be inserted. It is ii. Instructed not to gargle and not to do any hot
necessary to remove the obstruction for easy re- fomentation beside advised diet.
moval of an impacted tooth. If the impacted tooth iii. Sutures should be removed after seventh post
is completely covered, then the bone overlying it is operative day.
removed by means of bone burs or chisels or both. Depending on the variations in position of impacted
Removal of impacted tooth from its bed tooth, some slight variation in bone removal and sec-
● Sufficient amount of bone must be removed to tioning of teeth are required as follows:
allow the tooth to be lifted from its bed without ● Locked beneath the crown of second molar –
the necessity of heavy pressure. Requires sectioning of the tooth.

● Luxation of tooth is made with help of straight ● Not locked – Removal, if possible, without sectioning.
elevator or couplands elevator and force should be i. Crown-to-crown position

used to luxate the tooth. Force should not be ap- ● It requires removal of collar bone superior and
plied in the attempted removal of any impacted lateral to the root. The tooth is then elevated on
tooth, until all resistance due to dense bone has the mesial aspect of the cervical area. The tooth
been removed. This is especially in lower third is then sectioned along its furcation.
molar, since fracture of mandible may result. ii. Crown to cervix
● Once the tooth is luxated, delivery of tooth is at- ● Removal of bone over the crown’s occlusal,
tempted with the help of forceps. coronal, distal and buccal surfaces down to the
● One should be careful to prevent aspiration of contour of the crown.
tooth slipping out of dental forceps, while remov- ● Bone removal extends along the long axis of the
ing the tooth. third molar. Sectioning of the bifurcation and

Debridement single root will require removal of the anterior
● The socket toilet should follow the completion of and occlusal area.
extraction. Debridement of wound includes re- ● Remaining portion of tooth is elevated from the
moval of dental follicle which is attached to mesial aspect of the tooth.

socket. iii. Crown to root
● Besides, small bony spicules or any necrosed tis- ● Bone removal on the buccal aspect to expose the
sues should be removed. superior and lateral aspect of the third molar fol-
● Sharp bony edges due to cutting of bone should lowed by sectioning of the root as above.
also be made smooth with the help of bone file, iv. Unfused roots
especially on lingual side, as they may irritate ● The third molar is sectioned along the long axis
patient’s tongue. with bur/chisel avoiding the thin lingual plate.
● Finally, socket should be flushed with normal sa- Then, the distal half is removed using buccal plate
line to remove any foreign particles remaining. as the fulcrum followed by removal of other half.
Haemostasis v. Fused roots
● Haemostasis should be secured before closure of ● The tooth is divided along the cementoenamel
wound, otherwise it might lead to haematoma junction (CEJ), and the roots are then removed
formation and might spread into surrounding with the help of apex elevator using purchase
spaces. This can be done by applying pressure point on the tooth and the buccal bone as fulcrum.
with a pressure pack soaked in adrenalin.
● If the bleeding does not stop with pressure pack, Q.2. Describe the classification of impacted lower third
then one might consider applying bone wax on molar. What are its complications?
bleeding surfaces of bone. If bone wax is not
Ans.
available, then gel foam may be packed.
Closure of wound Impacted mandibular third molar
● It should be done after securing complete haemo- It is necessary for the surgeon to classify mandibular
stasis by giving interrupted sutures. impacted third molars to determine the difficulties en-
● The loop of the stitch should be large enough to countering the removal as well as to plan the surgical
facilitate its removal, and when flap is reflected procedure.
Winter’s classification (1926) 4 . Horizontal

This classification is based on position of the long 5. Buccoangular
axis of the impacted third molar tooth in relation to 6. Linguoangular
the long axis of the second molar. 7. Inverted position
This can be divided in to eight groups: 8. Unusual position
1. Vertical
2. Mesioangular These may also occur simultaneously in buccal version,
3. Distoangular lingual version and torso version.
4. Horizontal Complications likely to be encountered during and after
5. Buccoangular surgical removal of impacted lower third molar teeth
6. Linguoangular i. Possibility of damage to inferior dental nerve
7. Inverted position a. During the removal of distal bone – Particularly
8. Unusual position for deep distoangular impacted teeth.
Pell and Gregory classification (1933) b. During division of crown of horizontal tooth –
● Impacted mandibular third molars were classified Particularly if it lies low in the jaw.
very similar to that of Winter’s classification by c. During splitting of tooth with an osteotome – if
utilizing the three-dimensional tills of its long nerve is in contact with root of the tooth.
axis. d. During mesial application of elevator for MA
a. Relationship of teeth to the ramus of the mandible tooth – if nerve lies at apex.
b. Relative depth at which it is placed e. Where nerve grooves or perforates the root of
c. The long axis of impacted tooth in relation to tooth – the risk of dividing the nerve is high.
second molar If the risk is anticipated it can be handled by careful
Pell and Gregory’s classification includes a por- surgery, but not eliminated.
tion of George B. Winter’s classification is an ii. The lingual nerve is at risk
excellent one. a. From periodontal elevators raising the lingual
A. Relation of the tooth to the ramus of the man- flap – If the reflection of flap is too much lingual.
dibular and second molar b. From lingual flap retractors – Prolonged retraction
Class I of lingual nerve with other lingual tissues results
There is sufficient amount of space between in a neuropraxia even while it protects the nerve
ramus and distal side of second molar for the from more serious damage. Care must be taken to
accommodation of the mesiodistal diameter of see that the retractors are between nerve and bone.
the crown of the third molar. c. From the instruments used for both cutting and
Class II grasping the lingual bone; and from the lingual
The space between the ramus and distal side of plate itself, if split bone technique is used.
the second molar is less than the mesiodistal d. From a suture which may underrun the nerve, if
diameter of the crown of third molar. large bite of lingual flap is taken.
Class III iii. Patient having difficulty in swallowing due to dam-
All or most of the third molar is located within age to superior constrictor muscle, which sometimes
the ramus. happens because of fracture to the lingual plate.
B. Relative depth of the third molar in bone iv. Trismus, because of damage to masseter and medial
Position A: The highest portion of the tooth is on pterygoid muscle.
a level at or above the occlusal line. v. Fracture of angle of mandible if too much force is
Position B: The highest portion of the tooth is employed during luxation of tooth.
below the occlusal plane, but above the cervical vi. Dislocation of TMJ because of not taking mandibu-
line of the second molar. lar support during luxation.
Position C: The highest portion of the tooth is vii. Traumatic arthritis since patients keep their mouth
below the cervical line of the second molar. opened for long time.
C. The position of the long axis of the impacted viii. Hypersensitivity when patient takes hot and cold,
mandibular third molar in relation to the long because of exposure of cementum of second molar.
axis of the second molar (from Winter’s clas- ix. Damage to neighbouring tooth while removing the
sification) bone.
1. Vertical x. Slipping of impacted tooth into submandibular
2. Mesioangular space, if the lingual plate breaks.
3. Distoangular xi. Aspiration of tooth.
Q.3. Describe anyone classification for impacted man- Position C: The highest portion of the tooth is below
dibular third molar. Discuss radiological assessment of the cervical line of the second molar.
impacted mandibular third molar. C. The position of the long axis of the impacted man-
dibular third molar in relation to the long axis of
Ans.
the second molar (from Winter’s classification)
Classification of impacted mandibular third molar 1. Vertical
It is necessary for the surgeon to classify mandibular 2. Mesioagular
impacted third molars to determine the difficulties en- 3. Distoangular
countering the removal as well as to plan the surgical 4. Horizontal
procedure. 5. Buccoangular
Winter’s classification (1926) 6. Linguoangular
This classification is based on position of the long 7. Inverted position
axis of the impacted third molar tooth in relation to 8. Unusual position
the long axis of the second molar. These may also occur simultaneously in buccal ver-
This can be divided in to eight groups: sion, lingual version and torso version.
1. Vertical Assessment of lower third molars
2. Mesioangular ● Successful third molar surgery is dependent
3. Distoangular upon detailed preoperative assessment and

4. Horizontal treatment planning and the skilful application
5. Buccoangular of an appropriate operative technique.
6. Linguoangular ● Treatment planning is based on a thorough
7. Inverted position clinical evaluation of the patient with reference

8. Unusual position to the general and local factors. Systemic
Pell and Gregory classification (1933) evaluation is identical to any other surgical
● Impacted mandibular third molars were classified procedures.
very similar to that of Winter’s classification by General factors
utilizing the three-dimensional tills of its long axis. i. A conscious assessment of general size and built
a. Relationship of teeth to the ramus of the mandible. of the patient.
b. Relative depth at which it is placed. A large patient treatment of massive mandible
c. The long axis of impacted tooth in relation to presents a different problem from a small deli-
second molar. cately boned patient.
Pell and Gregory’s classification includes a por- ii. Patient attitude and demeanour gives valuable
tion of George B. Winter’s classification is an clues as to the way he or she will respond to the
excellent one. stress of surgery, and therefore type of anaesthe-
A. Relation of the tooth to the ramus of the man- sia or sedation which will be required.
dibular and second molar iii. Age and general fitness:
Class I ● These are important in the context of any op-
There is sufficient amount of space between ra- erative procedure, but undoubtedly increas-
mus and distal side of second molar for the ac- ing-age adds to the difficulty of the removal
commodation of the mesiodistal diameter of the of lower third molars.
crown of the third molar. ● Compared with a teenager, the young adult in
Class II later 20s will already have bone, which is

The space between the ramus and the distal side significantly more difficult to cut; and, teeth
of second molar is less than the mesiodistal diam- which require more force to separate them
eter of the crown of third molar. from the bone.
Class III ● At a variable age between 40s and late 60s,
All or most of the third molar is located within the the mandibular bone will develop a hard,
ramus. brittle quality and attached teeth with rigidity,
B. Relative depth of the third molar in bone which succumbs to an extraction force only
Position A: The highest portion of the tooth is on a after a substantial amount of investing bone
level at or above the occlusal line. has been removed.
Position B: The highest portion of the tooth is below iv. Size of the oral cavity, size of the tongue and be-
the occlusal plane, but above the cervical line of the haviour of the tongue should be noted when it
second molar. tends to spread over the occlusal surface of teeth or
to move into area of examination it can be antici- ● If the tooth is in a position which makes it difficult
pated that operatory is complicated. to keep clean and if it is already carious and if it
v. Size of rima oris – The degree to which the does not and will not occlude with a tooth which is
patient can open mouth with extensibility of to be retained and particularly if it is over erupted,
lips and cheeks. All these contribute to surgi- it should be extracted. If it bites on the gum flap of
cal access. the lower third molar, then its extraction may cut
vi. The condition of the first and second molars short an attack of pericoronitis, permitting more
may affect decision to remove the wisdom latitude in the timing of lower third molar surgery.
teeth.
[SE Q.1]
Large crowns, inlays and amalgam fillings in
second molar can be dislodged during elevation {Radiographic examination
of the third molar even though care is being ex- Radiographs used are
cised. 1. Intra oral periapical (IOPA) films:
Local examination ● Most commonly used for the assessment of the third
● Attention is then focused on each third molar in molar teeth.

turn observing how much of the crown is visible ● Show whole of lower second and third molars, bone
or palpable if it is unerupted. surrounding the latter and inferior dental canal.

● On examination, the state of eruption is noted. If ● Details which they reveal are better than with any
unerupted, probing the distal aspect of the sec- other technique.

ond molar will confirm whether the tooth is in ● The film should be positioned with care. In general,
communication with the mouth and if there is the mesial edge of the film should not lie further
any pocket leading down to the crown of third forward than the mesial surface of the first molar
molar. for vertical, mesioangular and distoangular impac-
● If partially erupted, the depth of any visible tions. For the horizontal teeth, the mesial edge
crown below the occlusal plane and its general should not lie further than the width of first molar.
relation to the level of alveolar crest is noted, as 2. Lateral radiographic views of the mandible
it is the distance between the distal surface of the ● When the unerupted tooth is deeply buried, it may
second molar and anterior border of the ascend- not be possible to get whole of it and adjacent struc-
ing ramus. tures on the IOPA film. For this, a lateral projection
● The external and internal oblique ridges of the should be used.
mandible are palpated. If the external oblique Disadvantage
ridge is low relatively vertical and relatively ● Distance between the film and the tooth is greater,
posterior to the tooth, then there will be thin so the definition is reduced.
alveolar bone, buccal to the third molar. If the ● The angulation of the central ray is so angulated
external oblique ridge lies high and well for- that the relationship between second and third
ward relative to the tooth, then the thick cortex molars is not accurately shown.
of the ridge will form the bone, buccal to the Advantages
third molar. ● Advantages of labial oblique view are that, they
● If the internal oblique ridge lies well back, then will show those teeth which are deeply buried,
there will be thin bone both distally and lingually grossly misplaced or involved in secondary pa-
to the wisdom tooth. Conversely, an anteriorly thology such as cyst.
placed internal oblique ridge carries thick bone 3. OPG (orthopantamograph)
around the third molar on the lingual side. ● Some of the disadvantages of lateral oblique can be
● The condition of the soft tissues over the wis- overcome by this view.
dom tooth itself is noted whether they are 4. Occlusal views
scarred and indented by the upper third molar. ● It is a radiograph which is difficult to take, but is in-
Presence of active pericoronitis or pus beneath dicated when the third molar is lying across the arch.
the gum flap is noted. Both these conditions re- ● The view reveals the buccolingual position of at least
quire treatment and there may be a delay before the crown of the impacted tooth. It is essential for the
operation. buccolingually placed teeth to identify the way, the
● The position and condition of the upper third mo- crown is pointing and to show the shape of the roots.
lar is checked and its occlusal relationships to the ● It is helpful to show the structures of the lingual al-
lower third molars are noted. veolar plate, where third molar is buccally placed.}
Localizing mandibular canal in relation to apices of Factors Easy Difficult

lower third molar:
6. Surrounding Elastic or cancel- Dense or cortical
● As the means of localizing this canal frankly sug-
bone lous
gested that a modification of tube shift can be
used to determine whether the mandibular canal is 7. Relationship Space distal to No space distance
Second molar Not related Related
medial to, lateral to or below the impacted third Inferior alveolar
molar. canal
● Principle involved is the same as that of the ‘clark
8. Oral sphincter Large Small
shift technique’ in localizing the maxillary im-
pacted cuspids. 9. Health status Satisfactory Medically compro-
mised
Frank’s technique
● By placing two films in identical positions in the
mouth when X-raying lower third molar and by

changing the position of the X-ray tube, we can
Q.4. Classify maxillary canine impactions. How do you
determine whether the canal lies lingually or buc-
manage a case of bilaterally impacted upper canine
cally to impaction, or lies in the same place as the
teeth?
tooth.
● To accomplish this, the X-ray angle must be Ans.
shifted 25° upwards and the second film should be
compared to film taken with the X-ray tube placed {SN Q.6}
parallel to occlusal plane of teeth.
● In the mouth, an X-ray taken from 25° below Classification of impacted maxillary cuspids
plane of occlusion will make a distant object i. Class I: Impacted cuspids located in the palate.
move downward in relation to object in the fore- a. Horizontal
ground. b. Vertical
● If mandibular canal lies lingual to impaction, then c. Semivertical (oblique)
it will move downwards in relation to roots of ii. Class II: Impacted cuspids located in the labial or the
third molar. buccal surface of the maxilla.
● Canal on buccal side of roots will appear to move a. Horizontal
upward on roots. b. Vertical
● If canal removes in same position, then it is di- c. Semivertical
rectly below the roots or between roots or in iii. Class III: Impacted cuspids located in both the pala-
groove in the root surface apically, lingually or tal process and the labial or buccal maxillary bone.
buccally. Example: Crown is on palate and root passes through
between roots of the adjacent tooth in the alveolar
process ending in a sharp angle on the labial or buc-
Evaluation of factors that render third molar surgery easy or
cal surface of maxilla.
difficult
iv. Class IV: Impacted cuspids located in the alveolar
process usually vertically between incisors and first
Factors Easy Difficult bicuspids.
1. Pell and Greg- Class I Class III v. Class V: Impacted cuspids located in an edentulous
ory classifica- Position A Position C maxilla.
tion
vi. This is also classified based on its unusual position
Horizontal
plane like tooth – In the floor of the nose.
Vertical plane ● In the antrum
● In infraorbital margin
2. Overlying Soft tissue Bone
impedimen
3. Crown Small Large
Surgical technique
4. Roots Incomplete Complete a. Choice of anaesthesia – Local or general anaesthesia.
Formation Favourable Unfavourable
Curvature Conical or conver- Long, slender and
Local anaesthesia – Infra orbital block, palatine
Morphology gent divergent nerve block and nasopalatine nerve block.
General anaesthesia – It is the choice in case of very
5. Follicular space Large Thin and small
apprehensive patients or uncooperative patients.
b. Choice of instruments susceptible bony margins may be trimmed

● Retractors smoothly. Then the wound is irrigated with nor-
● BP knife mal saline to remove any leftover bony particles
● Scissors and soft tissue particles.
● Periosteal elevators Hemostasis and suturing
● Haemostats ● Before closure of the wound, complete haemosta-
● Tooth forceps sis is secured by giving a pressure pack or packing

● Bone chisels and mallet bony cavity with gelfoam. Once haemostasis is
● Drills and Ronguer forceps secured, wound may be closed with interdental
● Elevators and suturing materials interrupted sutures palatolabially after closure of
Procedure wound with suture. A palatal splint may be given
Incision to protect the wound from infection to control the
● Depending on position of unerupted canine, either bleeding and to achieve satisfactory adaptation of
buccal or palatal incision may be given. If tooth palatal flap.
is on the buccal aspect, either semilunar or a Postoperative care and instructions
U-shaped incision just above the gingival margin ● Suitable antibiotics, analgesics, supportive ther-
extending up to mucobuccal fold or sulcus should apy, B-complex, vitamin C and general therapy
be taken. may be given.
● Bilateral impactions – Incision from first molar on ● Sutures may be removed after seventh postopera-
one side to the first molar on the opposite side of tive day.
the maxilla. Complications
Reflection of flap ● Damage to adjacent teeth leading to nonvitality or
● Periosteal elevator is used with a firm grip, since loosening of adjacent teeth.
palatal mucosa is firmly attached to the bone. Flap ● Perforation of maxillary sinus (O-A fistula).
should be retracted in such a way that sufficient part ● Perforation of nasal cavity (floor of nose) (O-N
of palate is exposed to permit ready accessibility. fistula).

● Care should be taken to avoid damage to neuro- ● Fracture of premaxilla.
vascular bundle emerging from the incisive and

greater palatine foramen. Q.5. Describe the various surgical steps involved in the
Bone removal removal of mesioangular impacted lower third molar.
● If tooth is on the surface, a bony bulge can be seen
Ans.
which serves as a landmark for removal of the
bone. The bone is removed until crown of tooth is [Same as LE Q.1]
exposed and perforation can be enlarged by means
of burs and chisels. Q.6. Classify impacted mandibular third molar. Write
● Care should be taken so that roots of adjacent in detail the steps in surgical removal of impacted man-
teeth are not injured. dibular left third molar.
● A groove is cut in the bone on mesial side of
Ans.
crown, so that an elevator can be passed beneath it.
Luxation and delivery of tooth [Same as LE Q.1]
● Luxation may be attempted after the resistance of
crown. Q.7. Describe in detail surgical procedure for removal of

● Suitable elevator is used to lift the tooth after the mesioangular impacted mandibular third molar.
crown emerges into position, which after the ap-
Ans.
plication of extraction forceps the tooth may be
removed. [Same as LE Q.1]
● If delivery of tooth is difficult because of bony
resistance, underlying pathology associated with Q.8. Classify impacted mandibular third molars. Enu-
tooth-like dilacerated roots, hypercementosis or merate the complications likely to be encountered dur-
locking with neighbouring teeth, then sectioning ing and after surgical removal of impacted lower right
of tooth is indicated. third molar teeth.
Debridement
Ans.
● Includes complete removal of dental follicle, bone
chips (any soft tissue and cartilage) and later [Same as LE Q.2]
Q.9. Classify impacted mandibular third molars. Enu-

Red line
merate the complications likely to be encountered dur-
● This third imaginary line of Winter is used to
ing and after surgical removal of horizontally impacted
measure the depth at which an impacted tooth lies
lower right third molar teeth?
in the mandible.
Ans.
[Same as LE Q.2] ● This is drawn perpendicular the amber line to an imagi-
Q.10. How would you extract an impacted canine from nary point of application of elevator. Usually, cemento
the palate surgically? Give the preoperative and postop- enamel junction on the mesial surface of impacted tooth
erative management in detail. is used except for distoangular teeth.
● As the red line increases by 1 mm, more difficult the
Ans. extraction will be.
● If red line is 9 mm or more, then the inferior surface of
[Same as LE Q.4]
crown of impacted tooth may beat the level of apex of
second molar or even below. If the distal aspect of the
SHORT ESSAYS: second molar is denuded, then it is advisable to extract
Q.1. Radiological examination of lower third molar. the second molar instead.
Ans. Q.3. Classification of impacted maxillary third molar.
[Ref LE .Q.3] Ans.
Q.2. Winter’s lines and their clinical significance. Classification of maxillary third molar impaction based on
anatomic position is as follows:
Ans. A. Relative depth of the impacted maxillary third mo-
lar in bone
{SN Q.1}
● Position and depth of an impacted tooth can be deter- {SN Q.2}
mined by a method first described by George Winter. Class A: Lowest portion of the crown of impacted
● WAR lines are three imaginary lines drawn on the maxillary third molar is on a line with occlusal plane
radiograph, which are given three distinct colours, of second molar.
i.e. white line, amber line and red line. Class B: Is between the occlusal plane of second
White line molar and the cervical line.
● This line is drawn along the occlusal surface of Class C: Is at or above the cervical line of second molar.
erupted mandibular molars and extended posteri-
orly over the third molar. The axial inclination of
the third molar becomes evident.
B. The position of the long axis of the impacted maxil-
● The occlusal surface of third molar vertically im-
lary third molar in relation to long axis of second
pacted is parallel to the ‘white line’, while, in case
molar
of a distoangular impaction, the white line and the
1. Vertical
occlusal surface of third molar converge to meet
2. Horizontal
in the second molar region. It can also be used as
3. Mesioangular
a guidance indicating the relative depth of the
4. Distoangular
tooth in mandible.
5. Inverted
Amber line
6. Buccoangular
● The second line is drawn from the surface of the
7. Linguoangular
bone lying distal to third molar to the crest of in-
These may also occur simultaneously in buccal version,
terdental septum between the first and second
lingual version and torso version.
molars.
C. Relationship of the impacted maxillary third molar
● It indicates the amount of alveolar bone enclosing
to maxillary sinus
the tooth. It shows only the tooth above and in
i. Sinus approximation (SA): No bone or a thin parti-
front of the amber line. Hence, it is very essential
tion of bone between the impacted maxillary third
to differentiate the shadow cast by external
molar and the maxillary sinus is known as maxillary
oblique ridge and that of bone to the tooth.
sinus approximation.
ii. No sinus approximation (NSA): Bone of 2 mm or b. During division of crown of horizontal tooth –
more thickness between impacted maxillary third Particularly if it lies low in the jaw.
molar and maxillary sinus is known as no maxillary c. During splitting of tooth with an osteotome – If
sinus approximation. nerve is in contact with root of the tooth.
d. During mesial application of elevator for MA
Q.4. Wharf’s assessment of mandibular third molar.
tooth – If nerve lies at apex.
Ans. e. Where nerve grooves or perforates the root of
tooth – The risk of dividing the nerve is high.
● Wharf’s assessment helps beginners to anticipate
If the risk is anticipated, then it can be sundered by
problems and avoid difficult impaction. The total scor-
careful surgery but not eliminated.
ing to individual cases is directly related to corre-
ii. The lingual nerve is at risk.
sponding difficulties that one is liable to encounter
a. From periodontal elevators raising the lingual
during removal of an impacted tooth. Scoring details
flap – If the reflection of flap is too much lingual.
are as follows:
b. From lingual flap retractors – Prolonged retrac-
1. Winter’s classification Horizontal 2 tion of lingual nerve with other lingual tissues
results in a neuropraxia even while it protects
Distoangular 2
the nerve from more resinous damage. Care
Mesioangular 1 must be taken to see that the retractors are be-
Vertical 0 tween nerve and bone.
1–30 mm 0
c. From the instruments used to both cut and grasp
2. Height of mandible
the lingual bone and from the lingual plate itself
31–34 mm 1 if split, bone technique is used.
35–39 mm 2 d. From a suture which may underrun the nerve if
large bite of lingual flap is taken.
3. Angulations of third 1–50° 0
molar iii. Patient having difficulty in swallowing due to dam-
age to superior constrictor muscle which sometimes
60–69° 1
happens, because of fracture to the lingual plate.
70–79° 2 iv. Trismus, because of damage to masseter and me-
80–89° 3 dial pterygoid muscle.
v. Fracture of angle of mandible if too much force is
90°1 4
employed during luxation of tooth.
4. Root shape Complex 1 vi. Dislocation of TMJ because of not taking mandib-
Favourable 2 ular support during luxation.
Unfavourable 3
vii. Traumatic arthritis, since patients keep their mouth
opened for long time.
5. Follicle Normal 0
viii. Hypersensitivity, when patient takes hot and cold
Possibly enlarged 1 because of exposure of cementum of second molar.
Enlarged 2 ix. Damage to neighbouring tooth while removing the
bone.
6. Exit path Space available 0
x. Slipping of impacted tooth in to submandibular
Distal cusp covered 1 space if the lingual plate breaks.
Mesial cusp covered 2 xi. Aspiration of tooth.
Both covered 3
Q.6. Localization of impacted maxillary canine.
Total 33
Ans.
Q.5. Early and late complications of impacted third In case of doubt whether the tooth is lying buccally or pal-
molar surgeries. atably, then following steps are considered:
● Shift sketch method: Technique of procedure is to
Ans.
expose two or more periapical radiographs of same area
Complications shifting the table horizontal between exposures.
i. Possibility of damage to infection dental nerve. ● As a result of changes in horizontal angulation, un-
a. During the removal of distal bone – Particularly erupted tooth or foreign body moves mesially or distally
for deep DA teeth. in relation to other or landmarks.
● Rule governing this S-S-method: If the unerupted tooth SHORT NOTES:

moves in the same direction in which tube is shifted,
then it is located on the lingual side. Q.1. Winter’s imaginary lines.
● If it moves in the opposite direction in which the tube is
Ans.
shifted, then the location is seen on labial or buccal side.
If there is no obvious change, then the crown probably [Ref SE .Q.2]
lies wedged in arch between adjacent teeth.
Q.2. Classify impacted maxillary third molars, based on
relative depth of the impacted maxillary third molar in
Q.7. Lingual spilt bone technique.
bone?
Ans.
Ans.
Lingual split bone technique
[Ref SE Q.3]
● It was described originally by Sir William Kelsey Fry.
● Later, popularized by T. Ward. Q.3. Which teeth are commonly impacted? Mention four
● Quick and clean technique. complications of prolonged retention of impacted teeth.
● Creates a saucerization of the socket, thereby reduc-
ing the size of the residual blood clot. Ans.

● Used for mandibular third molar removal, especially
Teeth that are commonly impacted are maxillary third mo-
those which are placed lingually.
lars, mandibular third molars, maxillary canines and man-
● Supports the mandible at the inferior border.
dibular premolars.
Steps
Complications due to retention of impacted teeth are as
● Vertical stop-cut is made by facing the chisel
follows:
bevel posteriorly, distal to the second molar.
i. Trismus, because of damage to masseter and medial
● With the chisel bevel downward, a horizontal cut
pterygoid muscle.
is made backward from the lower end of the verti-
ii. Fracture of angle of mandible, if too much force is em-
cal limiting stop-cut.
ployed during luxation of tooth.
● The buccal bone plate is removed above the hori-
iii. Dislocation of TMJ, because of not taking mandibular
zontal cut.
support during luxation.
● The distolingual bone is then fractured inward by
placing the cutting edge of the chisel along the dot- Q.4. Name four incisions for removal of impacted man-
ted line A. Bevel side of the chisel is facing upward dibular third molar.
and cutting edge is parallel to the external oblique
ridge. The chisel is held at 45° to the bone surface. Ans.
● Finally, small wedge of bone, which then remaining
● L-shaped incision
distal to the tooth and between the buccal and lingual,
● Bayonet flap
is cut. A sharp straight elevator is then applied and
● Envelope flap
minimum force is used to elevate the tooth. As the
● Triangular flap
tooth moves upward and backward, the lingual plate
gets fractured and facilitates the delivery of the tooth. Q.5. Mention four steps in exposure of unerupted
● After the tooth is removed, the lingual plate is
incisor.
grasped with the haemostat and freed from the
soft tissue and removed. Ans.
● Smoothening of the edges is done with bone file.
● Incision of flap
● Wound irrigated and sutured.
● Elevation of flap
● Retraction of flap
Q.8. WAR lines. ● Bone removal
Ans.
Q.6. Classification of impacted upper canine.
[Same as SE Q.2]
Ans.
Q.9. Intraoperative complications of surgical removal of
impacted mandibular third molar. [Ref LE .Q.4]
Ans. Q.7. Impacted tooth.

● An impacted tooth is a tooth, which is completely or The radiographs used to view the impacted teeth are
partially unerupted and is positioned against another i. IOPA radiograph
tooth bone or soft tissue, so that its further eruption ii. Lateral view of mandible
is unlikely and described according to its anatomic iii. OPG
position. iv. Occlusal view
Q.8. Postoperative complications of removal of im- Q.11. Mention Winter’s lines with significance of each.
pacted mandibular third molar.
Ans.
Ans.
[Same as SN Q.1]
Complications
Q.12. WAR lines in impaction.
i. Trismus, because of damage to masseter and medial
pterygoid muscle. Ans.
ii. Fracture of angle of mandible, if too much force is
[Same as SN Q.1]
employed during luxation of tooth.
iii. Dislocation of TMJ, because of not taking mandibu- Q.13. George Winter’s/WAR lines.
lar support during luxation.
Ans.
iv. Traumatic arthritis, since patients keep their mouth
opened for long time. [Same as SN Q.1]
Q.9. Pericoronitis. Q.14. Classify impacted maxillary third molars – any
one classification.
Ans.
Ans.
● Pericoronitis is defined as the inflammation of the soft
tissues of varying severity around an erupting or par- [Same as SN Q.2]
tially erupted tooth with breach of the follicle.
Q.15. Define impaction of tooth.
● Mandibular third molars are most often involved.
● It is one of the common causes for the removal of im- Ans.

pacted molars.
[Same as SN Q.7]
Q.10. Radiographs used in the assessment of lower third
molars.
Ans.
Topic 7
Maxillofacial Trauma
LONG ESSAYS:
1 . What are the signs and symptoms in Le Fort I fracture? How do you manage the same?
2. Describe the bones involved in Le Fort II fracture. How will you manage it?
3. Write the clinical features and treatment of Le Fort III fractures of midface.
4. Classify zygomatic complex fracture. Enumerate the C/F and its management.
5. Classify midface fracture. Discuss the management of malunited zygomatic fracture.
6. Write the golden hour of trauma importance and note on protocol to be followed in road traffic accident victim
management and on life support system.
7. Classify the fractures of the middle third facial skeleton. Write in detail about the clinical features, investiga-
tions and management of Le Fort I fracture. [Same as LE Q.1]
8. Classify the fractures of maxilla. Write in detail the clinical features, investigations and management of a
Le Fort I fracture. [Same as LE Q.1]
9. Discuss the signs, symptoms, complications and treatment of Le Fort I fracture of maxilla. [Same as LE Q.1]
10. Classify middle third fracture of the facial skeleton. Describe in detail the anatomical extension, clinical feature
and treatment of Le Fort I fracture. [Same as LE Q.1]
11. Describe the signs and symptoms of Le Fort I fracture and its management. [Same as LE Q.1]
12. Classify fractures of the mid face. Describe the clinical features and management of a Le Fort I fracture.
[Same as LE Q.1]
13. Classify fractures of middle third of the facial skeleton. How would you manage a Le Fort I fracture?
[Same as LE Q.1]
14. Describe signs, symptoms and management of Le Fort III fracture. [Same as LE Q.3]
15. Classify middle third facial fractures. Describe clinical features and management of a case of Le Fort III
fracture. [Same as LE Q.3]
16. Describe Le Fort III fracture and its management. [Same as LE Q.3]
17. Classify maxillary fractures. Describe the clinical features and management of fracture of zygoma.
[Ref LE Q.4]
18. Describe the clinical findings of zygomatic complex fracture. Enumerate the various methods of reducing the
zygomatic arch fracture and discuss anyone in detail. [Same as LE Q.4]
19. Describe emergency care in facial trauma. [Same as LE Q.6]
SHORT ESSAYS:
1. Classification of fractures of the middle third of facial skeleton. [Ref LE Q.1]
2. Le Fort I fracture. [Ref LE Q.1]
3. Le Fort II fracture. [Ref LE Q.2]
4. Emergency radiology in facial injury.
5. Classification of zygomatic fractures.
6. Blowout fracture of orbit.
7. Nasal fracture.
8. Orbital trauma assessment.
9. Surgical anatomy of orbit.
10. Gilles temporal approach.
11. Pyramidal fracture. [Same as SE Q.3]
12. Clinical features and management of zygomatic arch fractures. [Same as SE Q.5]
13. Blowout fracture. [Same as SE Q.6]
SHORT NOTES:
1. Diplopia.
2. CSF rhinorrhoea.
3. Cavernous sinus thrombosis.
4. Nonunion.
5. Epistaxis.
6. Greenstick fracture.
7. Malunion.
8. Principles of fracture management.
9. Fixation methods in trauma.
10. Advantages and disadvantages of indirect fixation of fractures.
11. Transosseous wiring.
12. Miniplate osteosynthesis.
13. Methods of wiring in oral surgery.
14. Ebernation.
1 5. Gillies temporal approach. [Ref SE Q.10]

16. CSF rhinorrhoea.
17. Define blowout fractures. [Ref SE Q.6]
18. Le Fort classification of maxillary fracture. [Ref LE Q.1]
19. Define Guerins fracture.
20. Give any four signs and symptoms of Le Fort III facial fractures. [Ref LE Q.3]
21. Diplopia.
22. Clinical features and management of zygomatic arch fractures? [Ref LE Q.4]
23. Asche’s forceps.
24. Bristow’s elevator.
25. Whalsham’s forceps.
26. Hanging drop sign.
27. Wire osteosynthesis. [Same as SN Q.11]
28. Gillies approach. [Same as SN Q.15]
29. Cerebrospinal fluid rhinorrhoea. [Same as SN Q.16]
30. CSF rhinorrhoea. [Same as SN Q.16]
31. What do you understand by the term ‘monocular diplopia’? [Same as SN Q.21]
32. Name four signs and symptoms of zygomaticomaxillary complex. [Same as SN Q.22]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. What are the signs and symptoms in Le Fort I frac- III. According to Rowe and Williams (1985)
ture? How do you manage the same? A. Fractures not involving the occlusion
i. Central region:
Ans.
a. Fractures of the nasal bones and/or nasal
(SE Q.1 and SN Q.18) septum
● Lateral nasal injuries
{(Fractures of the middle third of facial skeleton are ● Anterior nasal injuries
classified as follows: b. Fractures of the frontal process of the maxilla

I. In 1901, Rene Le Fort, based on his experimental c. Fractures of type (a) and (b) which extend
work with cadavers, classified maxillary fractures into the ethmoid bone (naso-ethmoid)
according to the level of injury as: d. Fractures of type (a), (b) and (c) which
i. Le Fort I extend into the frontal bone
ii. Le Fort II ii. Lateral region: Fractures involving the zygo-
iii. Le Fort III)} matic bone, arch and maxilla (zygomatic
complex) excluding the dentoalveolar com-
[SE Q.1] ponent
II. {A simple classification for ordinary practical pur- B. Fractures involving the occlusion
poses of diagnosis and treatment planning is as fol- i. Dentoalveolar
lows: ii. Subzygomatic
● Le Fort I (low level or Guerin)
i. Dentoalveolar fractures
● Le Fort II (pyramidal)
ii. Zygomatic complex fractures
iii. Nasal fractures iii. Suprazygomatic
● Le Fort III (high level or craniofacial dys-
iv. Naso-orbital-ethmoid fractures
v. Orbital fractures junction)}
vi. Le Fort fractures [SE Q.2]
● Le Fort I or low level or infrazygomatic or
Guerin fractures {Le Fort I (low level or Guerin type fractures)

● Le Fort II or pyramidal or infrazygomatic ● The fracture line extends from the nasal septum to
fractures the lateral pyriform rims, travels horizontally
● Le Fort III or suprazygomatic fractures above the teeth apices, runs below the zygomatic
All these fractures may be unilateral or bilateral buttress and crosses the lower third of the ptery-
vii. Extended Le Fort fractures goid laminae.
Signs and symptoms ● In edentulous patients, a custom acrylic occlusal

● Slight swelling of the upper lip as well as open splint or the patient’s own denture can be used.
bite is seen, especially if the fractured segment is ● MMF is removed at the end of the case, if intra-
mobile. oral fixation is not possible and if rigid fixation is

● Ecchymosis is seen in the buccal sulcus beneath performed.}
each zygomatic arch.
● Disturbance in occlusion along with mobility in
Q.2. Describe the bones involved in Le Fort II fracture.
the tooth bearing segment of the maxilla. How will you manage it?
● Damage to the cusp, especially premolar of max-
Ans.
illa is seen due to the impact of the mandibular
teeth on them in impacted type of fractures. A fracture may be defined as a sudden break in the continu-
● With Le Fort I, there is movement of the teeth and ity of the bone and it may be complete or incomplete.
the maxilla, but the nose and the upper face will Fractures of the middle third of facial skeleton are clas-
stay fixed. Fracture of the palate is also seen. sified as follows:
● On percussion of the maxillary teeth, a ‘cracked- I. In 1901, Rene Le Fort, based on his experimental work
pot sound’ can be heard. with cadavers classified maxillary fractures according
● No tenderness over, or disorganization and mobil- to the level of injury as:
ity of the zygomatic arch and bones. i. Le Fort I
Radiographic examination ii. Le Fort II
I. Routine radiographic examination of the face iii. Le Fort III
Includes the Water’s view, the Caldwell view (PA II. A simple classification for ordinary practical purposes
view), the lateral view and sometimes the sub- of diagnosis and treatment planning is as follows:
mentovertex view. Water’s projection provides i. Dentoalveolar fractures
the most comprehensive demonstration of the ii. Zygomatic complex fractures
facial skeleton. iii. Nasal fractures
II. Computed tomography (CT) iv. Naso-orbital-ethmoid fractures
Standard CT protocol of the face includes axial v. Orbital fractures
and either direct or reconstructed coronal images. vi. Le Fort fractures
3D reconstruction of the CT scan aids in diagno- ● Le Fort I or low level or infrazygomatic or
sis and treatment planning. Guerin fractures

Management of Le Fort I fractures ● Le Fort II or pyramidal or infrazygomatic frac-
● Reduction of mobile fractures should be done tures

early. ● Le Fort III or suprazygomatic fractures
● In case the repair of impacted fractures is delayed, All these fractures may be unilateral or bilateral.
then Rowe’s disimpaction forceps can be used. vii. Extended Le Fort fractures
These forceps are applied to the nasal floor and III. According to Rowe and Williams (1985)
hard palate. Otherwise, Hayton-Williams forceps A. Fractures not involving the occlusion
are placed behind the maxillary tuberosities intra- i. Central region:
orally. a. Fractures of the nasal bones and/or nasal
● Simple Maxillomandibular fixation (MMF) for septum
4 weeks, without the need for suspension wires ● Lateral nasal injuries
can be used to treat the comminuted fractures. ● Anterior nasal injuries
● Intraosseous wiring can be used sometimes with- b. Fractures of the frontal process of the
out postoperative MMF, but a soft diet is indicated maxilla
for several weeks. c. Fractures of type (a) and (b) which extend
● Rigid plating allows early function, but reduction into the ethmoid bone (naso-ethmoid)
and plate conformation must be perfect. d. Fractures of type (a), (b) and (c) which ex-
● Comminuted fractures that cannot be plated or tend into the frontal bone
wired are treated with MMF and suspension. ii. Lateral region: Fractures involving the zygo-
● The arch bar of the maxilla is suspended from matic bone, arch and maxilla (zygomatic
the pyriform fossa, the zygomatic arch, the complex) excluding the dentoalveolar com-
orbital rims or extraskeletally to a halo frame, ponent.
in patients who have extensive facial commi- B. Fractures involving the occlusion
nution. i. Dentoalveolar
ii. Subzygomatic ‘Dish face’ or ‘floating maxilla’ terms are given for
●
● Le Fort I (low level or Guerin) lengthening of face due to separation of middle third
● Le Fort II (pyramidal) from the skull base.
iii. Suprazygomatic ● Midline or paramedian split of the palate is seen.
● Le Fort III (high level or craniofacial dys- Management of Le Fort II fracture

junction) ● To establish occlusion, MMF/IMF is done.
● Disimpaction using the Rowe forceps may be needed.

[SE Q.3]
● After occlusion is established, the patient can be
{Le Fort II fracture treated with suspension from the maxillary arch bar
● It is also called as pyramidal fracture. to the zygomatic arches, lateral orbital rims or supe-
● It is so called because the force applied at the level of rior orbital rims with 24-gauge wire.
the nasal bones wherein the fracture line runs from the ● Open treatment can be carried out by exposing, re-
middle area of the nasal bone down either side, crosses ducing, wiring or plating the inferior orbital rim
the frontal process of the maxilla into the medial wall of fracture.
each orbit. ● Medial canthal incisions can be created to access the
● After entering inside each orbit, the fracture line medial canthal tendon and reduction-fixation of the naso-
crosses the lacrimal bone behind the lacrimal sac, frontal area should be performed with wires or plates.
before turning forwards to cross the infraorbital ● Labiobuccal or inferior rim incisions can provide
margin slightly medial to or through the infraorbital exposure of the zygomaticomaxillary suture for fixa-
foramen. tion with wires or plates.
● It then extends downwards and backwards across the ● For rigid fixation, the MMF/IMF can be removed at
lateral wall of the antrum below the zygomaticomaxil- the end of the procedure.
lary suture and divides the pterygoid laminae about
Malocclusion should be corrected and occlusion should
halfway up.
be rechecked.}
● It is separated from the base of the skull completely via
the nasal septum and may involve floor of the anterior Q.3. Write the clinical features and treatment of Le Fort III
cranial fossa. fractures of midface.
Signs and symptoms
Ans.
● Due to gross oedema of the middle third of the face,
the moon face appearance is seen. A fracture may be defined as a sudden break in the continu-
● Retro-positioning of the whole maxilla and gagging ity of the bone and it may be complete or incomplete.
of the occlusion are seen. Fractures of the middle third of facial skeleton are clas-
● On grasping the maxillary teeth, the midfacial skel- sified as follows:
eton moves as a pyramid and the movement can be I. In 1901, Rene Le Fort, based on his experimental work
detected at the infraorbital margin and the nasal with cadavers, classified maxillary fractures according
bridge. to the level of injury as:
● Fracture of the zygomatic buttress causes haema- i. Le Fort I
toma formation in the buccal sulcus opposite to the ii. Le Fort II
maxillary first and second molar teeth. iii. Le Fort III
● Step deformity at the infraorbital rims or nasofrontal II. A simple classification for ordinary practical purposes
junction is noticed. of diagnosis and treatment planning is as follows:
● Orbital wall fractures can cause limitation of ocular i. Dentoalveolar fractures
movement because of entrapment. ii. Zygomatic complex fractures
● CSF rhinorrhoea is possible and should be looked iii. Nasal fractures
for. iv. Naso-orbital-ethmoid fractures
● Bilateral circumorbital ecchymosis gives an appear- v. Orbital fractures
ance of ‘raccoon eyes’. vi. Le Fort fractures
● In the surrounding area, subconjunctival haemor- ● Le Fort I or low level or infrazygomatic or
rhage develops. Guerin fractures

● Diplopia and gross unilateral enophthalmos may be ● Le Fort II or pyramidal or infrazygomatic frac-
seen in cases of orbital floor injury. tures

● Infraorbital nerve damage may lead to anaesthesia or ● Le Fort III or suprazygomatic fractures
paraesthesia of the cheek. All these fractures may be unilateral or bilateral.

● Deformity of nose with epistaxsis. vii. Extended Le Fort fractures
III. According to Rowe and Williams (1985) Separation of the frontozygomatic suture may cause
●
A. Fractures not involving the occlusion ‘Hooding of eyes’.

i. Central region: ● Deformity of the zygomatic arches along with disor-
a. Fractures of the nasal bones and/or nasal ganization and lengthening of the nasal skeleton.
septum ● Cerebro spinal fluid (CSF) rhinorrhoea.
● Lateral nasal injuries ● Depression of ocular levels.
● Anterior nasal injuries ● Inability to move lower jaw leads to difficulty in
b. Fractures of the frontal process of the max- mouth opening.

illa Management
c. Fractures of type (a) and (b) which extend The bicoronal flap combined with midfacial degloving
into the ethmoid bone (naso-ethmoid) allows maximal exposure. However, to maintain attach-
d. Fractures of type (a), (b) and (c) which ex- ment of the soft tissues to the stable skeleton, multiple
tend into the frontal bone discontinuous approaches such as labiobuccal, lateral
ii. Lateral region: Fractures involving the zygo- brow, inferior rim, open sky and others are frequently
matic bone, arch and maxilla (zygomatic com- used.
plex) excluding the dentoalveolar component
Q.4. Classify zygomatic complex fracture. Enumerate
B. Fractures involving the occlusion
the C/F and its management.
i. Dentoalveolar
ii. Subzygomatic Ans.
● Le Fort I (low level or Guerin)
Classification of zygomatic complex fractures
● Le Fort II (pyramidal)
According to Rowe and Williams (1985)
iii. Suprazygomatic
I. Fractures stable after elevation
● Le Fort III (high level or craniofacial dis-
a. Arch only (medially displaced)
junction)
b. Rotation around the vertical axis
Le Fort III fractures i. Medially
● Le Fort III fractures also known as suprazygomatic ii. Laterally
fractures results from force at the level of orbit. II. Fractures unstable after elevation
● It extends from the frontonasal suture transversely back- a. Arch only (inferiorly displaced)
wards, parallel with base of the skull and involves full b. Rotation around the horizontal axis
depth of the ethmoid bone including the cribriform i. Medially
plate. ii. Laterally
● Within the orbit, the fracture runs below the optic fora- c. Dislocation en bloc
men into the posterior limit of the inferior orbital fissure. i. Inferiorly
● From the base of the inferior orbital fissure, the fracture ii. Medially
line extends in two directions: (i) backwards across the iii. Posterolaterally
maxillary fissure to fracture the roots of the pterygoid d. Comminuted fractures
laminae, and (ii) laterally across the lateral wall of the Circumorbital ecchymosis
orbit separating the zygomatic bone from the frontal
bone. {SN Q.22}
{SN Q.20} Clinical features of zygomatic fracture
● Enophthalmos
Signs and symptoms
● Displacement of palpebral fissure
● Gross oedema of midface.
● Abnormal nerve sensibility
● Bilateral circumorbital ecchymosis with subcon-
● Diplopia
junctival haemorrhage.
● Flattening of the malar prominence
● Dish face appearance with lengthening of the
● Flattening over the zygomatic arch
face.
● Facial skeleton as a single unit becomes mobile.
● When lateral displacement occurs, tilting of the ● Alteration of globe level

occlusal plane and gagging of one side is seen. ● Tenderness and deformity at the zygomatic buttress
● The bones at the frontozygomatic suture are sepa- of the maxilla
rated along with tenderness. ● Crepitation from air emphysema
● Pain
● Epistaxis ● Indirect reduction with fixation is advised

● Trismus for the unstable fractures of the zygomatic
Management bone.
I. Reduction and fixation II. With fixation
Intraoral methods i. Transosseous wiring
● Indirect reduction is carried out which involves a. Frontozygomatic suture: Reduction and fixation
disimpaction and reduction of the fracture by ap- of a separated frontozygomatic suture can be
plication of an instrument to the deep aspect of done by an open reduction and direct approach.
the zygomatic bone through an indirect approach, The lateral orbital rim can also be fixed in a
remote from the fracture line. similar way.
● Transverse buccal sulcus incision for access to the b. Infraorbital margin: Two small holes are drilled
infratemporal region. on either side of the fracture and the fracture
● Cadwell–Luc approach for access to the orbital fragments are reduced and fixed by passing a
floor and zygomatic body. stainless steel wire. However, the infraorbital
Extraoral approaches rim is very delicate and wiring of the fragments
● The Gillies temporal incision is quite difficult, hence rarely used.
● Coronal incision ii. Pin fixation
● Lateral eyebrow ● Less commonly used method.
● Upper eyelid incisions ● The required firmness is achieved by means of
● Lower eyelid (subciliary or infraorbital) incision bone pins with self-tapping threads, which are
Zygomatic arch fractures inserted into the zygomatic bone and another
● Zygomatic arch fractures may be reduced effec- pin into the lateral aspect of the supraorbital
tively by closed reduction. ridge.
● Just below the zygomatic arch anterior to the ar- ● After the reduction of the fracture, the pins are
ticulating eminence through a preauricular trans- connected by rods and two universal joints.
cutaneous stab incision, a J-shaped, curved hook iii. Bone plating
elevator is inserted. ● During fracture at frontozygomatic suture, there
● After positioning the tip of the hook directly under is a tendency of the comminuted fractured parti-
the dislocated bone fragments by well-controlled cles along the floor of the orbit to contract in-
lateral traction, reduction is achieved. wards during healing. Therefore, small bone
● There is no need for rigid internal fixation, as the plates can sometimes be used instead of transos-
temporalis and masseter muscles and fascia, along seous wiring to establish fixation.
with the adjacent soft tissues splint the arch suf- iv. Fixation with a pack in the maxillary sinus
ficiently to stabilize the fragments. ● The pack is used to support the fractured zygo-
● No functional loads should be exerted that will matic complex, especially the comminuted or-
result in displacement. bital floor fracture.
● Without fixation means disimpaction and reduc- ● An incision in the buccal sulcus bone is
tion of fracture by direct application of an instru- exposed, blood clot and other debris is removed,
ment to the deep aspect of the zygomatic bone the zygoma repositioned gently with fingers and
through an indirect approach away from the frac- a pack soaked in Whitehead’s solution is inserted
ture line. in a circular pattern. The incision should then be
Gillies temporal fossa approach closed at the end of treatment.
● A Bristow’s elevator is passed down through the ● The pack should remain till the fractured seg-
incision beneath the zygomatic bone, which is ments become stable.

then gradually reduced to its position.
● The incision is then closed in layers. Q.6. Classify midface fracture. Discuss the management
Transverse buccal sulcus incision of malunited zygomatic fracture.
● A bone hook or curved elevator is passed behind
Ans.
supraperiosteally, to contact the deep part of the
zygomatic bone exerting an upward, outward and A fracture may be defined as a sudden break in the
forward pressure. Since less amount of force is continuity of the bone and it may be complete or
required, this method is preferred. incomplete.
Fractures of the middle third of facial skeleton are clas- Management

sified as follows: i. Cosmetic: Loss of contour or prominence of cheek
I. In 1901, Rene Le Fort, based on his experimental work will be seen. Correction may be done either by surgi-
with cadavers, classified maxillary fractures according cal refracturing or camouflaging the deformity, by
to the level of injury as: means of onlay bone grafting or alloplastic material
i. Le Fort I like hydroxyapatite blocks.
ii. Le Fort II ii. Neurological: The paraesthesia, dysaesthesia or an-
iii. Le Fort III aesthesia may be present. Observation for recovery
II. A simple classification for ordinary practical purposes of infraorbital nerve should be done for 6–12 months
of diagnosis and treatment planning is as follows: otherwise surgical exploration of the nerve can be
i. Dentoalveolar fractures done
ii. Zygomatic complex fractures iii. Antral: Persistent sinusitis may be due to presence
iii. Nasal fractures of loose necrotic bone pieces or a foreign body,
iv. Naso-orbital-ethmoid fractures which should be removed via Caldwell–Luc
v. Orbital fractures operation
vi. Le Fort fractures iv. Masticatory: Depressed zygomatic arch fracture im-
● Le Fort I or low level or infrazygomatic or pinges on the coronoid process bringing about limi-
Guerin fractures tation of the mandibular movements and opening. In
● Le Fort II or pyramidal or infrazygomatic fractures extensive fracture via coronal incision, the arch
● Le Fort III or suprazygomatic fractures should be exposed, refractured and stabilized by di-
All these fractures may be unilateral or bilateral rect fixation method. Osteotomy and bone grafting
vii. Extended Le Fort fractures can be done, if required.
III. According to Rowe and Williams (1985) v. Ophthalmic: Change of the ocular level, diplopia,
A. Fractures not involving the occlusion enophthalmos and occulorotatory restriction are the
i. Central region: residual deformities, which are difficult to correct
a. Fractures of the nasal bones and/or nasal secondarily.
septum
● Lateral nasal injuries Q.7. Write the golden hour of trauma importance and
● Anterior nasal injuries note on protocol to be followed in road traffic accident
b. Fractures of the frontal process of the victim management and on life support system.
maxilla
Ans.
c. Fractures of type (a) and (b) which extend
into the ethmoid bone (naso-ethmoid) Fundamental principles of treatment with sound surgical
d. Fractures of type (a), (b) and (c) which basis should be always followed.
extend into the frontal bone i. Quick and thorough assessment of injured patient.
ii. Lateral region: Fractures involving the zygo- ii. Life-threatening situations should be quickly recog-
matic bone, arch and maxilla (zygomatic com- nized and treated.
plex) excluding the dentoalveolar component iii. Acute trauma care involves many specialities, therefore
B. Fractures involving the occlusion proper specialized consultations are asked for.
i. Dentoalveolar ● Facial trauma must be considered in a slightly dif-
ii. Subzygomatic ferent way compared to trauma elsewhere.

● Le Fort I (low level or Guerin) ● It is important to restore the function and aesthetics,
● Le Fort II (pyramidal) to avoid any psychological impact.

iii. Suprazygomatic ● Initial proper treatment is always better than multi-
● Le Fort III (high level or craniofacial disjunc- ple secondary procedures.

tion) ● It also avoids prolonged hospitalization, disability
and added expenses.

Malunion of the zygomaticomaxillary complex ● Sometimes inadequate primary treatment may result
It will show following signs and symptoms: in severe deformities that become difficult to treat
i. Cosmetic later on.
ii. Neurological General wound management
iii. Antral ● A gauze piece moistened with betadine solution is
iv. Masticatory spread over the wound to protect it further from con-
v. Ophthalmic tamination.
● Surrounding skin should be cleaned gently with lib- ● Debridement

eral application of warm saline, dilute cetavlon or ● Haemostasis
dilute hydrogen peroxide, taking care to swab away ● Closure in layers – Primary closure
from the wound margins. ● Dressing
● A male patient should be cleanly shaven and female ● Prevention of infection
patients should have all cosmetics removed. The ● Pain control
eyebrows should never be shaved. ● Follow-up
● A careful wound examination including palpation Supportive therapy

should be carried out to detect foreign bodies at the Drains: Superficial wounds do not require drainage, but
depth of the wound, e.g. blood clots, dirt, wooden deeper wounds involving oral cavity require insertion of
splinters, broken teeth, denture pieces, glass pieces, penrose or rubber drain between sutures or by stab in-
tar, hair, bone splinters, etc. sertion. Drains should be removed after 2 to 4 days.
● Solvents, such as ether or benzene, remove tar, oil, Dressings: Antibiotic ointment along with dry gauze
grease or paint from a wound. Tissue holding forceps dressing should be changed in 48 h. Large wounds
or scalpel can be used to remove the embedded for- need pressure dressing. Sutures can be removed 5th to
eign matter. 7th day.
● It is mandatory to remove the foreign particles, to Prevention of infection: Strict sterile technique, wound
prevent fibrosis or traumatic tattooing of the skin. closure by eliminating all dead spaces and adequate
● The wound should be irrigated with copious amount supportive antibiotic therapy with follow-up is neces-
of saline solution and with suction for intraoral sary.
wounds. Prophylaxis against tetanus
● Laceration of the scalp may be masked due to blood ● Whenever there is inclusion of dirt and debris in the
crust and entangled hair. wound, protection against infection by the Clostrid-
● Haemostasis is also essential for good wound ium tentani organism must be provided.
healing. ● In a person who has been immunized with previous
● Atraumatic instruments such as fine skin hooks and inoculation with the tetanus toxoid, a ‘booster’ dose
Adson’s tissue holding forceps are very helpful in of 1 mL of tetanus toxoid should be given.
handling and approximation of the tissue of the face. ● Passive immunity can be produced by administering
● Gentle sponging of tissues should be done. 1500 units of tetanus antitoxin at weekly intervals,
Specific wounds until three doses have been given.
i. Abrasions
Q.8. Classify the fractures of maxilla. Write in detail
● The basic wound cleansing should be done fol-
the clinical features, investigations and management of
lowed by topical application of antibiotic oint-
a Le Fort I fracture.
ment with compression dressing.
● Topical antibiotic is applied to cover superficial Ans.
abrasions and left open.
[Same as LE Q.1]
● Slowly the crust of dried blood and serum will
form a scab and it will fall-off as the healing takes Q.9. Discuss the signs, symptoms, complications and
place. treatment of Le Fort I fracture of maxilla.
ii. Contusion
Ans.
Ice pack can be applied to stop further extravasation
of blood. [Same as LE Q.1]
iii. Haematomas
Q.10. Classify middle third fracture of the facial skele-
● Most haematomas get reabsorbed and persistent
ton. Describe in detail the anatomical extension, clinical
haematoma may require incision and drainage.
feature and treatment of Le Fort I fracture.
● Antibiotic cover should be given to prevent hae-
matoma from getting infected. Ans.

iv. Incised wounds
[Same as LE Q.1]
The wound should be taken care as early as possible.
The wound is cleaned, explored and the bleeding ar- Q.11. Describe the signs and symptoms of Le Fort I
rested and closed by primary intention. fracture and its management.
v. Lacerated wounds
Ans.
● Cleaning of wound
● Removal of foreign bodies [Same as LE Q.1]

Q.12. Classify fractures of the mid face. Describe the Q.2. Le Fort I fracture.
clinical features and management of a Le Fort I frac-
Ans.
ture.
[Ref LE Q.1]
Ans.
Q.3. Le Fort II fracture.
[Same as LE Q.1]
Ans.
Q.13. Classify fractures of middle third of the facial
skeleton. How would you manage a Le Fort I fracture? [Ref LE Q.2]
Ans. Q.4. Emergency radiology in facial injury.
Q.14. Describe signs, symptoms and management of Radiological examination in facial injury can be also sup-
Le Fort III fracture. plemented by CT scan examinations, whenever the facili-
ties are available.
Ans.
Minimum X-rays are required for the following:
[Same as LE Q.3] I. In case of fractures of middle third of the face
● 15/30 degrees occipitomental view
Q.15. Classify middle third facial fractures. Describe
● Submentovertex view
clinical features and management of a case of Le Fort III
● Cranial posteroanterior view (skull)
fracture.
● Lateral skull view
Ans. ● PA view – Water’s position
II. For zygomaticomaxillary complex

[Same as LE Q.3]
● Occipitomental view 15° and 30°
Q.16. Describe Le Fort III fracture and its management. ● PA view – Water’s position
● Submentovertex projection
Ans.
● Tomography/CT scan of the orbit
[Same as LE Q.3] III. For mandibular fractures

● Orthopantomogram (OPG)
Q.17. Classify maxillary fractures. Describe the clinical
● Lateral oblique views of the mandible (right and
features and management of fracture of zygoma.
left)
Ans. ● PA view of the mandible
● Towne’s view for fractured condyles

[Same as LE Q.4]
The occlusal view for mandible or maxilla and intra-
Q.18. Describe the clinical findings of zygomatic com- oral periapical views for individual tooth may be
plex fracture. Enumerate the various methods of reduc- required to be taken.
ing the zygomatic arch fracture and discuss anyone in
detail. Q.5. Classification of zygomatic fractures.
Ans. Ans.
[Same as LE Q.4] According to Rowe and Williams 1985, the zygomatic arch
fractures are classified as follows:
Q.19. Describe emergency care in facial trauma.
I. Fractures that are stable after elevation
Ans. a. Arch only (medially displaced)
b. Rotation around the vertical axis
[Same as LE Q.6]
i. Medially
ii. Laterally
SHORT ESSAYS: II. Fractures that are unstable after elevation
a. Arch only (inferiorly displaced)
Q.1. Classification of fractures of the middle third of b. Rotation around the horizontal axis
facial skeleton. i. Medially
ii. Laterally
Ans.
c. Dislocation en bloc
[Ref LE Q.1] i. Inferiorly
ii. Medially ● Surgical emphysema.

iii. Posterolaterally ● Optic foramen reflects most of the fractures, thus pro-
d. Comminuted fractures tecting the optic nerve as a result of its density.
Circumorbital ecchymosis ● Damage of cranial nerves may cause symptoms such as
Clinical features of zygomatic fracture are ophthalmoplegia, dilation of the pupil and anaesthesia
● Enophthalmos in the distribution of ophthalmic branch of the fifth cra-
● Displacement of palpebral fissure nial nerve may occur.
● Abnormal nerve sensibility
● Diplopia Q.7. Nasal fracture.

● Flattening of the malar prominence
Ans.
● Flattening over the zygomatic arch
● Alteration of globe level ● Depending on the direction of force applied, the pattern
● Tenderness and deformity at the zygomatic buttress of nasal fractures varies.
of the maxilla ● Force applied from a frontal direction may cause a se-
● Abnormal nerve sensibility vere flattening of the nasal bones and septum.
● Crepitation from air emphysema ● Lateral forces may result in only a depression of the
● Pain ipsilateral nasal bone or may also be forceful enough to

● Epistaxis rule out fracture the contralateral nasal bone.
● Displacement of palpebral fissure ● Forces from below may cause fractures of the septum.
● Trismus ● Damage to these membranes is serious, since it can lead
to obstruction, increased secretions or an impaired sense

Q.6. Blowout fracture of orbit.
of olfaction.
Ans. Signs and symptoms
● Pain and oedema
● Flattening or any other type of deformation of the

{SN Q.17}
shape of nose
● Blowout fractures are fractures which result due to ● Epistaxis or bleeding from the nose
direct trauma to the globe, which causes an increase ● Rhinitis, which may lead to increased tear produc-
in intraorbital pressure and decompression due fraction in the eyes and a runny nose
ture of the orbital floor. ● Airway blockage due to bleeding, fluid discharge or
● Orbital floor fractures can occur alone or in combina- tissue swelling
tion with extensive facial bony disruption. ● Crepitance
● Orbital floor fractures may occur in combination ● Bruising or discolouration (ecchymosis) of the tis-
with zygomatic arch fractures, Le Fort II or III sues around the eyes
midface fractures and medial wall or orbital rim ● Nasal septum may be deviated to one side
fractures. ● A step-deformity may be palpated
Management
● Within the first 3 h following injury, the fracture
● In case of fracture of the floor of the orbit, the bone frag- should be reduced.
ments are displaced into the antral cavity. These bone ● Usually, waiting 3–7 days is preferable as it allows
pieces are held on by the periosteum. oedema to resolve and positioning the bones cor-
● The orbital fat tends to herniate into the antral cavity rectly with more stability. It will be easier, since in-
through the displaced fracture. flammation and fibrosis may make the fragments less
● Enophthalmos is seen as a result of herniation of orbital mobile by this time.
contents and also due to increase in orbital volume. ● Walsham’s and Asch’s septal forceps are used for
● The inferior oblique muscle and inferior rectus muscle manipulating the fragments. Direction of force must
may get entrapped in the fracture. This restricts the nor- be in the opposite direction of the fracturing force,
mal movement of the eye. which is in an anterolateral direction.
● The upward and outward rotation of the eye is restricted ● In case of laterally displaced segments, they may be
causing diplopia. reduced externally with direct pressure.
● There will also be circumorbital oedema and ecchymosis. ● The septal cartilage is grasped and repositioned into
● Paraesthesia in distribution of infraorbital nerve region. its groove in the vomer.
● Rupture of the periostieum leads to subconjunctival ● Splinting may be required for immobilization, though
haemorrhage. some simple fractures require no splinting.
Types of splinting used are

● ● Eyeball is suspended through the Lockwood’s ligament.
a. Intranasal splinting The Lockwood’s suspensory ligament is a fascial sling,
● Ribbon gauze which supports the globe of the eye, passing from the
● Stainless steel splint medial attachment in the region of the lacrimal bone, to
b. Extranasal splinting get inserted laterally into the Whitnall’s tubercle on the
● Plaster of Paris lateral wall of the orbit just below the frontozygomatic
● Lead splints suture.
● Normally, the eyeball projects slightly beyond the or-
Q.8. Orbital trauma assessment. bital rim. The eyeball is filled with vitreous humour, and
Ans. remaining of the orbital cavity is filled with fat.
● In the infraorbital region in a PNS view, there are usu- Q.10. Gilles temporal approach.
ally two radiopaque lines seen. Ans.
● The superior line represents the infraorbital rim and the
inferior line represents floor of the orbit.

● Water’s view projection of the skull shows the ‘hanging
{SN Q.15}
drop’ sign of the orbital floor fracture. Gillies temporal approach
● This appearance is due to the herniated fat and extrava- ● Between the temporal fascia and the temporal mus-
sated blood, and appears as a smooth opaque convexity cle, a natural anatomical space exists into which
which faces downwards suspended from the roof of the an instrument can be inserted and it can be utilized
maxillary sinus. to elevate the displaced zygoma or its arch into
● Opacity of the maxillary and ethmoidal sinuses can also position.
be noted due to extravasation of blood into them.
● Sometimes, in the presence of opacity of the maxillary
Technique
sinus, isolated orbital fractures cannot be detected ● The hair is shaved from the temporal region of the
through the Water’s view; therefore other imaging tech- scalp.
niques like computed tomography can be used. ● The external auditory meatus is plugged with cotton
Q.9. Surgical anatomy of orbit. to prevent any fluid or blood getting inside.
● Incision of about 2–2.5 cm in length is made and
Ans. inclined forward at an angle of 45° to the zygomatic
● The orbit is bounded by medial and lateral surfaces, and arch well in the temporal region. Injury to the super-
has a roof and a floor. ficial temporal vessels is avoided.
● The medial orbital wall is very thin and ethmoidal. Air ● The temporal fascia is exposed, which appears as
cells lie beneath this wall. white glistening structures.

● The lateral wall and the roof are thick. ● The incision is taken into the fascia and fibres of
● The orbital floor is contributed from the maxillary, zy- temporalis muscles will be seen.
gomatic and palatine bones. ● Long Bristow’s periosteal elevator is passed below
● It is the shortest of all the walls; it does not reach the the fascia and above the muscle.
orbital apex, measures 35–40 mm and terminates at the ● The instrument is then inserted through it downward
posterior edge of the maxillary sinus. and forward. The tip of the instrument is adjusted
● It is very thin in the region of infraorbital groove, which medially to the displaced fragment.
later becomes the infraorbital canal. ● A thick gauze pad is kept on lateral aspect of the
● The infraorbital nerve, a branch of the maxillary nerve skull to protect it from the operating pressure of
runs in the infraorbital groove and exits through the canal. elevator.
● The infraorbital artery, a tributary of the maxillary ar-
tery and the infraorbital vein are also found within the {SN Q.15}
infraorbital groove flanking the infraorbital nerve and ● The operator grasps the handle of the elevator
exiting the infraorbital canal. with both hands. Assistant has to stabilize the
● The floor of the orbit is made up of orbital portion of the
head of the patient.
maxillary bone and part of zygomatic bone. Laterally, it ● The tip of elevator is manipulated upward, for-
is bounded by the inferior orbital fissure. Posteriorly it ward and outward.
is made up of the orbital process of the palatine bone, ● As soon as reduction is complete, a snap sound
and a small portion of the ethmoid bone. Medially, the can be heard.
floor is bounded by lacrimal bone.
● Chaemosis
● Wound is closed in layers. For 5–7 days, pressure
● Restriction of extraoccular mobility
should not be exerted on the area of surgery.
● Visual loss
● Patient is instructed to sleep in supine position or
● Signs of meningitis
not to sleep on the operated side.
● Intracranial complications occur rarely
Q.4. Nonunion.
Q.11. Pyramidal fracture. Ans.
Ans. ● Nonunion occurs due to the lack of bone healing be-
[Same as SE Q.3] tween the segments that persist indefinitely without evi-
dence of bone healing unless surgical treatment is un-
Q.12. Clinical features and management of zygomatic dertaken to repair the fracture.
arch fractures. ● Characteristics of nonunion are pain and abnormal mo-
Ans. bility following treatment.

● No evidence of healing can be seen in radiographs.
[Same as SE Q.5] ● Nonunion is most commonly caused due to inadequate
Q.13. Blowout fracture. reduction and immobilization, infection of fracture site,

decreased vascularity and systemic factors.
Ans.
Q.5. Epistaxis.
[Same as SE Q.6]
Ans.
SHORT NOTES: ● Epistaxis is the unilateral haemorrhage from the nose.

● It occurs whenever there is haemorrhage into the sinus,
Q.1. Diplopia. as a result of disruption of the sinus mucosa.
● Caused because of draining of the maxillary sinus into
Ans.
the nose through the middle meatus.
● Diplopia is a very serious complication of the zygo-
matic fracture. It is caused by interference with the ac- Q.6. Greenstick fracture.
tion of extraoccular muscles and also due to oedema and Ans.
haemorrhage around these muscles, which may be ei-
ther temporary or permanent. It is blurred double vision ● Greenstick fracture is that type of fracture in which one
experienced by patient. cortex of the bone is broken with the other cortex being
● It is of the following two types: bent.
i. Permanent or temporary ● It is an incomplete fracture seen in young children, be-
ii. Monoocular and binocular cause of inherent resiliency of the growing bone.
Q.2. CSF rhinorrhoea. Q.7. Malunion.

Ans. Ans.
● CSF rhinorrhoea is a complication of the midface ● Malunion is defined as improper alignment of the
fracture. healed bony segments.
● It occurs when the cribriform plate of the ethmoid has ● All malunions are not clinically significant.
been comminuted. One of the common complaints may ● They can be treated with orthodontics or osteotomies
be of a salty taste in the back of the throat when the CSF after complete bony union.
passes through it. ● It can result in facial asymmetry, enophthalmos and
ocular dystopia.
Q.3. Cavernous sinus thrombosis.
Q.8. Principles of fracture management.
Ans.
Ans.
Cavernous sinus thrombosis is a sequela of direct extension
or retrograde thrombophlebitis of ethmoid or sphenoid Principles of fracture management are
sinuses. ● Reduction
The clinical features are ● Fixation
● Proptosis ● Immobilization
Q.9. Fixation methods in trauma. for two screws on either side of the fracture resists the
anteroposterior and rotary movement of the fractured
Ans.
segment.
Methods of fixation in trauma are as follows:
Q.13. Methods of wiring in oral surgery.
I. Closed fixation (indirect fixation)
● Intermaxillary fixation (IMF) Ans.
II. Open or Internal fixation (direct fixation)
Methods of wiring in oral surgery are
● Intraoral devices
● Transosseous wiring
● Plates and screws
IMF/MMF
● Suspension wires
● Extraoral devices
i. Frontal suspension
External pin fixation
ii. Circumzygomatic suspension
Q.10. Advantages and disadvantages of indirect fixation iii. Infraorbital
of fractures. iv. Pyriform aperture
v. Peralveolar
Ans.
Q.14. Ebernation.
Advantages of indirect fixation of fractures
● Simplicity Ans.
● Low cost ● Ebernation is one of the signs of nonunion.
● Less time-consuming ● It is the rounding off and sclerosis of the fractured bone
● Noninvasive ends.
Disadvantages of indirect fixation of fractures ● It can be detected radiographically.
● Oral hygiene
Q.15. Gillies temporal approach.
● Absolute stability not possible
● Atrophy of muscles and loss of biting force Ans.

● TMJ may be affected
[Ref SE Q.10]
Q.11. Transosseous wiring. Q.16. CSF rhinorrhoea.
Ans. Ans.
● Transosseous wiring or intraosseous wiring is cheap, ● CSF rhinorrhoea is seen in Le Fort II fracture.
easy to use and biologically well tolerated by the ● Depending on the damage of the cribriform plate and
patients. involvement of the anterior cranial fossa, cerebrospinal
● It is a kind of semirigid fixation. fluid leak occurs.
● Most of the time it is associated with IMF, if occlusal ● It is usually arrested, if the fracture is reduced.
discrepancies exist.
● Two holes are drilled with a small round bur on either Q.17. Define blowout fractures.
side at an adequate distance from the fracture line to Ans.
provide stability and to prevent the wire from cutting
out as it is twisted and tightened. [Ref SE Q.6]
Q.18. Le Fort classification of maxillary fracture.
Q.12. Miniplate osteosynthesis.
Ans.
Ans.
[Ref LE Q.1]
● Monocortical semirigid fixation of maxillary fractures
with miniplates or screws eliminates bony movements Q.19. Define Guerins fracture.
and allows primary healing to occur.
Ans.
● Miniature plates are designed to produce rapid immobi-
lization. Le Fort I (low level or Guerin type fractures)

● They are often applied in the region of the frontozygo- ● The fracture line extends from the nasal septum to
matic suture, zygomatic buttress and rim of pyriform the lateral pyriform rims, travels horizontally
aperture. above the teeth apices, runs below the zygomatic
● These plates and screws provide three-dimensional sta- buttress and crosses the lower third of the ptery-
bility and placement of these plates with the provision goid laminae.
Q.20. Give any four signs and symptoms of Le Fort III ● The tip of elevator is manipulated upward, forward and
facial fractures. outward. The snap sound will be heard as soon as reduc-
tion is complete.
Ans.
[Ref LE Q.3] Q.25. Whalsham’s forceps.
Q.21. Diplopia. Ans.
Ans. ● Whalsham’s forceps are used for reduction of nasal

fractures. It has two curved blades, one is padded and
● Diplopia is a very serious complication of the zygo-
other unpadded.
matic fracture caused by interference with the action of
● The padded blade is inserted internally into the nostril
extraoccular muscles and also due to oedema and haem-
and the unpadded blade is placed externally and ma-
orrhage around these muscles which may be either
nipulated for reduction of nasal fracture.
temporary or permanent.
● It is blurred double vision experienced by patient. Q.26. Hanging drop sign.
● It is of the following two types:
i. Permanent or temporary Ans.

ii. Monoocular and binocular
● ‘Hanging drop’ sign of the orbital floor fracture is seen
Monocular diplopia in Water’s view projection of the skull.
It is double vision through one eye when the other eye ● This appearance is due to the herniated fat and extrava-
is closed. It requires immediate expert opinion. This indi- sated blood. It appears as a smooth opaque convexity,
cates a serious cause, such as detached lens or some other which faces downwards suspended from the roof of the
traumatic injury of the globe. maxillary sinus.
Q.22. Clinical features and management of zygomatic Q.27. Wire osteosynthesis.
arch fractures?
Ans.
Ans.
[Same as SN Q.11]
[Ref LE Q.4]
Q.28. Gillies approach.
Q.23. Asche’s forceps.
Ans.
Ans.
[Same as SN Q.15]
● Asche’s forceps are used for reduction of nasal fractures
and also for the alignment of nasal septum. Q.29. Cerebrospinal fluid rhinorrhoea.
● Both the blades are inserted internally on each side of
the septum. In case of nasal bone fracture reduction, one Ans.

blade is inserted internally and other externally to hold [Same as SN Q.16]
nasal bone laterally and medially respectively.
Q.30. CSF rhinorrhoea.
Q.24. Bristow’s elevator.
Ans.
Ans.
[Same as SN Q.16]
● Bristow’s elevator is used to reduce the zygomatic frac-
ture. Q.31. What do you understand by the term ‘monocular
● Long Bristow’s periosteal elevator is passed below the diplopia’?
fascia and above the muscle. The instrument is then in-
serted through it downward and forward and the tip of Ans.
the instrument is adjusted medially to the displaced [Same as SN Q.21]
fragment.
● A thick gauze pad is kept on lateral aspect of the skull Q.32. Name four signs and symptoms of zygomatico-
to protect it from the operating pressure of elevator. maxillary complex.
● The operator grasps the handle of the elevator with both
Ans.
hands. Assistant has to stabilize the head of the patient
to reduce the zygomatic bone. [Same as SN Q.22]
Topic 8
Mandibular Fractures
LONG ESSAYS:
1. Classify fractures of mandible. Give your treatment for a compound, comminuted and unfavourable fracture
of angle of mandible.
2. Describe different methods of reduction of fractured mandible.
3. Describe the healing process of a fractured mandible. Discuss the early and the late complications arising in
the treatment of mandibular fractures. How will you manage these complications?
4. A 40-year-old man, who is edentulous posteriorly, reports with a fracture in angle of mandible. Write in detail
about clinical features, diagnostic means and management.
5. Classify fractures of condyle. Describe the clinical features and management of unilateral condylar fracture.
6. Describe the signs, symptoms, diagnosis and treatment of bilateral condylar fractures.
7. Write in short the principles of fracture management in the maxillofacial region. Add notes on different treat-
ment modalities for a fracture mandible involving teeth in the line of fracture.
8. Write about management of unfavourable fracture of angle region of edentulous mandible in a 60-year-old
person. [Same as LE Q.4]
9. Classify fracture of mandibular condyle and its signs and symptoms. How do you manage a case of unilateral
condylar fracture with displacement in an adult? [Same as LE Q.5]
10. Write in detail clinical features, diagnosis and management of bilateral condylar fracture in an 8-year-old boy.
[Same as LE Q.6]
SHORT ESSAYS:
1. What is the basic difference between simple and compound fracture of bone?
2. Clinical features of fracture of body of mandible.
3. Signs and symptoms of bilateral condylar fractures in children. [Ref LE Q.6]
4. How do you manage a case of unilateral condylar fracture with displacement in adults? [Ref LE Q.5]
5. Principles of fracture management. [Ref LE Q.7]
6. Dentoalveolar fractures.
7. Name any four different types of dental wiring techniques. Describe in short any one wiring technique for
dentoalveolar fracture.
8. Rigid internal fixation.
9. Dynamic compression plates.
10. Champy’s osteosynthesis line for monocortical plating.
11. Fracture of the body of edentulous mandible.
12. Describe the vertically unfavourable fracture line at the angle of the mandible.
13. Fracture of body of mandible in children. [Same as SE Q.2]
14. Methods of wiring in oral surgery. [Same as SE Q.7]
15. Transosseous wiring. [Same as SE Q.7]
16. Gunning splints. [Same as SE Q.11]
17. Draw diagrams to explain vertically and horizontally favourable fracture of mandible. [Same as SE Q.12]
18. Healing of fractures. [Ref LE Q.3]
SHORT NOTES:
1 . Name four X-rays taken for fracture mandible.
2. Nonunion.
3. Pathological fractures.
4. Horizontal favourable fracture of angle of mandible.
5. Mention any eight causes for the nonunion of fractured fragments of the mandible.
6. Unfavourable fracture of mandible.
7. Green stick fracture.
8. Malunion and nonunion.
9. Treatment option for subcondylar fractures of mandible.
10. Fixation methods in trauma.
11. Bone plates.
12. Eyelet wiring.
13. Circummandibular wiring.
14. Arch bars wiring.
15. Lag screws.
16. Transosseous wiring.
17. Compression bone plates. [Ref SE Q.9]
18. Methods of wiring in oral surgery.
19. Eburnation.
20. Fracture management in edentulous jaws. [Ref SE Q.11]
21. Fracture of body of mandible – signs and symptoms. [Ref SE Q.2]
22. Indications for extraction of tooth related to fracture line.
23. Battle’s sign.
24. Wire osteosynthesis. [Same as SN Q.16]
25. Dynamic compression plate. [Same as SN Q.17]
26. Gunning type splint. [Same as SN Q.20]
27. Gunning splint. [Same as SN Q.20]
28. What is a Battle’s sign? What is the differential diagnosis of it? [Same as SN Q.23]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Classify fractures of mandible. Give your treat- 7. Condylar process: This is the area of the condylar pro-
ment for a compound, comminuted and unfavourable cess superior to the ramus region.
fracture of angle of mandible. 8. Coronoid process: This includes coronoid process of the
mandible superior to the ramus region.
Ans.
9. Dentoalveolar process: This region would normally
Mandibular fractures are classified by the anatomic areas contain teeth.
involved.
Based on presence of serviceable teeth at the fracture line:
Dingman and Natvig defined these regions as follows:
Kazanjian and Converse classifies the mandibular frac-
1. Midline: It is the fracture between central incisors.
tures by presence or absence of serviceable teeth in relation
2. Canine region fracture: It is bounded by vertical lines
to the line of fracture. This may be helpful in determining
distal to the canine teeth fractures.
treatment.
3. Symphysis fracture: This occurs within the area of the
1. Class I: On both sides of the fracture line, teeth are
symphysis.
present.
4. Body: It is from distal symphysis to a line coinciding
2. Class II: Only on one side of the fracture line, teeth are
with the alveolar border of the masseter muscle (usually
present.
including the third molar/between the canine region and
3. Class III: In this class, patient is completely edentulous.
the angle).
5. Angle: This is triangular region bounded by the anterior Rowe and Killey have divided mandibular fractures into
border of the masseter muscle to the posterosuperior two classes:
attachment of the masseter muscle (usually distal to the 1. Those involving basal bone – Single unilateral, double
third molar). unilateral, bilateral or multiple.
6. Ramus: It is bounded by superior aspect of the angle to 2. Those not involving basal bone – Alveolar process
two lines forming an apex at the sigmoid notch. fracture.
Fracture of the angle of the mandible 3. Triangular comminuted fracture at the inferior
● It is affected by the medial pterygoid muscle and the border associated with angle fracture
masseter muscle. The medial pterygoid is the stron- 4. Frazcture of edentulous mandible
ger one. 5. Malunited fractures
● The classification of fractures in this region can be: 6. Nonunion of the fracture
vertically favourable or unfavourable and horizon- 7. Fractures with large extraoral lacerations
tally favourable or unfavourable.
The intraoral incision for fixation of transosseous wir-
● The posterior fragment will be pulled lingually, if the
ing at the upper border is chosen for the fractures at the
vertical direction of the fracture line favours the un-
angle with minimum displacement or for the edentulous
opposed action of the medial pterygoid muscle.
areas of the body fracture.
● Similarly, the posterior fragment will be displaced
upwards, if the horizontal direction of the fracture

Q.2. Describe different methods of reduction of frac-
favours the pull of masseter and medial pterygoid
tured mandible.
muscle in upward direction.
● A favourable fracture line makes the stabilization of Ans.
the fragments easier.
Different methods of reduction of fractured mandible
● On the posterior segment, the presence of erupted
are
teeth would prevent gross displacement of this frag-
I. Open reduction
ment if the crown impacts on the opposing upper
II. Closed reduction
tooth.
Various treatments for fracture of angle of the mandible I. Open reduction
Transosseous wiring (intraosseous wiring) ● Open reduction is usually necessary in multiple dis-
● Direct wiring across the fracture line is an effec- placed fractures, especially at the angle and para-
tive method of fixation of jaw bone fractures. symphysis region.
● Transosseous wiring can be done through intra- ● Intraosseous wiring or bone plating should be done
oral or extraoral approach. at lower border of the mandible without damaging

● Holes are drilled in the bony fragments on either the developing teeth buds.
side of the fracture line, after which a length of Indications
26-gauge stainless steel wire is passed into the ● Unfavourable fracture at the symphysis or body of
holes and across the fracture. the mandible.

● The fracture must be reduced independently with ● Displaced bilateral condylar fractures.
the teeth in occlusion before the free ends of the ● Delayed treatment of noncontacting displaced
wire are lightened and twisted. fracture fragments.

● The twisted ends are cut short and tucked into the ● Malunion.
nearest drill hole. The single strand wire fixation ● Mandibular fracture opposing an edentulous
in this horizontal manner is the simplest form of maxilla.

fixation with intraosseous wiring. It can be modi- ● Edentulous mandibular fracture with severe
fied in various ways depending on the following: displacement.

a. Position of fracture ● In cases where closed reduction is contraindi-
b. Muscle forces acting on the fragments cated.

c. Degree of comminution ● Medically compromised patients: Decreased pul-
d. Number of fragments to be fixed monary function, severe seizure disorders, GI

e. Nature of the fracture line – oblique, straight, etc disorders and patients with psychiatric or neuro-
● The variations can be two-hole, three-hole and logic problems may need open reduction.
four-hole techniques. ● Complex facial fractures: These fractures can be
● Obwegeser’s figure of eight wiring, Hayton– reconstructed best after open reduction and fixa-
William’s modification of figure of eight wiring, tion of the mandibular segments to provide a sta-
etc. These variations are mainly used at the inferior ble base for restoration.
border of the mandible through extraoral incision. ● Other fractures: It includes open reduction with
Indications for extraoral incision with transosseous primary bone grafting in fractures of a severely
wiring at the inferior border atrophic edentulous mandible with severe dis-
1. Unfavourable and grossly displaced fracture at the placement of the fracture segments, or a nonunion
angle of the mandible after closed reduction of a severely atrophic eden-
2. Severe overriding of the fragments tulous mandible fracture.
Contraindications Contraindications
● Medically unfit patients ● History of seizures
Advantages ● Compromised pulmonary function
● Anatomic reduction ● Psychiatric conditions
● Fixation in desired position ● GI disorders
● Early return of function Advantages

● No airway compromise ● Conservatize procedure
● No nutritional compromise ● No surgical complication
Disadvantages ● Can be done in medically compromised patients
● Surgical procedure Disadvantages

● Complications of surgery ● Airway compromise
II. Closed reduction ● Loss of function
Example: Arch bar, eyelet wiring and Risdon’s wiring. ● Nutrition compromise
● Closed reduction can be the treatment for most of ● Occlusion is used as guide
the mandibular fractures, because of its simplic- ● Speech – Social inconvenience
ity, low cost and noninvasive nature of treatment. ● Rehabilitation is difficult
● The presence of teeth will provide an accurate

Q.3. Describe the healing process of a fractured mandi-
guide for reduction.
ble. Discuss the early and the late complications arising
● It is important to recognize any pre-existing oc-
in the treatment of mandibular fractures. How will you
clusal abnormalities, such as anterior open bite as
manage these complications?
teeth may be brought into contact during reduc-
tion, yet be occluding incorrectly owing to lingual Ans.
inclination of the fractured fragments.
● Wear facets on the teeth may provide valuable
[SE Q.16]
clues to previous contact areas. {Healing of fractured mandible takes place as follows:
Indications i. Primary healing: It takes place if callus formation is
● Favourable fractures: Closed reduction reduces prevented by close approximation, rigid fixation and
the risk of morbidity. immobilization of fractured fragments.
● Grossly comminuted fractures: The small frag- ii. Healing by secondary intention: Steps involved in frac-
ments of the bones can coalesce and heal by ex- ture healing by secondary intention are as follows:
cellent blood supply of the face. a. Haematoma formation
● Fractures of the severely atrophic edentulous ● There is break in the continuity of bone and rup-
mandible. ture of blood vessels from cortex, medulla, peri-
● Closed reduction would not require stripping of osteum, surrounding muscles and adjacent soft
the periosteum, which is the major source of tissues leading to a haematoma formation.
blood supply to the edentulous mandible. ● Haematoma surrounds the fractured bone ends
● Lack of soft tissue overlying the fracture site: and extends into the marrow space for 6–8 h after
Bone plates, screws and wires interfere with the the accident. There is an acute traumatic inflam-
bone union by further disrupting the soft tissue matory phase.
covering. b. Organization of haematoma
● Fractures in children involving the developing ● The haematoma contains periosteum, bone, mus-
dentition to protect the developing tooth bud. cle, fascia, bone marrow, new capillaries and fi-
● Infected lower jaw fractures. brin network. Polymorphs and macrophages take
● Coronoid process fracture: Extreme trauma may part in digestion and removal of devitalized tis-
displace the bone into the temporal fossa, causing sues. Osteoclasts resorb bone spicules and bone
trismus and swelling in the region of zygomatic fragments. Giant cells are formed and fibroblasts
arch, swelling in the retromolar area and in the invade the blood clot.
lateral crossbite. Usually, it does not require any ● Early organization of haematoma is character-
treatment unless otherwise the occlusion is dis- ized by proliferation of blood vessels. Their
turbed or the coronoid process impinges on the course retards blood flow resulting in stasis and
zygomatic arch. proliferation of mesenchyme. Calcium level of
● Condylar fractures: Mostly treated by closed re- the capillaries increases and granulation tissue is
duction, when there is minimal disturbance in formed.
occlusion and in cases of nondisplaced fracture. c. Formation of provisional fibrous callus
● Fibroblastic cells secrete osseomucin which is ● Paresis

deposited in-between collagen network. Ground ● Cosmetic compromise
substance and coarse collagen fibres form the
Following proper surgical protocols will reduce postopera-
matrix known as ‘osteoid tissue’. Here, the min-
tive complications.
erals are yet to be deposited.
A. Early complications
● Granulation tissue is replaced by loose connec-
1. Infection: Patient’s local or general resistance will be
tive tissue and there is obliteration of capillaries.
lowered, predisposing to infection. Especially debili-
This stage is called fibrous callus.
tated patients, diabetics and patients on steroid ther-
d. Primary (bony) callus formation
apy are prone to infection.
● Calcium deposition commences 10–15 days
2. Nerve damage: Anaesthesia of the lower lip occurs
later. Hence, the callus is soft and is not visible
due to neuropraxia of the inferior alveolar nerve. It is
on the radiograph.
the most common complication.
● The alkaline phosphates present in the osteo-
3. Displaced teeth and foreign bodies: May be swal-
blasts are high. Depending on the location and
lowed.
function, the following callus is formed:
Chest X-ray should be done and if needed, bronchos-
i. Anchoring callus: It is formed on the external
copy should be carried out to explore and remove the
surface of bone, between the anchoring cal-
foreign body.
lus and the two fractured ends. This is carti-
4. Pulpitis.
laginous and therefore is thought that it does
5. Gingival and periodontal complications.
not occur in mandibular fracture.
B. Late complications
ii. Uniting callus: It is seen at interfragmentary
1. Malunion: It results due to improper fixation method,
gap and by the time it forms, bone resorption
early removal of immobilization device, tissue en-
takes place at the bone ends.
trapment in the fragments, etc.
iii. Sealing callus: It is seen across bone ends
2. Delayed union: It results due to local factors such as
and in bone marrow spaces.
infection and general factors such as osteoporosis or
e. Secondary callus
nutritional deficiency.
● Matured bone replaces immature bone; hence, it
3. Nonunion: Radiologically, there is rounding off and
is visible in the radiographs. This process is seen
sclerosis of the bone ends. This condition is called
in-between 20–60 days.
‘eburnation’. This is caused by:
● Alkaline phosphatase plays an important role in
i. Infection at the fracture site.
osteogenesis. Acid phosphatase and lysosomal
ii. Inadequate immobilization.
enzymes of osteoclast act at acidic pH and help
iii. Unsatisfactory approximation with tissue en-
in autolysis.
trapment.
● Definitive callus formation is the last stage of
iv. In an elderly debilitated patient, with the ultra-
healing.
thin edentulous mandible. Considerable loss of
f. Remodelling of bone
bone and soft tissue.
● Resorption of callus takes place except in inter-
vi. Inadequate blood supply after radiotherapy.
fragmentary gap. If bone is not subjected to
vii. The presence of bone pathology like tumours, etc.
functional stress, true matured bone will not
viii. General diseases, e.g. osteoporosis, nutritional
form. True Haversian system oriented to stress
deficiency and disorders of calcium metabolism.
factors replaces nonoriented pseudo-Haversian
4. Sequestration of bone.
system of secondary callus. Thus, the bone is
5. Traumatic myositis ossificans: It is rare.
moulded and sculptured to conform to the size of
6. Scars.
the remainder of bone.}
Complications of mandibular fracture manage- Q.4. A 40-year-old man, who is edentulous posteriorly,
ment reports with a fracture in angle of mandible. Write in
● Infection detail about clinical features, diagnostic means and
● Bleeding management.
● Lip numbness
Ans.
● Malocclusion
● Nonunion Edentulous mandibular fractures

● Malunion ● An edentulous mandible is always resistant to frac-
● Trismus ture, since there is a high degree of resorption in the

● Tooth loss molar region.
● Bilateral body fracture of an edentulous mandible is 5. Fractured ends should be freshened up, soft tissue
very common to see. entrapment is cleared off and then fixed.
● Attachment of the mylohyoid muscle is at a higher Techniques for treatment
level when compared to normal dentulous mandible. 1. Closed reduction with gunning splint fixation
With associated medical problems in these patients, there is 2. Open reduction (intraoral or extraoral) with transos-
i. Alveolar resorption is four times greater in the seous, circumferential wire ligation and transfixation
mandible than in the maxilla. with Kirschner wires
ii. Inferior alveolar vascular supply to the bone is 3. Percutaneous intramedullary pinning
greatly compromised. 4. Intraoral open reduction with bone graft and max-
iii. Too little cancellous bone for repair (osteoendos- illomandibular fixation
teum). 5. External splint fixation appliance
iv. Normal healing potential is retarded. 6. Extraoral open reduction and fixation with mal-
v. Open reduction amounts to stripping of perios- leable mesh
teum, which impairs osteogenesis, as there is 7. Extraoral open reduction and fixation with bone
greater dependence on periosteal supply in atro- plating
phic mandible.
Signs and symptoms Q.5. Classify fractures of condyle. Describe the clinical
● The molar areas may be more prone to fracture. features and management of unilateral condylar fracture.
● Bilateral fracture of the edentulous mandible.
Ans.
● Extreme downward and backward angulation of the
anterior fractured fragment that creates a typical Fractures of condyle

‘bucket handle’ type of displacement. 1. Unilateral and bilateral fractures
● Respiratory distress in an elderly patient. 2. Simple, compound or comminuted fractures of the
● Eburnation seen as ‘elephant foot deformity’. condyle
● Nonunion due to infection. 3. Wassmund’s five types of condylar fractures
● Anterior open bite is seen in bilateral angle fracture. 4. Lindhal’s classification of fractures
● Ipsilateral open bite is seen in unilateral angle fracture. Wassmund’s classification (1934)
● Retrognathic occlusion and flattened appearance of Type I: It is defined as a fracture of the neck of the condyle
the lateral aspect of the face. with relatively slight displacement of the head. The angle
● Elongated face may be the result of bilateral angle between the head and the axis of the ramus varies from
fractures, allowing the anterior mandible to be dis- 10° to 45°. He states that these fractures tend to reduce
placed downward. spontaneously.
● Inability to close the jaw causing premature dental Type II: These fractures produce an angle from 45° to
contact. 90°, resulting in tearing of the medial portion of the
● Swelling at the angle externally and there may be joint capsule.
obvious deformity. Type III: In these fractures, the fragments are not in
● Step deformity behind the last molar tooth may be contact and the head is displaced mesially and forward
visible. owing to traction of the lateral pterygoid muscle. The
● Undisplaced fractures are usually revealed by the fragments are generally confined within the area of the
presence of a small haematoma adjacent to the angle glenoid fossa. He recommended an open reduction for
on either the lingual or buccal side. this fracture type.
● Occlusion is often deranged. Mandibular movements Type IV: These fractures of the condylar head articulate
are painful. on or in a forward position with regard to the articular
● Trismus is usually present. eminence.
● On palpation, bone tenderness at the angle externally Type V: This group consists of vertical or oblique
can always be elicited. fractures through the head of the condyle. Wassmund
Treatment suggested a bone graft to reconstitute the condylar,
1. Early stabilization of the fracture is mandatory. when considerable displacement of the fragments has
2. Closed reduction with mandibular prosthesis held in occurred.
place by circummandibular wiring. Lindhal’s classification (1977)
3. In nonunion or delayed healing, open reduction is a. Based on anatomic location of the fracture (level
with titanium mesh. condylar fracture)
4. In severely atrophic edentulous ridge fracture, open ● Condylar head: The condylar head is usually
reduction is with primary bone grafting. defined as the portion of the condyle superior to
the narrow constriction of the condylar neck. ● If the condylar head is dislocated medially and all
Fractures of the condylar head are intracapsular, oedema has subsided due to passage of time, a char-
since the capsule attaches to the condylar neck. acteristic hollow over the region of the condylar head
They may be further classified as vertical frac- is observed.
tures, compression fractures and comminuted ● Deviation of the mandible on opening towards the
fractures. side of the fracture.

● Condylar neck: This is the thin constricted area ● Unilateral posterior crossbite and retrognathic occlu-
located immediately below the condylar head. sion.

Anatomically, it is the region where the caudal ● Paraesthesia of the lower lip in the absence of a frac-
portion of the joint capsule attaches. These fracture of the body or angle of mandible on that side.
tures are therefore extracapsular. ● Shortens the ramus and produces gagging of the oc-
● Subcondylar: This region is located below the clusion on the ipsilateral molar teeth.
condylar neck and extends from the deepest point ● Painful limitation of protrusion and lateral excursion
of the sigmoid notch anteriorly and to the deepest to the opposite side.
point along the concave posterior aspect of the ● Rarely the mandible will be locked and middle ear
mandibular ramus. Depending on the location, bleeding may present externally.

these fractures are described as ‘high’ or ‘low’ ● Tenderness over the condylar area on palpation.
subcondylar fractures. ● It may be possible to determine whether the condylar
b. Based on the relationship of the condylar segment head is displaced from the glenoid fossa by palpation
to the mandibular fragment within the external auditory meatus.
● Nondisplaced. Investigations
● Deviated: This involves only an angulation of the The techniques applied are
condylar fragment in relation to the distal man- 1. Conventional radiography
dibular segment. The fractured ends remain in a. Orothopantomogram (OPG)
contact, with no separation or overlap. b. Reverse Towne’s view
● Displacement with medial or lateral overlap: c. Transcranial views of temporomandibular
The fractured end of the proximal condylar seg- joints
ment lies either medially or laterally to the 2. CT scan
proximal end of the distal mandibular segment. 3. MRI
Medially displaced condylar fragment is more 4. Arthrography
common. Treatment
● Displacement with anterior or posterior overlap: Unilateral intracapsular fracture in adults
● These are uncommon. This kind of fracture does not cause much of a defor-
● No contact between the fracture segments. mity. Therefore, conservative treatment is considered
c. Based on the relationship between the condylar appropriate and IMF for a period of 2–3 weeks in
head and the glenoid fossa case of malocclusion.
● Nondisplaced: The condylar head is in normal Unilateral extracapsular fracture in adults
relation to the glenoid fossa. A low condylar neck fracture is treated by open re-
● Displacement: The condylar head remains duction method in case of severe malocclusion caused
within the fossa, but there is alteration in the by the fracture or dislocation. No effective treatment
joint space. is undertaken, if the fractured segments are not dis-
● Dislocation: The condylar head lies completely placed and there is no disturbance to the occlusion.}
outside the confines of the fossa. Usual location of Surgical approach
dislocation is anteromedial, due to the pull of lat- 1. Preauricular approach
eral pterygoid muscle. ● Alkayat–Bramley
● Rowe’s extension
[SE Q.4] ● Obwegeser’s modification
● Hockey stick
{Signs and symptoms 2. Retromandibular approach
● Swelling and tenderness over the TMJ. 3. Submandibular approach
● Haemorrhage from ear on affected side. 4. Bicoronal (bilateral condylar fracture along with
● ‘Battle’s sign’: Ecchymosis of the skin just below the frontal bone fracture).
mastoid process on same side is known as ‘Battle’s Methods of immobilization of condyle
sign’. ● Transosseous wiring
● Kirschner wire ● IMF is not reliable for the proper reduction of the
● Intramedullary screw fractured site, though it may establish occlusion.
● Bone pins ● Open reduction of at least one side to establish the
● Bone plating normal height is recommended and then the treat-

ment protocol is same as that for unilateral extracap-
Q.6. Describe the signs, symptoms, diagnosis and treat-
sular fracture.
ment of bilateral condylar fractures.
● When bilateral extracapsular fracture is associated
Ans. with other gross midfacial fracture, open reduction

of the both the sides should be considered.
[SE Q.3] Q.7. Write in short the principles of fracture manage-
{Signs and symptoms of bilateral condylar fractures ment in the maxillofacial region. Add notes on different
The signs and symptoms for unilateral fracture may
● treatment modalities for a fracture mandible involving
be noticed on both sides. teeth in the line of fracture.
● Swelling over both fracture sites.
Ans.
● Overall mandibular movement is usually more re-
stricted compared to that in unilateral fracture. [SE Q.5]

● An anterior open bite is present, if there is displace-
{Principles of fracture repair include: (i) reduction, (ii)
ment of the condyles from the glenoid fossa or over- fixation, (iii) stabilization and (iv) prevention of infection.
riding of the fractured bone ends. Aims
● Pain and limitation of opening and restricted protru-
i. Satisfactory facial form
sion and lateral excursions. ii. Satisfactory functional occlusion
● The appearance of an elongated face may be the re-
iii. Satisfactory posttreatment range of movement of the
sult of bilateral subcondylar fracture. jaw
● Bilateral condylar fractures are frequently associated
iv. No second surgery for facial recontour in malocclu-
with fracture of the symphysis or parasymphysis.} sion
Investigations v. No bone grafting
The techniques applied are Treatment of fractures involves basically two tech-
1. Conventional radiography: niques:
a. Orothopantomogram (OPG) i. Closed technique
b. Reverse Towne’s view ii. Open technique
c. Transcranial views of temporomandibular I. Reduction
joints a. Closed technique
2. CT scan ● Closed treatment is based on the principle that
3. MRI when the teeth of a fractured segment are in cor-
4. Arthrography rect occlusion, then the bone fragments to which
[SE Q.3] they are attached will also be satisfactorily re-
duced.
{For children under the age of 10 ● Healing of the bone is seen by secondary inten-
This age group is more likely to develop ankylosis
● tion with callus formation.
due the condylar fracture. External reduction devices
● The treatment is completely functional for both uni- ● Manipulation instruments can be employed to
lateral and bilateral condylar fractures. bring the segments to occlusion.
● IMF may be required for a period of 7–10 days in ● For example, Rowe’s disimpaction forceps can
case of extreme pain.} be used to disimpact the fractured maxilla and
Bilateral intracapsular fracture in adults bring it to occlusion.
● An intermaxillary fixation for a period of 3–4 weeks ● Walsham’s forceps can be used to manipulate
is recommended, as the amount of displacement of certain nasal fractures.
both the condyles may be different. Intraoral or extraoral traction
● Physiotherapy after IMF prevents any restriction of They are employed in cases where reduction has
mouth opening. delayed or in cases where muscular trismus prevents
Bilateral extracapsular fracture in adults effective manipulation.
● Usually, this fracture results in instability and gross ● Intraoral traction involves fixation of prefabri-
displacement of the mandible. cated arch bars to the maxillary mandibular
arches and elastic traction of the segment nor- Q.9. Classify fracture of mandibular condyle and its
mal occlusion using elastics. signs and symptoms. How do you manage a case of uni-
● Extraoral traction, on the other hand, involves lateral condylar fracture with displacement in an adult?
anchorage from intact skull for traction. The pro-
Ans.
cess of traction is extremely slow and the patient
is encouraged to open and close the mouth to [Same as LE Q.5]
facilitate the elastic traction. When satisfactory
Q.10. Write in detail clinical features, diagnosis and
occlusion is achieved, elastics are removed inter-
management of bilateral condylar fracture in an 8-year-
maxillary. Fixation is done using wires.
old boy.
b. Open technique
● Open reduction is the surgical intervention for Ans.
reduction of the fractured segments.
[Same as LE Q.6]
● After introduction of antibiotics, possibility of
surgical opening of facial bone fractures increased

significantly. SHORT ESSAYS:
● Healing takes place by primary intention and no
Q.1. What is the basic difference between simple and
callus formation occurs during healing.
compound fracture of bone?
II. Fixation
a. Closed fixation (indirect fixation) Ans.
Intermaxillary fixation Inter maxillary fixation
Simple or closed
(IMF) or Maxillo mandibular fixation (MMF): It
These are fractures that do not produce wound open to
refers to immobilization of the jaws by wiring in a
the external environment, whether it is through the skin,
closed position. It is done by means of wires, arch
mucosa or periodontal membrane.
bars and splints.
Compound or open
b. Internal fixation (direct fixation)
It is a fracture in which external wound involving skin,
Intraoral devices
mucosa or periodontal membrane communicates with
● Plates and screws
break in the bone.
Extraoral devices Q.2. Clinical features of fracture of body of mandible.

● External pin fixation
Ans.
III. Immobilization
● In this phase, the fixation device is retained to stabi-
{SN Q.21}
lize the reduced fragments into their normal anatomi-
cal position, until clinical bony union takes place. Clinical features of fracture of body of mandible are
● The fixation device is utilized for a particular pe- as follows:
riod to immobilize the fractured fragments. ● Swelling and bone tenderness similar to that as seen
● Immobilization period depends on the type of frac- in fracture of angle of mandible.
ture and the bone involved. For maxillary fractures ● Even slight displacement of the fracture results in
3–4 weeks of immobilization period is sufficient, derangement of the occlusion.

while for mandibular fracture it is 4–6 weeks. ● Premature contact occurs on the distal fragment.
● In condylar fracture, the recommended immobili- ● Fractures between adjacent teeth tend to cause gingi-
zation period is 2–3 weeks only, for prevention of val tears.

ankylosis of TMJ. ● When there is gross displacement, inferior dental artery
IV. Prevention of infection and rehabilitation of func- may be torn and this can give rise to severe intraoral
tion haemorrhage and ecchymosis in the floor of mouth.
● Appropriate antibiotics should be used to prevent ● Flattened appearance of lateral aspect of face.
intraoperative and postoperative infections.} ● Inability to open or close the jaw.
● Crepitation on palpation.
Q.8. Write about management of unfavourable fracture

of angle region of edentulous mandible in a 60-year-old Q.3. Signs and symptoms of bilateral condylar fractures
person. in children.
Ans. Ans.
[Same as LE Q.4] [Ref LE Q.6]
Q.4. How do you manage a case of unilateral condylar ii. German silver
fracture with displacement in adults? iii. Jelenko
c. Cap splints
Ans. 2 . Intermaxillary fixation with osteosynthesis
[Ref LE Q.5] a. Transosseous wiring
b. Circumferential wiring
Q.5. Principles of fracture management. c. External pin fixation
d. Bone clamps
Ans.
e. Transfixation with Kirschner wire
[Ref LE Q.7] f. Hayton–William’s wiring
3. Osteosynthesis without intermaxillary fixation
Q.6. Dentoalveolar fractures.
a. Noncompression small plates
Ans. b. Compression plates
c. Miniplates
● Dentoalveolar injuries are defined as those fractures in
d. Lag screws
which avulsion, subluxation or fracture of the teeth oc-
The method of dental wiring is employed in situations
curs in association with a fracture of the alveolus.
where the patient cannot afford the expensive bone plates.
● This may occur alone or in conjunction with some other
Transosseous wiring
type of mandibular fracture.
● Transosseous wiring refers to direct wiring across
● Fracture of the crown of individual teeth.
the fracture line.
● Any missing fragments of crown or missing fillings
● It is an effective method of fixation and immobi-
should be noted as these may be embedded within the
lization of the mandible and the angle.
soft tissues or more rarely swallowed or inhaled.
● Minimum specialized equipment required for this
● Exposure or near exposure of the pulp chamber, which
method of fixation.
requires immediate treatment.
Technique
● Fractures of the roots of teeth.
● Holes are drilled across the fracture lines and
● Excessively mobile teeth should be noted for later peri-
soft stainless steel wire of 0.45 mm diameter is
apical radiographs.
passed through the holes across the fracture.
● Subluxation of teeth causes derangement of occlusion.
● Accurate reduction of the fractured segments is
● Vertical split or a horizontal fracture just below the gin-
by twisting the wires tightly and the twisted
gival margin results from indirect trauma against the
wire tucked into the nearest hole.
opposing dentition or violent impact by a small hard
● The reduction of the fractured segments should
object such as missile.
be done independently with teeth in occlusion.
Multiple fractured but firm teeth indicate that the
● Wires are applied on the upper border or the
jaws were clenched during trauma. By palpating the
lower border depending upon the type of fracture.
mandible with the thumbs on the teeth and fingers
● Transosseous wiring can be done either through
in the lower border of the jaw and carefully applying
intraoral or extraoral approach.
pressure, clinician can detect a crepitation in a
● The transosseous wiring at the upper border of
fracture.
the mandible, either through intraoral or extra-
● Electrical or thermal vitality tests at this stage are unre-
oral incision is preferred for the fractures of the
liable.
angle of the mandible with minimum displace-
Q.7. Name any four different types of dental wiring ment or for the edentulous area of the body
techniques. Describe in short any one wiring technique fracture.
for dentoalveolar fracture. ● It is sufficient for the upper border wire to pass
through the outer cortical plate alone, as the

Ans.
fixation is always combined with IMF.
1. Intermaxillary fixation
a. Dental wiring Q.8. Rigid internal fixation.
i. Direct interdental
Ans.
ii. Eyelet
iii. Continuous or multiple loop wiring Rigid fixation without IMF is achieved through bone plates.
iv. Risdon’s wiring There are basically two main systems of fixation of man-
b. Arch bars dibular fractures:
i. Erich i. Compression plates
The compression plates are placed on (Arbeitsgemein

● Q.10. Champy’s osteosynthesis line for monocortical
schaft fur Osteosynthesefragen/Association for the plating.
study of Internal Fixation) (AO/ASIF) principles.
Ans.
These plates, however, skilfully adapted to mandible,
the upper border and the lingual plates open during the Champy’s line of osteosynthesis
final tightening of the screws. These plates include ● Mandible is a blunt V-shaped tubular bone. It con-
two pear-shaped holes at the extreme ends of the plate. sists of dense outer and inner cortical plate with
● These holes have the widest diameter near the frac- cancellous bone in-between. Similarly, cortical bone
ture lines. And, compression plate is placed in such a along the external oblique ridge and the inferior re-
way that the two holes lie on either side of the frac- gion of the chin is thick and dense.
ture line. ● The dense bone provides an excellent anchorage for
● The screw is inserted in the narrowest part of the osteosynthesis screws. However, fixation of the
bone such that after tightening, its head comes to rest screws in the region of the alveolar process is diffi-
in the wider diameter of the bone. A tension band cult due to presence of roots of the teeth.
should be applied at the level of alveolus, before ● Masticatory forces produce tensional forces in the
tightening screws. alveolar region or at the upper border and compres-

ii. Noncompression miniplates sion forces at the lower border. This explains the
● A natural line of compression exists along the lower cause of distraction of fracture segments in the upper
border of the mandible. On the basis of this, they border and compression in the lower border.
suggested that fractures of the angle of the mandible ● According to Champy, the transitional zone in-be-
can be secured with single plate as near to the upper tween the areas of tension and compression is the
border as feasible. In case of fracture of the parasym- line of zero force running along the inferior alveolar
physis region, two plates are ideally advised: One nerve. Plates are placed along this line.
juxtaalveolar and the other at the lower border. ● Champy calculated the forces applied to these plates
● This can be used virtually in all types of mandibular under physiological strains and produced the most
body fractures determined by the ideal line of os- desirable shape of minimum thickness and reasonable
teosynthesis. It is well known as Champy’s line of malleability to neutralize the harmful tension forces
osteosynthesis, where miniplate fixation is most that causes displacement of the fracture segments.
stable. ● Originally, Champy made these plates using stainless
steel. But currently titanium plates are also available.

Q.9. Dynamic compression plates.
These plates are known as noncompression miniplates.
Ans. Areas of plate application
● Single noncompression miniplate on the superior
{SN Q.17} border of the mandibular angle fractures on the

external oblique line was recommended by
● Plates and screws are made up of stainless steel and
Champy.
need removal later on. These plates are very bulky.
● For fractures posterior to the mental foramen, a
● Dynamic compression plates (DCP) system makes
single plate is placed below the dental roots and
compression osteosynthesis possible, because of
above the inferior alveolar nerve.
the screw holes designed according to the spheri-
● For fractures anterior to mental foramen, two
cal gliding principle for a 2.7 mm screw.
plates are necessary to neutralize the torsional
● In Eccentric Dynamic compression plates (EDCP),
forces: One is placed in the subapical region and
eccentric gliding hole principle is used. In eccentric
the other along the lower border of the mandible.
dynamic compression plate, there are two lateral
oblique holes in addition to conventional spherical Q.11. Fracture of the body of edentulous mandible.
gliding holes.
Ans.
● When the screw with the spherical head is driven into

the two inner holes, they provide interfragmentary com- {SN Q.20}
pression. It is possible by means of two outer holes to
Gunning splints are used as means of closed reduction
produce additional compression at the alveolar margin
for the edentulous mandible.
of the fractured fragment.
● Gunning originally made these vulcanite splints for
● The two lateral oblique holes takeover the function of
fractured dentate mandible. Gunning splints are
the tension bend in the alveolar margin.
resulting in displacement, then the fracture line is

modified dentures which have bite blocks in the
considered as unfavourable. The elevator group of
place of teeth and a provision of space in the incisor
muscles exert an upward, forward and medial pull;
region for feeding.
while, depressor group of muscles exert a downward
● These splints can be used either in the upper or lower
and backward pull in an intact mandible. Whenever
edentulous jaws. In case of completely edentulous
there is a break in the continuity at the angle region,
patients, immobilization is carried out by attaching
then these two muscle groups lose their coordinated
the upper splint to the maxilla by peralveolar wires
movements and have independent action.
and the lower splint to the mandibular body by cir-
● In unilateral angle fracture, posterior ramus frag-
cumferential wires.
ment is the lesser fragment, while the body of the
● The upper and the lower splints are connected with
mandible bearing the teeth becomes the greater frag-
wires or elastic bands for intermaxillary fixation. A
ment. The greater fragment’s position is stabilized to
slightly overclosed relation of the gunning splint
certain extent by the occlusion of the teeth, while
helps in effective reduction.
posterior ramal fragment can show displacement
● To minimize the entry of food particles under the fit-
independently.
ting surface, the splint edges should overextend
a. Horizontally favourable fracture
around the sulcus.
When the fracture line passes from the alveolar margin
downward and forward, then upward displacement of
the posterior fragment is prevented by physical obstruc-
Construction
tion caused by the body of the mandible. Hence, such a
● The impression of the mandible is taken and the splints
fracture line is termed as horizontally favourable.
are constructed on models obtained from these impres-
b. Horizontally unfavourable fracture
sions.
On the other hand, the line of fracture passes downward
● Using acrylic resin, the splints are constructed and the
and backward, then the upward movement of the poste-
fitting surface is lined with black gutta percha.
rior fragment is unopposed. This type fracture is termed
● In a slightly overclosed relationship, the occluding sur-
horizontally unfavourable. Sometimes, the upward dis-
faces can be made to fit together satisfactorily.
placement can be prevented by presence of a tooth on
● Alternatively, a trough can be cut in the occlusal surface
the posterior fragment which comes into contact with
of one splint and filled with gutta percha. The opposing
maxillary tooth.
occlusal surface is then shaped to fit into the trough and
c. Vertically favourable fracture
a satisfactory fit obtained at operation by softening the
When the angle fracture is viewed from above or the
gutta percha and pressing the two splints together.
occlusal surface (in the vertical plane), then buccolin-
● Intermaxillary fixation is done by applying hooks into
gual direction of the fracture line can be studied. Here,
each.
the displacement of the posterior fragment can be no-
● Modification of the patient’s dentures can also be used
ticed in the medial direction to the spasm of medial
as splint, if these have been preserved.
pterygoid and mylohyoid muscle. Here, the fracture line
● During operation, it is necessary to adapt the splint to
which passes from outer or buccal plate obliquely back-
the alveolus of each jaw after reduction.
ward and lingually will tend to resist the muscle pull
Q.12. Describe the vertically unfavourable fracture line mentioned and is thus termed a vertically favourable
at the angle of the mandible. type fracture.
d. Vertically unfavourable fracture
Ans.
When the fracture line passes from the inner or lingual
According to the direction of fracture and favourability plate obliquely backward and buccally inward, then
for treatment movement of the posterior fragment will take place as a
a. Horizontally favourable fracture result of the medial pterygoid muscle pull. This type of
b. Horizontally unfavourable fracture fracture is termed vertically unfavourable. This classifi-
c. Vertically favourable fracture cation is of clinical importance for treatment, planning
d. Vertically unfavourable fracture and fixation. Based on this, the amount of placement
● This classification is aimed towards the angle frac- can be judged and the type of fixation can be chosen.
tures. Here, the direction of fracture line is important
for resisting the muscle pull. When the muscle pull Q.13. Fracture of body of mandible in children.
resists the displacement of the fragments, then the
Ans.
fracture line is considered as favourable. If the muscle
pull distracts the fragments away from each other, [Same as SE Q.2]
Q.14. Methods of wiring in oral surgery. muscular contraction. This is because of weakness
caused due to the pre-existing bone pathology.
Ans.
Areas of structural weakness may result from the following:
[Same as SE Q.7]
a . Generalized skeletal disease
Q.15. Transosseous wiring. i. Endocrinal disorders – Hyperparathyroidism or
postmenopausal osteoporosis.
Ans.
ii. Developmental disorders – Osteopetrosis and os-
[Same as SE Q.7] teogenesis imperfecta.
iii. Systemic disorders – Reticuloendothelial diseases,
Q.16. Gunning splints.
Paget’s disease, osteomalacia and severe anaemia.
Ans. b. Localized skeletal disease
Various cysts, odontomes, tumours, osteomyelitis
[Same as SE Q.11]
and osteoradionecrosis affect the local region.
Q.17. Draw diagrams to explain vertically and horizon-
Q.4. Horizontal favourable fracture of angle of mandible.
tally favourable fracture of mandible.
Ans.
Ans.
● When the muscle pull resists the displacement of the
[Same as SE Q.12]
fragments, then the fracture line is considered as
Q.18. Healing of fractures. favourable.
● If the muscle pull distracts the fragments away from
Ans.
each other, resulting in displacement, then the fracture
[Ref LE Q.3] line is considered as unfavourable.
● When the fracture line passes from the alveolar margin
downward and forward, then upward displacement of

SHORT NOTES: the posterior fragment is prevented by physical obstruc-
Q.1. Name four X-rays taken for fracture mandible. tion caused by the body of the mandible.
● Hence, such a fracture line is termed horizontally
Ans.
favourable.
● Panoramic radiograph
Q.5. Mention any eight causes for the nonunion of frac-
● Lateral oblique radiograph
tured fragments of the mandible.
● Posteroanterior radiograph
● Occlusal view Ans.
● Periapical view
Causes for the nonunion of fractured fragments of the man-
● Reverse Towne’s view
dible are as follows:
Q.2. Nonunion. i. Infection at the fracture site
ii. Inadequate immobilization
Ans.
iii. Unsatisfactory approximation with tissue entrapment
● Nonunion indicates a lack of bony healing between the iv. The ultrathin edentulous mandible in an elderly de-
segments that persist indefinitely without evidence of bilitated patient
bone healing, unless surgical treatment is undertaken to Considerable loss of bone and soft tissue
repair the fracture. vi. Inadequate blood supply after radiotherapy
● Nonunion is characterized by pain and abnormal mobil- vii. The presence of bone pathology like tumours, etc.
ity following treatment. viii. General diseases, e.g. osteoporosis, nutritional defi-
● The most likely cause of nonunion is inadequate reduc- ciency and disorders of calcium metabolism
tion and immobilization, infection of the fracture site,
Q.6. Unfavourable fracture of mandible.
decreased vascularity and systemic fractures.
Ans.
Q.3. Pathological fractures.
● When the muscle pull resists the displacement of the
Ans.
fragments, then the fracture line is considered as favour-
Pathological fractures able. If the muscle pull distracts the fragments away
This is a spontaneous fracture of the mandible occurring from each other, resulting in displacement, then the
from mild injury or as a result of a normal degree of fracture line is considered as unfavourable.
● If the line of fracture passes downward and backward, ● The sigmoid notch is identified, so that a Bauer type
then the upward movement of the posterior fragment is retractor can be positioned into it.
unopposed. This type of fracture is termed horizontally ● The proximal condylar segment is then carefully
unfavourable. Sometimes, the upward displacement can identified. If the proximal segment is displaced me-
be prevented by presence of a tooth on the posterior dially, the mandible is distracted inferiorly with a gag
fragment which comes into contact with maxillary of the Mason type, so that the proximal segment can
tooth. be positioned laterally.
● When the fracture line passes from the inner or lingual ● A four-hole miniplate of the Wurzburg type was then
plate obliquely backward and buccally inward, move- attached to the proximal segment with one or two
ment of the posterior fragment will take place as a result screws.
of the medial pterygoid muscle pull. This type of frac- ● The periosteum of the proximal segment is then ele-
ture is termed vertically unfavourable. vated only to the degree necessary for plate place-
ment to preserve as good a blood supply as possible.
Q.7. Green stick fracture. ● A percutaneous trochar is placed through a horizon-
Ans. tal stab incision in the preauricular region, so that the

correct angulation could be obtained for making the
● It is fracture, where one cortex of the bone is broken drill holes.
with the other cortex being bent. ● Intermaxillary fixation is instituted using previously
● It is an incomplete fracture usually seen in young chil-
inserted arch bars or wiring. After this, fracture is
dren, because of inherent resiliency of the growing bone. reduced with attention being given to a proper align-
Q.8. Malunion and nonunion. ment of the posterior border of the ramus as ascer-
tained by inspection and instrumental palpation of
Ans. the fractured site.
● The plate is then attached to the distal segment with
Malunion
● Malunion is defined as improper alignment of the
two further screws.
● The incision is closed. Patients are asked to wear
healed bony segments.
● Not all malunions are clinically significant.
training elastics between their fixation bars for 2–10
● These malocclusions may be treated with orthodon-
days.
tics or osteotomies after complete bony union. Q.10. Fixation methods in trauma.
● It may also result in facial asymmetry, enophthalmos
Ans.
and ocular dystopia.
Nonunion Closed fixation (indirect fixation)
● Nonunion indicates a lack of bony healing between Intermaxillary fixation (IMF or MMF): It refers to im-
the segments that persist indefinitely without evi- mobilization of the jaws by wiring in a closed position.
dence of bone healing, unless surgical treatment is It is done by means of wires, arch bars and splints.
undertaken to repair the fracture. Internal fixation (direct fixation)
● Nonunion is characterized by pain and abnormal Intraoral devices
mobility following treatment. ● Plates and screws
● The most likely cause of nonunion is inadequate re- ● Transosseous wiring
duction and immobilization, infection of the fracture Extraoral devices

site, decreased vascularity and systemic fractures. ● External pin fixation
Q.9. Treatment option for subcondylar fractures of Q.11. Bone plates.

mandible.
Ans.
Ans.
● The usage of bone plates had revolutionized the trend
Surgical technique for subcondylar fractures towards the surgical approach of condylar fractures.
● Under general anaesthesia, subcondylar fractures ● Bone plates provide both rigidity and stabilization with
were first reduced and fixed. an added advantage of easy application.

● The fracture can be approached through an incision ● Bone plates can be applied through intraoral or extraoral
along the anterior border of the ascending ramus techniques.

used electively for oblique subcondylar.
Q.12. Eyelet wiring.
● The masseter muscle was reflected laterally to the
posterior border at a subperiosteal level. Ans.

Advantages of one fragment and engages the cortex of opposite

● This is a firm and stable technique of wiring. fragment with its threads draws the fragments together
● If any of the eyelets break, only the particular eyelet and compresses them when tightened.
may be changed without disturbing the rest of the ● Gliding holes and thread hole must be coaxial.
wiring
Q.16. Transosseous wiring.
Disadvantages
● Requires the presence of firm and healthy teeth adja- Ans.
cent to each other
● This is used for low subcondylar fractures. The condyle
● Time-consuming
approach through the submandibular incision and holes
● May cause extrusion of the teeth due to wire around
are drilled in the fragmented segments and wire passed
the neck of the tooth
across the major segment. A pull through wire is used for
Q.13. Circummandibular wiring. passing the wire through a hole drilled in minor fragment.
● Preauricular incision is preferred for high condylar frac-
Ans. tures. Here, the fragments are drilled obliquely from the
● Circummandibular wiring can be used successfully and external surface to the fracture surface in order to de-
effectively in the immobilization of oblique fractures in crease the risk of injuring maxillary artery and other
edentulous mandible. blood vessels and to facilitate the insertion of wire.
● The wiring can be done by passing 0.45 mm stainless ● In case of dislocation of the condyle due to fracture, tran-
wire circumferentially around the mandible. sosseous wiring should be assisted with other methods of
● A curved awl is pushed through the skin beneath the fixation to counteract the pull of the lateral pterygoid.
mandible and directed into the mouth on the lingual side Q.17. Compression bone plates.
of the bone. One end of certain length of 0.45 mm stain-
Ans.
less steel is passed through the tip of the awl, which is
pulled on the lingual side. [Ref SE Q.9]
● Now the awl is withdrawn to lower border of the man-
Q.18. Methods of wiring in oral surgery.
dible and before withdrawing it out of the skin, it is
pushed into the buccal sulcus where the wire is detached Ans.
from the awl and the awl is withdrawn through the
Methods of wiring in oral surgery are
original puncture. The two ends of 0.45 mm stainless
steel wire are tied together and tightened.
IMF/MMF
Q.14. Arch bars wiring. ● Suspension wires
● Frontal suspension
Ans. ● Circumzygomatic suspension
Two types of arch bars are available: (i) prefabricated and ● Infraorbital
(ii) made individually for a given patient. ● Pyriform aperture
Indications for use ● Peralveolar
● When the remaining teeth are insufficient to allow Q.19. Eburnation.

efficient eyelet wiring.
Ans.
● When the distribution of the teeth in the arch is such
that efficient intermaxillary fixation is not possible. Eburnation is one of the signs of nonunion.
● In cases of simple dentoalveolar fractures or where ● It is the rounding off and sclerosis of the fractured bone
multiple tooth bearing fragments in either jaw re- ends.

quires reduction into an arch form before intermaxil- ● It can be detected radiographically.
lary fixation is applied. Q.20. Fracture management in edentulous jaws.

Q.15. Lag screws. Ans.
Ans. [Ref SE Q.11]
● Compression of the fractured fragments can be accom- Q.21. Fracture of body of mandible – signs and symp-
plished by means of lag screws. This technique is ap- toms.
plied for the treatment of oblique fractures in long bones.
Ans.
● Few oblique mandibular fractures can also be treated
through this method. A screw that glides through cortex [Ref SE Q.2]
Q.22. Indications for extraction of tooth related to frac- Q.24. Wire osteosynthesis.
ture line.
Ans.
● Longitudinal fracture involving the crown and the root, Q.25. Dynamic compression plate.
splitting the tooth
● Complete subluxation of the tooth from its socket Ans.
● Pre-existing large periapical pathology
[Same as SN Q.17]
● Grossly infected fracture line
● Bad periodontal status of the tooth and third degree Q.26. Gunning type splint.
mobility due to periodontitis Ans.
● Functionless teeth
● Advanced caries [Same as SN Q.20]

● Root stumps
Q.27. Gunning splint.
Q.23. Battle’s sign. Ans.
● Ecchymosis of the skin just below the mastoid process Q.28. What is a Battle’s sign? What is the differential
on the same side. diagnosis of it?
● This particular physical sign also occurs with fractures
Ans.
of the base of the skull.
● This type of sign is seen in unilateral condylar fracture. [Same as SN Q.23]
Topic 9
Cysts of Orofacial Region
LONG ESSAYS:
1. Classify cysts that occur in mouth. Describe the treatment of dentigerous cyst.
2. Classify cystic lesions in jaw. Describe the clinical features and the treatment of odontogenic keratocyst involv-
ing lower third molar areas.
3. Define cyst. Describe the pathogenesis, clinical features and radiographic appearance of radicular cyst.
4. Classify odontogenic cysts of the jaw. Describe the signs, symptoms and management of the cyst of the maxilla
involving the maxillary antrum.
5. Define cyst. Enumerate the method of treatment of any jaw cyst. Describe anyone method in detail.
6. Describe various methods of treatment of dentigerous cyst. [Same as LE Q.1]
7. Classify odontogenic cyst. Give in detail the treatment plan for large dentigerous cyst in the body of mandible.
[Same as LE Q.1]
8. Classify cysts of the jaws and write in detail about dentigerous cyst. [Same as LE Q.1]
9. Classify odontogenic cysts. Give in detail the treatment plan for large dentigerous cyst. [Same as LE Q.1]
10. How do you manage a case of cyst in relation to unerupted upper canine tooth in patient aged 12 years.
[Same as LE Q.1]
11. Classify odontogenic cysts of the jaws. Write in detail about the management of cysts of the jaw by laying
special emphasis on the management of odontogenic keratocyst. [Same as LE Q.2]
12. Write the aetiology, clinical features, diagnosis and treatment of odontogenic keratocyst of the mandible
affecting a young adult of 20 years. [Same as LE Q.2]
1 3. Classify odonotogenic cyst of the jaws and describe the management of OKC. [Same as LE Q.2]
14. Define and classify cysts of the jaws and oral cavity. Discuss the aetiopathogenesis, clinical features and
management of odontogenic keratocyst in the ramus of mandible. [Same as LE Q.2]
15. What is a keratocyst? What are the causes for recurrence of keratocyst and normal technique of management
of keratocyst occurring in the posterior body and ramus of the mandible? [Same as LE Q.2]
16. Discuss the pathogenesis of odontogenic keratocyst and its management. [Same as LE Q.2]
17. Classify cysts of the jaw and write about keratocyst. [Same as LE Q.2]
18. Classify cysts of the jaw and discuss in detail the pathology and the management of odontogenic keratocyst of
the maxilla. [Same as LE Q.2]
19. Classify cystic lesions. Describe the management of a radicular cyst. [Same as LE Q.3]
SHORT ESSAYS:
1 . Classification of odontogenic cysts. [Ref LE Q.4]
2. Mention the merits and demerits of enucleation and marsupialization procedures of cystic lesions.
3. Write four indications of marsupialization.
4. Mention the principle of marsupialization and give any four disadvantages of the procedure.
5. Write four advantages of enucleation of cyst. [Ref LE Q.5]
6. Define cyst. Mention various developmental odontogenic cysts of jaws.
7. What is ‘enucleation technique’? Mention any four merits of this procedure. [Same as SE Q.5]
SHORT NOTES:
1. Theories of cyst expansion.
2. Cornoy’s solution.
3. Causes of recurrence potential of keratocyst.
4. Name the cysts of the maxillary antrum.
5. Aneurysmal bone cyst.
6. Residual cyst.
7. Define enucleation. [Ref LE Q.5]
8. Marsupialization.
9. Globulomaxillary cyst.
10. Nasolabial cyst.
11. Traumatic bone cyst.
12. Benign cystic lesions of the mandible.
13. Apical granuloma.
14. Periapical granuloma. [Same as SN Q.13]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Classify cysts that occur in mouth. Describe the c. Lateral periodontal cyst – Lateral botryoid
treatment of dentigerous cyst. odontogenic cyst
d. Calcifying odontogenic (Gorlin) cyst
Ans. 2. Inflammatory
a. Radicular cyst (apical/lateral periodontal)
I. Intraosseous cysts b. Residual cyst
Epithelial cysts Cysts of nonodontogenic epithelial origin
Cysts of odontogenic epithelial origin 1. Fissural
1. Developmental a. Median mandibular
a. Primordial cyst (keratocyst) b. Median palatal
b. Dentigerous (follicular) cyst c. Globulomaxillary
2. Incisive canal (nasopalatine duct or median ante- supernumerary tooth; sometimes, other adjacent
rior maxillary) cyst teeth may also fail to erupt, may be tilted or oth-
Nonepithelial cysts erwise be out of alignment.
1. Solitary bone cyst (traumatic) ● A smooth, hard, painless swelling can be seen due
2. Aneurysmal bone cyst to lateral expansion. Later the bone covering the
3. Stafne’s bone cavity centre of the convexity becomes thinned, as the
Cysts of the maxillary antrum cyst expands and can be indented with pressure on
1. Surgical ciliated cyst of maxilla palpation, with further expansion. This fragile
2. Benign mucosal cyst of the maxillary an- outer shell of bone becomes fragmented and the
trum sensation imparted and sound produced on palpa-
II. Soft tissue cyst tion over the area is described aptly as egg-shell
A. Odontogenic cysts crackling, which is also true for other large odon-
1. Gingival cysts togenic cysts.
a. Adult ● Still later, the cyst lining may come to lie imme-
b. Newborn diately beneath the oral mucosa and fluctuation

B. Benign mucosal cyst of the maxillary antrum – can be elicited.
nonodontogenic cysts Radiological features
1. Anterior median lingual cyst ● Unilocular radiolucency is associated with crowns
2. Nasolabial cyst (or nasoalveolar cyst) of unerupted impacted teeth. At times, a multi-
C. Retention cysts locular effect can be seen when the cyst is of ir-
Salivary gland cysts regular shape due to bony trabeculations.
a. Mucocoele ● Cysts have a defined sclerotic margin.
b. Ranula ● With the pressure of an enlarging cyst, the un-
D. Developmental/congenital cysts erupted tooth can be pushed away from its di-
a. Dermoid and epidermoid cysts rection of eruption, e.g. the lower molar may be
b. Lymphoepithelial cyst (cervical/intraoral) pushed to the inferior border or into ascending
c. Thyroglossal duct cyst ramus; whereas, the upper cuspid may be
d. Cystic hygroma pushed up into the maxillary sinus or floor of
E. Parasitic cysts the nose.
a. Hydatid cysts ● As compared to the other jaw cysts, dentigerous
b. Cysticerosis cysts have a higher tendency to cause root resorp-

F. Heterotropic cysts tion in adjacent teeth.
Oral cysts with gastric or intestinal epithelium ● Radiologically, the dental follicle expands around
Dentigerous cyst the unerupted or impacted tooth in variations, i.e.

Dentigerous cyst results because of enlargement of (a) circumferential, (b) lateral and (c) coronal.
the follicular space of the hole or part of the crown Pathogenesis
of an impacted or unerupted tooth and is attached to ● The development of dentigerous cyst is mainly
the neck of the tooth. due to accumulation of fluid between the reduced
Site enamel epithelium or within the enamel organ it-
● More frequently in the mandible than in the self of unerupted or impacted teeth.
maxilla. ● In case of a dilated follicle, a pericoronal of more
● Late erupting teeth are most frequently involved than 3–4 mm is considered as a cyst.
in descending order. These are lower third molars, ● Another possibility suggested for the develop-
upper cuspids, upper third molars and lower bi- ment of dentigerous cysts is due to early degen-
cuspid teeth. eration of the stellate reticulum and is likely to be
Clinical features associated with enamel hypoplasia.
● Dentigerous cysts have the potential to attain a Treatment
large size; often it is the pronounced facial asym- In a patient with mixed dentition phase, best possible
metry or the problem of ill-fitting dentures that treatment is marsupialization.
forces a patient to seek treatment. ● Treatment via an intraoral approach or extra-
● Pain may be a presenting symptom, if secondary oral approach is decided by the size of the cyst,
infection is present. adequate access and whether it is desirable to
● A tooth from the normal series is usually found save the involved tooth.
to be missing clinically, unless the cause is a ● Marsupialization (Partsch surgery)
This is usually indicated in children if large

● II. Soft tissue cyst
cyst is present and the involved tooth/teeth are A. Odontogenic cysts
to be maintained. 1. Gingival cysts
● The tooth may erupt into occlusion, as the a. Adult
defect heals with normal bone or orthodontic b. Newborn
forces may be used to bring the tooth into B. Benign mucosal cyst of the maxillary antrum –
occlusion. Nonodontogenic cysts
Enucleation a. Anterior median lingual cyst
● Alternatively, the cyst can be enucleated together b. Nasolabial cyst (nasoalveolar cyst)
with the involved tooth in adults, as the possibility C. Retention cysts
of the tooth eruption is low. Salivary gland cysts
● In children, an attempt could be made to salvage a. Mucocoele
the tooth, in which case, the lining is separated b. Ranula
from the neck of the tooth with a scalpel. D. Developmental/congenital cysts
● This procedure is worth attempting, when root a. Dermoid and epidermoid cysts
formation is complete, so that the risk of tooth b. Lymphoepithelial cyst (cervical/intraoral)
dislodgement is low. c. Thyroglossal duct cyst
Behaviour and prognosis d. Cystic hygroma
● It is widely believed that ameloblastomas fre- E. Parasitic cysts
quently arise in dentigerous cysts and some have a. Hydatid cysts
even termed them as preameloblastic lesions. b. Cysticerocis
F. Heterotropic cysts
Q.2. Classify cystic lesions in jaw. Describe the clinical Oral cysts with gastric or intestinal epithelium
features and the treatment of odontogenic keratocyst III. Keratocyst
involving lower third molar areas. Incidence
● Primordial cysts comprise approximately 5%–
Ans.
10% of odontogenic cysts of the jaws.
I. Intraosseous cysts ● Seen predominantly in the second, third and
Epithelial cysts fourth decades of life, though they can occur in

Cysts of odontogenic epithelial origin any age group.
1. Developmental ● They have a slight predilection for the males than
a. Primordial cyst (keratocyst) females.

b. Dentigerous (follicular) cyst Site
c. Lateral periodontal cyst – Lateral botryoid ● They are usually seen in the mandible than in the
odontogenic cyst maxilla. About one half of the former are seen to
d. Calcifying odontogenic (Gorlin) cyst involve the angle of the mandible with extension
2. Inflammatory for varying distances into the ascending ramus
a. Radicular cyst (apical/lateral periodontal) and body of the mandible.
b. Residual cyst ● They can also be seen anywhere in the jaws, in-
Cysts of nonodontogenic epithelial origin cluding the midline, though most of the cysts are
1. Fissural seen posterior to the first bicuspids.
a. Median mandibular Clinical features
b. Median palatal ● The physical features of a jaw cyst depend on the
c. Globulomaxillary dimensions of the lesion.

2. Incisive canal (nasopalatine duct or median ante- ● A small cyst is unlikely to be diagnosed on routine
rior maxillary) cyst examination of the mouth, and is generally de-

Nonepithelial cysts tected accidentally on a radiographic examination.
1. Solitary bone cyst (traumatic) ● In case of the odontogenic keratocyst, patients
2. Aneurysmal bone cyst will not show any symptoms until the cysts have
3. Stafne’s bone cavity reached a large size at times involving the entire
Cysts of the maxillary antrum ascending ramus.
1. Surgical ciliated cyst of maxilla ● This is because the primordial cyst initially
2. Benign mucosal cyst of the maxillary extends in the medullary cavity and clinically
antrum observable expansion of the bone occurs later.
● Displacement of the teeth may be seen due to the ● The defect is closed primarily and it is left to
enlarging size of the cyst that may lead to percus- heal by secondary intention or can be filled
sion of the teeth overlying the cyst and may with hydroxyapatite crystals, autogenous
produce a dull or hollow sound. bone graft, corticocancellous chips, alloge-
● A single missing tooth from the normal series nous bone powder or chips or blocks.
should invite suspicion of the existence of an ● In case of large multilocular lesions with or
odontogenic keratocyst of the primordial type. without cortical perforation, may require re-
● The teeth adjoining the cyst will have vital pulps section of the involved bone which is usually
unless there is coincidental disease of the teeth. followed by primary or secondary reconstruc-
● Buccal expansion of the bone is commonly seen, tion with a choice of reconstruction plates of
and lingual and palatal expansion is rare. stainless steel, vitallium and titanium. Use of
● Large mandibular cysts invariably deflect the titanium or stainless steel mesh, and bone
neurovascular bundle into an abnormal position. grafting procedures with the help of iliac crest
● Neuropraxia of the nerve results with the onset of graft, costochondral graft or allogenous bone
labial paraesthesia or anaesthesia, if acute infec- grafts is recommended.
tion is present along with the accumulation of Carnoy’s solution
pus within the sac. ● Stoelinga and van Hoelst (1981) proposed a
● Sensation returns to normal when tension is re- more conservative approach to treat large kerato-
lieved via a sinus tract or surgical drainage with cysts, i.e. chemical cauterization. Composition
spontaneous discharge of pus. of Carnoy’s solution: glacial acetic acid, chloro-
Radiological features form, absolute alcohol and ferric chloride.
● Keratocyst can be either unilocular or multi- ● After enucleation, to remove any remaining lin-
locular. ing of the cyst this chemical cauterizing agent is

● Majority of the unilocular radiolucencies have applied along the walls of cystic cavity. This so-
a smooth periphery. Some may have scalloped lution chemically cauterizes any remaining cells
margins, which suggest an unequal growth of cystic lining thus preventing recurrence.
activity.
● Multilocular cysts can have various radiographic Q.3. Define cyst. Describe the pathogenesis, clinical fea-
appearances, e.g. one large cyst and some smaller tures and radiographic appearance of radicular cyst.
daughter cysts giving the polycystic appearance.
Ans.
Treatment
Treatment should always be based on clinical as- ‘A cyst is a pathologic cavity that may be filled with fluid,
sessment, accurate diagnosis and appropriate tests semifluid or gaseous contents but never pus and may or
of the cystic aspirate. may not be lined by epithelium’.
● If the access is good, small single cysts with Radicular cysts
regular spherical outline can be enucleated ● The radicular cyst is defined as an inflammatory cyst,
through an intraoral approach. which results because of infection extending from
● Extraoral approach is preferred in case of the pulp into the surrounding periapical tissues.
larger or less accessible cysts with regular ● It may develop apically, when it is termed as a peri-
spherical. apical (periodontal) radicular cyst, or it may develop

● All fragments of the extremely thin lining are on the side of the root of a pulpless tooth, when it is
removed. termed as a lateral (periodontal) radicular cyst. This
● Marginal excision can be done in case of uni- cyst should be differentiated from a developmental
locular lesions with scalloped or loculated lateral periodontal cyst, which is associated with a
periphery and small multilocular lesions, i.e. vital tooth.
resection of the containing block, while main- Incidence
taining the continuity of the posterior inferior ● They are seen more commonly in males than in fe-
borders as in the ascending ramus, angle and males.

body of the mandible. In case of difficulty of ● In the first decade, very few cases are seen and peak
access, extraoral exposure is necessary. incidence is in the third and the fourth decades.
● In case of cystic lining being adherent and in Site
contiguity to the overlying mucosa or mus- ● Site is usually the anterior maxilla than the mandible,
cle, it should be excised along with marginal as the maxillary incisors are most prone to caries,
excision. trauma and pulpal death, due to developmental
defects and irritating effects of synthetic restorative the development of the cyst then occurs in three
materials. phases:
● In the mandible, cysts more commonly involve the The exact mechanisms involved in all the phases are
mandibular posterior teeth. There may be separate debatable.
small cysts arising from each apex of a multirooted 1. The phase of initiation: Chronic low-grade inva-
tooth. sion from the pulp leads to the formation of the
Clinical features periapical granuloma. This leads to the activation
● Usually, no symptoms are seen and may be discov- and proliferation of epithelial rests in the peri-
ered, when periapical radiographs are taken for teeth odontal ligament in the form of strands, arcades or
with nonvital pulps. rings.
● Swellings which are slowly enlarging are often com- 2. The phase of cyst formation: A cystic cavity
plained of radicular cysts and at times attain a large forms, lined by stratified squamous epithelium
size. due to various possible mechanisms, e.g.
● Pain may be a significant chief complaint in the pres- ● Death of the central cells occurs due to in-
ence of suppuration. crease in the size and reduction of nutrients

● In the beginning the enlargement is bony hard, as the and oxygen to maintain them.
cyst increases in size and the covering bone becomes ● Central epithelial cells desquamate and oth-
thin and exhibits springiness due to fluctuation. ers orient towards the periphery, adjacent to
● In the maxilla, buccal and palatal or only palatal the source of nutrition from the connective
expansion due to the lateral incisor or a palatal root tissue.
will be noted. In the mandible, lingual expansion is ● Epithelial cells orient towards the periphery to
very rare. isolate the central necrotic zone.

● The mucosa overlying the cystic expansion, as with 3. The phase of enlargement: Once initiation of cyst
the other cysts, is at first of normal colour; then it has occurred, the continuation of enlargement
may become conspicuous, because of the presence of may occur due to various different mechanisms,
dilated blood vessels and finally it will take on a which is true for any cyst, i.e.
profound dark bluish tinge in case of large cysts. ● Mural growth
● An intraoral sinus tract may be identified with dis- ● Accumulation of fluid
charging pus or brownish fluid, when the cyst is in- ● Retention of fluid
fected. The involved tooth/teeth are found to be ● Production of a raised intrastatic pressure
nonvital, discoloured, fractured, with heavy restora- ● Bone resorption with increase in cystic size
tions or with a failed root canal. Cystic contents (aspirate)

● They may be sensitive to percussion or hypermobile, The uninfected cystic fluid straw-coloured or brownish
or displaced. and has cholesterol, small quantity of keratin flakes may
● It may involve deciduous or the permanent dentition. be identified.
● Temporary paraesthesia or anaesthesia of the re- In case of a long-standing infection, a dirty caseous
gional nerve distribution may be evident as with material may be expressed or frank pus present.
other cysts, when infection is present. Pathology
● Pathologic fracture may be the form of presentation The cyst is lined by stratified squamous epithelium, the
in the mandible as with other large cysts. lining of which may be thin or thick up to 5 mm. An
Radiological features inflammatory infiltrate of polymorphonuclear leuco-
● The common description of radicular cysts is a cytes will be seen in the lining. Epithelial lining may
round, pear or ovoid shaped radiolucency. show the presence of Ruston’s or hyaline bodies, mi-
● A narrow radiopaque margin is seen that extends totic cells or ciliated cells.
from the lamina dura of the involved tooth/teeth. The fibrous capsule is composed of collagen and con-
● In case of very large cysts or infected cysts, this pe- nective tissue. Acute and chronic inflammatory infiltrate
ripheral white line is occasionally absent. may be found in the fibrous capsule.
● Resorption of root is rarely seen. A lateral radicular Treatment
cyst may be seen, which is associated with an acces- ● Nonvital teeth associated with cyst can either be ex-
sory root canal or lateral perforation during root ca- tracted (depending on conditions of sufficient bone
nal therapy. support and restorative possibilities), or be retained
Pathogenesis by endodontic treatment apicoectomy.
The epithelial lining is derived from epithelial cell ● External sinus tracts should always be excised to
rests of Malassez in the periodontal ligament and prevent epithelial ingrowth.

The commonly employed surgical procedure for ra-

● Radiological features
dicular cyst is enucleation with primary closure. ● Well-defined radiolucent expansion of the
● Very small cyst is removed through the tooth maxilla, with radiopaque margins, that is
socket. closely related to the maxillary sinus.
● Large period cysts that encroach upon the maxillary Treatment
antrum or in the alveolar neurovascular bundle or ● Surgical enucleation
the nose may be preliminarily treated by marsupial- 2. Benign mucosal cyst of maxillary antrum
ization. ● Also known as mucocoele/retention cyst of maxil-
Behaviour and prognosis lary antrum.

Some well-documented studies have been published, Aetiology
which contend that squamous carcinomamay arise from ● Occurs due to infection and inflammation of
the epithelial lining of radicular cysts. Browne and co- mucous glands ducts
workers (1972) reported that epithelium dysplasia and Site
keratin metaplasia may precede carcinomatous transfor- ● Commonly seen in the floor of the sinus, also
mation. other walls may be involved

● Generally unilateral, though sometimes, bilat-
Q.4. Classify odontogenic cysts of the jaw. Describe the
eral or multiple cysts may occur
signs, symptoms and management of the cyst of the
Clinical features
maxilla involving the maxillary antrum.
● They are discovered on radiographic examinations.
Ans. ● Sometimes patient may have dull pain over the
antral region, or sometimes may be a sense of

[SE Q.1]
fullness or numbness in the maxillary region.
{Odontogenic cyst of jaw ● If lateral wall is involved or the cyst is large in
1 . Gingival cyst of infants size, then patient may complain of nasal ob-
2. Gingival cyst of adults struction.
3. Lateral periodontal cyst Radilogical features
4. Odontogenic keratocyst ● Cystic lesion is spherical or ovoid with radi-
5. Dentigerous cyst opacity within the maxillary antrum that has a

6. Eruption cyst smooth uniform outline.
7. Botryoid odontogenic cyst ● When suspected on an intraoral radiograph, an
8. Glandular odontogenic cyst orthopantomograph must be taken to confirm.

9. Calcifying odontogenic cyst} Treatment
Cysts associated with maxillary antrum ● In symptomatic patient, it is advisable to re-
1. Surgical ciliated cyst of the maxilla move the cystic lesion via Caldwell–Luc ap-
● These are very uncommon cysts. proach and enhance drainage via cannulation
● They can be iatrogenic, as the patient always through intranasal antrostomy.
gives previous history of some surgical procedure ● In symptomatic patients, it is best to follow up
that was carried out in the maxilla, wherein maxil- with periodic radiographs, as most cystic lesions
lary sinuses were opened surgically. remains static or undergo spontaneous regres-
Aetiology sion with conservative medical treatment with
● The cysts develop from the epithelial lining antibiotic, decongestants and antral lavage.
of the maxillary sinus which was trapped in
Q.5. Define cyst. Enumerate the method of treatment of
the surgical incision during closure, follow-
any jaw cyst. Describe anyone method in detail.
ing a maxillary surgical procedure that in-
volved the sinus lining, Caldwell–Luc or Ans.
maxillary fractures that had involved the
‘A cyst is a pathologic cavity that may be filled with fluid,
antrum.
semifluid or gaseous contents but never pus and may or
Site
may not be lined by epithelium’.
● In close proximity to the maxillary sinus, but
● A cyst can be treated either by enucleation or by marsu-
there is no communication between them.
pialization.
Clinical features
● Dull and localized pain in maxilla; and, the
[SE Q.5]
cystic lesion is otherwise not associated with
any tooth. {Enucleation
Disadvantages of marsupialization
{SN Q.7}
● Pathological lining of the cyst cavity is left behind,
Principle which might pose as a cause for development of

Enucleation allows for the cystic cavity to be covered neoplastic changes in the future.
by a mucoperiosteal flap and the space fills with ● Healing can be delayed in cases of large cyst in older
blood clot, which will eventually organize and form patients and cyst perforating the palatal mucosa.
normal bone. ● It has to be regularly irrigated to prevent infection.
Indications ● Prolonged healing time.
● For treatment of odontogenic keratocysts ● Regular cleansing of the cavity is needed. Failing
● Recurrence of cystic lesions of any cyst type which may lead to infection.
● Patient’s inconvenience.
● Formation of cyst-like pockets that may have food-

Advantages stuffs.
● Primary closure of the wound.
Q.6. Describe various methods of treatment of dentiger-
● Healing is rapid.
ous cyst.
● Postoperative care is reduced.
● Thorough examination of the entire cystic lining can Ans.

be done. [Same as LE Q.1]
Disadvantages
● It is not possible to directly observe the healing of Q.7. Classify odontogenic cyst. Give in detail the treatment
the cavity after primary closure, as with marsupial- plan for large dentigerous cyst in the body of mandible.
ization Ans.
● The unerupted teeth in a dentigerous cyst will be re-
moved with the lesion in young persons. [Same as LE Q.1]

● Mandible will become weak due to removal of large
Q.8. Classify cysts of the jaws and write in detail about
cyst, making it prone to jaw fracture. dentigerous cyst.
● Adjacent vital structures can be damaged.
● Necrosis of the pulp. Ans.

Surgical technique [Same as LE Q.1]
● Enucleation and packing: This technique is used
when it is believed that due to a previous infection Q.9. Classify odontogenic cysts. Give in detail the treat-
or in infected large cysts, a primary closure would ment plan for large dentigerous cyst.
be unsuccessful as it could lead to a breakdown of Ans.
the wound; or, where there is difficulty in ap-
proximating the wound edges. In such instances, [Same as LE Q.1]
enucleation is performed and then the cavity is Q.10. How do you manage a case of cyst in relation to
packed as in marsupialization. The wound heals unerupted upper canine tooth in patient aged 12 years.
with granulation tissue until epithelialization is
complete. Ans.
This method is also used as a secondary measure, [Same as LE Q.1]
when there is dehiscence after primary closure.}
Marsupialization (Partsch surgery) Q.11. Classify odontogenic cysts of the jaws. Write in
● It is indicated in children, if there is very large size
detail about the management of cysts of the jaw by lay-
cyst and the involved tooth/teeth are to be maining special emphasis on the management of odontogenic
tained. keratocyst.
● The tooth may erupt into occlusion, as the defect Ans.
heals with normal bone or orthodontic forces may be
[Same as LE Q.2]
used to bring the tooth into occlusion.
Advantages of marsupialization Q.12. Write the aetiology, clinical features, diagnosis
● It is relatively simple procedure and poses no risk to and treatment of odontogenic keratocyst of the mandi-
the adjacent vital structures. ble affecting a young adult of 20 years.
● It does not create an oronasal or an oroantral
Ans.
fistula.
● It consumes less time and there is less blood loss. [Same as LE Q.2]
Q.13. Classify odonotogenic cyst of the jaws and de- Marsupialization

scribe the management of OKC. Advantages of marsupialization
● It is relatively simple procedure and poses no risk
Ans.
to the adjacent vital structures.
[Same as LE Q.2] ● It does not create an oronasal or an oroantral
fistula.
Q.14. Define and classify cysts of the jaws and oral cav-
● It consumes less time and there is less blood loss.
ity. Discuss the aetiopathogenesis, clinical features and
Disadvantages of marsupialization
management of odontogenic keratocyst in the ramus of
● Pathological lining of the cyst cavity is left be-
mandible.
hind, which might pose as a cause for develop-
Ans. ment of neoplastic changes in the future.
● Healing can be delayed in cases of large cyst in
[Same as LE Q.2]
older patients and cyst perforating the palatal
Q.15. What is a keratocyst? What are the causes for mucosa.
recurrence of keratocyst and normal technique of man- ● It has to be regularly irrigated to prevent infection.
agement of keratocyst occurring in the posterior body ● Prolonged healing time.
and ramus of the mandible? ● Regular cleansing of the cavity is needed. Failing
which, may lead to infection.

Ans.
[Same as LE Q.2] ● Formation of cyst-like pockets that may have
foodstuffs.
Q.16. Discuss the pathogenesis of odontogenic kerato-
Enucleation
cyst and its management.
Advantages of enucleation
Ans. ● Entire cystic lining is removed. Therefore, there is
no fear of any neoplastic change in the remnants

[Same as LE Q.2]
of the lining.
Q.17. Classify cysts of the jaw and write about kerato- ● Rapid healing occurs as the wound is closed pri-
cyst. marily.
Disadvantages of enucleation
Ans.
● In young people, germinated tooth or unerupted
[Same as LE Q.2] teeth involved with the cyst are extracted or re-
moved with the lining of the cyst.
Q.18. Classify cysts of the jaw and discuss in detail the
● Pathological jaw fractures can occur in case of
pathology and the management of odontogenic kerato-
enulcleation of a large cyst.
cyst of the maxilla.
● The procedure endangers the adjacent vital struc-
Ans. tures.
● Direct observation of wound healing as in case of
[Same as LE Q.2]
marsupialization is not possible.
Q.19. Classify cystic lesions. Describe the management
of a radicular cyst. Q.3. Write four indications of marsupialization.
Ans. Ans.
[Same as LE Q.3] Indications of marsupialization
● Age: In a young child with developing tooth germs,
or when development of the displaced teeth has not

SHORT ESSAYS: progressed, enucleation would damage the tooth
Q.1. Classification of odontogenic cysts. buds. In the elderly, debilitated patient, marsupializa-
tion is less stressful and a reasonable alternative.
Ans.
● Proximity to vital structures: When the cyst is
[Ref LE Q.4] present very close to the vital structures, oronasal

or oroantral fistula can be formed and it can in-
Q.2. Mention the merits and demerits of enucleation
jure neurovascular structures or damage vital
and marsupialization procedures of cystic lesions.
teeth. In this case, marsupialization should be
Ans. considered.
● Eruption of teeth: In a young patient with a dentiger- Q.7. What is ‘enucleation technique’? Mention any four
ous or pseudofollicular keratocyst, marsupialization merits of this procedure.
will permit the eruption of the unerupted tooth or any
Ans.
other developing teeth that have been displaced.
● Size of cyst: In very large cysts where enucleation could [Same as SE Q.5]
result in a pathological fracture, marsupialization can
be accomplished through a more limited bony opening.
● Vitality of teeth: When the apices of many adjacent
SHORT NOTES:
erupted teeth are involved within a large cyst, enucle- Q.1. Theories of cyst expansion.
ation could prejudice the vitality of these teeth.
Ans.
Q.4. Mention the principle of marsupialization and give Theories of cyst enlargement
any four disadvantages of the procedure. 1. Mural growth
Ans. 2. Peripheral cell division
3. Accumulation of the contents
Principle of marsupialization 4. Hydrostatic enlargement
Marsupialization (Partsch) or decompression refers to 5. Secretion (transudation and exudation)
creating a surgical window in the wall of the cyst and
evacuation of the cystic contents. This process de- Q.2. Cornoy’s solution.
creases intracystic pressure and promotes shrinkage of Ans.
the cyst and bone fill. The only portion that is removed
is the piece removed to produce the window. ● Stoelinga and van Hoelst (1981) proposed a more con-
Disadvantages of marsupialization servative approach to treat large keratocysts, i.e. chemi-
● Pathological lining of the cyst cavity is left behind, cal cauterization. Composition of Carnoy’s solution:
which might pose as a cause for development of glacial acetic acid, chloroform, absolute alcohol and
neoplastic changes in the future. ferric chloride.
● After enucleation, to remove any remaining lining of the
● Healing can be delayed in cases of large cyst in older
patients and cyst perforating the palatal mucosa. cyst this chemical cauterizing agent is applied along the
● It has to be regularly irrigated to prevent infection. walls of cystic cavity. This solution chemically cauter-
● Prolonged healing time. izes any remaining cells of cystic lining thus preventing
● Regular cleansing of the cavity is needed. Failing recurrence.
which, may lead to infection. Q.3. Causes of recurrence potential of keratocyst.
● Formation of cyst-like pockets that may have foodstuffs. Ans.

Recurrence potential of keratocyst
Q.5. Write four advantages of enucleation of cyst.
Keratocysts tend to recur. This aggressive peculiarity
Ans. was first reported by Pindborg and Hansen (1963). The
recurrence rate varies from 5% to 62% with most occur-
[Ref LE Q.5]
ring in first 5 years.
Q.6. Define cyst. Mention various developmental odon- Some of the possible reasons that report this feature are
togenic cysts of jaws. as follows:
● Tendency to multiply.
Ans.
● Presence of satellite cysts.
Cyst ● Cystic lining is very thin and fragile and portion
A cyst is a pathological cavity or sac within the hard or of it may be left behind.
soft tissue that may contain fluid, semi-fluid or gas ● Epithelial lining of keratocysts have growth po-
which may be lined by epithelium, fibrous tissue or tential.
occasionally even by neoplastic tissue. ● In the oral mucosa, cyst can arise from the basal cells.
Developmental odontogenic cyst of jaw ● Patients with nevoid basal cell carcinoma syn-
1. Primodial cyst (keratocyst) drome have a particular tendency to form multiple
2. Dentigerous (follicular) cyst primordial cysts.
3. Lateral periodontal cyst – Lateral botryoid odonto-
genic cyst Q.4. Name the cysts of the maxillary antrum.
4. Calcifying odontogenic (Gorlin) cyst Ans.
● Surgical ciliated cyst of the maxilla. Q.7. Define enucleation.

● Benign mucosal cyst of the maxillary antrum.
Ans.
Q.5. Aneurysmal bone cyst.
[Ref LE Q.5]
Ans.
Q.8. Marsupialization.
Aneurysmal bone cyst
Ans.
It basically consists of blood-filled spaces within the
bone of different sizes surrounded by fibrous connective Principle
tissue and fine trabeculae of reactive immature bone. Marsupialization (Partsch) or decompression refers to
Clinical features creating a surgical window in the wall of the cyst and
● Usually seen in the long bones. It is uncommon in evacuation of the cystic contents. This process de-
the jaws and occurs only in 2% of the total cases. creases intracystic pressure and promotes shrinkage of
● Age group is usually ,20 years. the cyst and bone fill. The only portion that is removed
● It is most common in mandibular posterior region and is is the piece removed to produce the window.
rare in maxilla. Appears as a fast-growing swelling in the Indications
jaw, usually not associated with pain or paraesthesia. ● Age: In a young child, with developing tooth germs,
● Limitation of movement due to pain or tenderness in or when development of the displaced teeth has not
the region. progressed, enucleation would damage the tooth
Radiographic features buds. In the elderly, debilitated patient, marsupializa-
● Unilocular or multilocular radiolucency. tion is less stressful and a reasonable alternative.
● An occlusal view of the lesion will show thinning ● Proximity to vital structures: When the cyst is pres-
and expansion of the cortical plates. ent very close to the vital structures, oronasal or
● A characteristic ‘honeycomb’ or ‘soap bubble’ ap- oroantral fistula can be formed and it can injure neu-
pearance has been described in the radiograph. rovascular structures or damage vital teeth. In this
● It has also been described as a ‘blown out’ bone cav- case, marsupialization should be considered.
ity lined by supraperiosteal new bone formation. ● Eruption of teeth: In a young patient with a dentiger-
Treatment ous or pseudofollicular keratocyst, marsupialization

● The treatment of choice is enucleation or curettage. will permit the eruption of the unerupted tooth or any
● Usually, cortical perforation and soft tissue spread is other developing teeth that have been displaced.
not reported. ● Size of cyst: In very large cysts, where enucleation
● Once periosteum and thinned out cortex is removed, could result in a pathological fracture, marsupializa-
welling up of dark venous blood is seen from cavity, tion can be accomplished through a more limited
described characteristically as ‘blood soaked sponge’ bony opening.
appearance. Reduction in bleeding is an indication of ● Vitality of teeth: When the apices of many adjacent
complete removal of the entire lesion. erupted teeth are involved within a large cyst, enucle-
● Surgical defect heals like any other cystic cavity in ation could prejudice the vitality of these teeth.
about 6–8 months. Disadvantages of marsupialization
● Inadequate removal may lead to recurrence. ● Pathological lining of the cyst cavity is left behind,
which might pose as a cause for development of

Q.6. Residual cyst.
neoplastic changes in the future.
Ans. ● Healing can be delayed in cases of large cyst in older
patients and cyst perforating the palatal mucosa.

● Residual cyst is retained periapical cyst from teeth that
● It has to be regularly irrigated to prevent infection.
have been removed.
● Prolonged healing time.
● It can be found in maxilla or mandible.
● Regular cleansing of the cavity is needed. Failing
● Histology of lining is a nondescriptive stratified squa-
which, may lead to infection.
mous epithelium.
● Morphologically, the cyst may present as a well-defined
● Formation of cyst-like pockets that may have food-
radiolucency that can vary in size from few millimetre
stuffs.
to several centimetre.
● Clinically, these cysts are found on routine radiographic Q.9. Globulomaxillary cyst.
examination.
Ans.
● Usually, residual cysts do not expand bone.
● Treatment is by surgical curettage. Globulomaxillary cyst

● Also known as lateral fissural cyst. Treatment

● Believed to arise from epithelial remnants trapped be- ● Enucleation is the treatment of choice.
tween the developing frontonasal process and the ● The lesion is approached intraorally via the buccal
maxillary process. In other words, it occurs at the point sulcus.

of fusion between the premaxilla and the maxilla, al- ● Due to its proximity with the ala of the nose, some
though the origin of this cyst is highly controversial. amount of nasal mucosa may need to be sacrificed
● It is a rare lesion seen between the maxillary lateral for total removal.
incisor and canine. Q.11. Traumatic bone cyst.
● Teeth associated with this lesion are vital.
● The cyst may cause displacement of the teeth on ei-

Ans.
ther side of it. Usually, the crowns of the lateral inci- Traumatic bone cyst
sor and canine are seen flaring away from each other. ● The traumatic cyst is a pseudocyst (lacks an epithe-
Radiographic features lial lining).
● This is seen between the maxillary lateral incisor and ● It occurs in other bones of the skeleton.
canine. Clinical features
● Classically described as a pear-shaped or teardrop- ● Can be seen most frequently in young person.
shaped radiolucency with the apex towards the alve- ● No definite sex prediction, but seen more commonly
olar bone and base towards the crown of the teeth. in males than females.
● Lamina dura of the teeth associated with the lesion is ● When the cavity is open surgically, a small amount
intact. of serosanguinous fluid, shreds of necrotic blood
Treatment clot and fragments of fibrous connective tissue are
Treatment is by enucleation with care taken to protect seen.
the apex of the canine and lateral incisor. Treatment
● Since the definitive diagnosis of solitary bone cyst
Q.10. Nasolabial cyst. cannot be established without surgical exploration
Ans. after opening the cavity, enucleation of the lining is
done.
Nasolabial cyst ● If the cavity is then closed, it has been found that
● Rare developmental cyst. healing and filling of the space by bone occurs in
● It is a soft tissue cyst and does not produce any bony most cases in 6–12 months.
destruction, but occasionally pressure resorption of ● Seldom, a second surgical procedure is necessary.
the adjacent bone may take place.
Q.12. Benign cystic lesions of the mandible.
Aetiology
● It is a fissural cyst thought to arise from embryonic Ans.
remnants of tissue entrapped between the lines of
Benign cystic lesions of the mandible
fusion of the median nasal process, lateral nasal pro-
1. Dentigerous cyst
cess and maxillary process.
2. Calcifying epithelial Odontogenic cyst (COC)
Clinical features
3. Odontogenic Keratocyst (OKC)
● Usually seen in the region of the upper lip lateral to
the midline in the buccal sulcus just below the ala of Q.13. Apical granuloma.
the nose. Ans.
● Usually seen in adults in their fourth to fifth decade.
● Female predilection. Periapical granuloma

● Rarely seen bilaterally. Chronic periapical periodontitis is also known as peri-
● Slow-growing lesion, gradually causes loss of naso- apical granuloma.
labial fold and bulges into the inferior meatus and It is a low-grade infection and the most common se-
appears also in the labial sulcus. quelae of pulpitis or acute periapical periodontitis.
Radiographic features Clinical features
● Since it is a soft tissue lesion, no bone destruction is ● Involved tooth is usually nonvital and slightly tender
seen on the radiograph. to percussion.

● Pressure resorption may be seen on an occlusal view. ● Patient may complain of mild pain on biting or chew-
Histological features ing on solid food.

● The cyst is lined by pseudostratified columnar epi- ● The sensitivity is due to hyperaemia, oedema and
thelium. inflammation of the apical periodontal ligament.

● Goblet cells and cilia are also seen. ● Many cases are entirely asymptomatic.
Treatment Q.14. Periapical granuloma.

● It consists of extraction of the involved tooth under
Ans.
certain condition. Root canal therapy with or without
apicoectomy is done. [Same as SN Q.13]
● If left untreated, it may undergo transformation into
apical periodontal cyst through proliferation of the

epithelial rests in the area.
Topic 10
Benign Tumours of the Jaw
LONG ESSAYS:
1. Classify odontogenic tumours of jaw bones. How do you diagnose and manage a case of ameloblastoma of
mandible?
2. Describe fibro-osseous lesions of the jaws. Enumerate the treatment for fibrous dysplasia.
3. Classify odontogenic tumours of the jaw. How do you diagnose ameloblastoma? Outline the method of treating
tumour involving mandibular third molar area. [Same as LE Q.1]
4. Differentiate between benign and malignant tumours. Describe the signs and symptoms and management of an
ameloblastoma involving the angle of the mandible. [Same as LE Q.1]
5. Classify odontogenic tumours. Write in detail about ameloblastoma and its management. [Same as LE Q.1]
6. Classify odontogenic tumours of the mandible. How do you manage ameloblastoma involving the anterior body
portion of the mandible? Give clinical signs and symptoms of the lesion. [Same as LE Q.1]
7. Classify odontogenic tumours of the jaws. Describe the surgical management of ameloblastoma of the lower jaw.
[Same as LE Q.1]
8. Define ameloblastoma. How will you evaluate and manage a case of ameloblastoma? [Same as LE Q.1]
9. Describe the differential diagnosis and management of radiolucent lesions of posterior body and ramus of
mandible. [Same as LE Q.1]
SHORT ESSAYS:
1 . Myxoma.
2. Define tumour and classify odontogenic tumours. [Ref LE Q.1]
3. Pindborg tumour.
4. Odontoma.
5. Adenoameloblastoma.
6. Calcifying epithelial odontogenic tumour. [Same as SE Q.3]
7. Odontomes. [Same as SE Q.4]
8. Adenomatoid odontogenic tumour. [Same as SE Q.5]
SHORT NOTES:
1 . Define ameloblastoma.
2. Adenomatoid odontogenic tumour. [Ref SE Q.5]
3. Management of ameloblastona. [Ref LE Q.1]
4. Unicystic ameloblastoma.
5. Mention various treatment modalities of ameloblastoma. [Same as SN Q.3]
6. Fibrous dysplasia. [Same as SN Q.14]
7. Compound odontoma.
8. Saucerization.
9. Papilloma.
10. Define odontoma.
11. What are odontomas? Mention its types.
12. What is complex odontoma? Give brief description.
13. Staging of tumour.
14. Fibrous dysplasia.
15. Cherubism.
16. Monostatic fibrous dysplasia. [Same as SN Q.14]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Classify odontogenic tumours of jaw bones. How . Adenomatoid odontogenic tumour
b
do you diagnose and manage a case of ameloblastoma of c. Calcifying epithelial odontogenic tumour
mandible? (CEOT)
Ans. B. Marked inductive change in connective tissue
(mixed origin)
a. Ameloblastic fibroma
[SE Q.2]
b. Ameloblastic odontoma
{Classification of benign odontogenic tumours (Kramer, c. Odontoma
Pindborg and Shear, 1992) d. Complex odontoma
1. Odontogenic epithelium without odontogenic ec- e. Compound odontoma
tomesenchyme 2. Mesodermal odontogenic tumours
1. Ameloblastoma a. Odontogenic myxoma
2. Calcifying epithelial odontogenic tumour (CEOT) b. Odontogenic fibroma
or Pindborg tumour c. Cementoma
3. Clear cell odontogenic tumour i. Periapical cemental dysplasia (PCD)
4. Squamous odontogenic tumour ii. Benign cementoblastoma
2. Odontogenic epithelium with odontogenic ecto- iii. Cementifying fibroma
mesenchyme with or without dental hard tissue iv. Familial multiple (gigantiform) cementoma
formation (florid osseous dysplasia – FOD)
1. Ameloblastic fibroma WHO Classification of nonodontogenic tumour of the
2. Ameloblastic fibrodentinoma (dentinoma) jaws (Kramer, Pindborg and Shear, 1992)
3. Odontoameloblastoma Osteogenic neoplasms
4. Adenomatoid odontogenic tumour (AOT) Cemento-ossifying fibroma
5. Complex odontoma Non-neoplastic bone lesions
6. Compound odontoma 1. Fibrous dysplasia of the jaws
3. Odontogenic ectomesenchyme with or without 2. Cemento-osseous dysplasias
included odontogenic epithelium a. Periapical cemento-osseous dysplasia
1. Odontogenicfibroma b. Focal cemento-osseous dysplasia
2. Myxoma (odontogenic myxoma, myxofibroma) c. Florid cemento-osseous dysplasia (giganti-
3. Benign cementoblastoma (true cementoma) form)
Classification of odontogenic tumours (Gorlin, Chaudhry Other cemento-osseous dysplasias
and Pindborg, 1961) a. Cherubism
1. Epithelial odontogenic tumours b. Central giant cell granuloma.}
A. Minimal inductive change in connective tissue Classification of benign odontogenic tumour
(ectodermal origin) 1. Benign ectodermal tumours
a. Ameloblastoma a. Ameloblastoma
. Adenomatoid odontogenic tumour

b Clinical features (signs and symptoms)
c. Calcifying epithelial odontogenic tumour ● Ameloblastoma is typically asymptomatic, and is
2. Benign mesodermal tumours rarely diagnosed in the early stages of development.

a. Odontogenic myxoma ● It remains undiscovered until the lesional growth
b. Cementoma produces swelling either in the intraoral and/or extra-

3. Benign tumours having ectodermal and mesoder- oral jaw. Tooth eruption and dental occlusion distur-
mal elements bances or incidental findings are seen in the radio-
a. Ameloblasticfibroma graph.
b. Ameloblastic fibro-odontoma ● Patients complain of slow growing, painless, hard,
c. Odontoameloblastoma nontender and ovoid swelling, which is often larger

4. Odontomas in size, as it causes little discomfort in early stage.
a. Complex odontoma ● Other complaints may be mobile teeth, exfoliation of
b. Compound odontoma teeth, ill-fitting dentures, malocclusion, ulcerations,

5. Melanotic neuroectodermal tumour of infancy. nasal obstructions and inability to occlude properly.
Ameloblastoma In later stage with nerve involvement, there will be
According to WHO, ‘It is a true neoplasm of enamel sensory changes of the lower lip.
organ type tissue, which does not undergo differentia- ● Pain may be experienced if secondarily infected.
tion to a point of enamel formation’. In 1992, WHO Large persistent lesion may exhibit fluctuation and
classification categorized ameloblastoma as a benign, egg-shell crackling.
but locally invasive epithelial odontogenic neoplasm
with strong tendency to recur.
Pathogenesis {SN Q.3}
1. Late developmental sources: Cell rests of enamel Management
organ, either remnants of dental lamina or epithelial Aim
cell rests of Malassez or remnants of Hertwig’s a. Complete eradication of the lesion
sheath and follicular sacs. b. Reconstruction of resultant defect
2. Early embryonic sources: Disturbances of develop- Successful treatment is the treatment that renders
ing enamel organ, dental lamina and tooth buds. an acceptable prognosis and causes minimum
3. Basal cells of the surface epithelium of the oral disfigurement.
mucosa. Curettage
4. Secondary developmental sources: Epithelium of ● Least desirable line of treatment, as it has high
odontogenic cysts, particularly primordial, lateral recurrence chances.
periodontal cyst, dentigerous cyst and odontomas. ● The characteristic feature of the tumour is that
5. Heterotropic epithelium in other parts of body, espe- it microscopically infiltrates bone beyond the
cially from the pituitary gland. tumour–bone interface seen in imaging.
Age ● A safe margin of involved bone is opposite
It is usually seen in the first decade or as late as the 2 cm for solid multicystic lesions.
seventh decade. Overall average age is 36 years. For intraosseous solid multicystic ameloblastoma
Sex 1. En bloc resection or marginal resection without
No sex predilection. It can occur equally in men and continuity defect
women. 2. Segmental resection with continuity defect
Site Aggressive reconstruction in maxilla
● The lesion may occur in either of the jaws. 1. Tumour confined to maxilla without orbital floor
● The ratio of ameloblastoma of the mandible to max- involvement – Partial maxillectomy
illa is 5:1. 2. Tumour involving orbital floor, but not the perior-
● The common sites involved are the posterior bital area – Total maxillectomy
maxilla and the posterior molar ramus region of 3. Tumour involving orbital content – Total maxil-
the mandible (60%). In blacks, ameloblastomas lectomy with orbital exenteration
occur more frequently in the anterior region of the 4. Tumour involving skull bone – Skull-base resec-
maxilla. tion plus neurosurgical procedure
Classification Multiple ameloblastoma
a. Central or intraosseous. ● Recurrence rate up to 50% during first 5 years.
b. Peripheral or extraosseous: This is usually seen in ● Long-term follow-up is a must
the gingiva and mucosa of the alveolar process.
Q.2. Describe fibro-osseous lesions of the jaws. Enumer- Swelling

ate the treatment for fibrous dysplasia. Swelling is unilateral and slow growing with pro-
gressive enlargement. As the lesion grows, facial
Ans.
asymmetry becomes more evident and it may be the
Fibrous dysplasia of the jaws patient’s chief complaint.
Fibrous dysplasia was first described by von Reckling- The fusiform oval (low plateau), firm and smoothly
hausen in 1891. In 1938, Lichtenstein introduced the contouring swelling of the affected jaw is noticed. It
term ‘fibrous dysplasia’. The pathogenesis is not under- most commonly results from the expansion of the
stood completely, but trauma and endocrine distur- buccal cortical plate. The lingual cortex is rarely in-
bances were labelled as culprits. More recently molecu- volved. In mandible, it may cause a protuberance and
lar basis has been identified. excrescence of the inferior border. As a rule, the
It is a self-limiting condition in which there is gradual growth of the lesion ceases with skeletal growth.
replacement of normal medullary bone by an abnormal Initially the teeth involved in the lesion are firm, but
fibrous connective tissue proliferation. The mesenchy- may be displaced by the bony mass or occlusal level
mal tissue contains variable amounts of an osseous can be changed. The more aggressive clinical form
matrix that presumably arises through metaplasia and may produce rapid growth, pain, nasal obstruction or
consists only of woven bone. exophthalmos.
Types Radiological feature
● Solitary or monostotic lesion is 80%–85% more It is variable, ranging from radiolucent to a densely
common (involving a single bone). radiopaque mass. Four different pictures can be seen
● Multifocal or polyostotic lesion (involving bones) radiologically:
is relatively uncommon. i. The characteristic feature is ‘ground glass’
a. In Jaffe type, three-fourths of the entire may be appearance in mature stage, i.e. a homoge-
involved. nous radiopacity with the numerous trabecu-
b. In Lichtenstein syndrome, the entire skeleton lae of woven bone or orange peel appearance.
may be involved, along with cutaneous mela- ii. In early stage, some lesions may be seen as
nin pigmentation. unilocular or multilocular radiolucencies.
c. Mazabraud syndrome – The fibrous dysplasia iii. In intermediate stage, radiolucent lesion inter-
is associated with soft tissue myxomas, usually mediate with patchy, irregular opacities simi-
muscular (adjacent to the FD lesion). lar to Paget’s disease can be seen.
McCune–Albright syndrome: It is more severe. Oc- iv. A fingerprint bone pattern and superior dis-
curs commonly in females. The patients with polyos- placement of mandibular canal can be seen.
totic fibrous dysplasia have multiple areas of cutane- In maxilla, there is obliteration of the maxillary
ous melanotic pigmentation (café au lait macules) sinus by the lesional tissue. Shows increased bone
and autonomous hyper function of one or more of the density of base of the skull involving the occiput,
endocrine glands (precocious sexual development sphenoid, roof of the orbit and frontal bones.
and onset of puberty). The most important characteristic feature of fi-
Aetiology brous dysplasia is the poorly defined clinical and
It is unknown. Many hypotheses have been pro- radiological demarcating margins of the lesion.
posed. The lesion appears to blend into the surrounding
i. A non-neoplastic, hamartomatous growth re- normal bone without any evidence of a circum-
sulting from altered mesenchymal cell activity scribed border.
or a defect in the control of bone cell activity. ● Serum chemistry levels: Serum calcium, phos-
ii. Focal bone expression of a complicated endo- phorus and alkaline phosphatase are within
crine disturbance (oestrogen receptors are normal ranges, because of the slow growth
seen in osteogenic cells of a patient). rate.
iii. Inherited basis. ● Histologically, the lesion is essentially a fi-
Monostotic fibrous dysplasia of the jaws brous one, made up of proliferating fibroblasts
Onset in a compact stroma of interlacing collagen fi-
It occurs during the first or second decade of life. bres. Irregular bony trabeculae. It may be scat-
It is characterized by insidious, asymptomatic, pain- tered haphazardly or ‘c’ shaped trabeculae may
less and slow growing lesion. occur, giving ‘Chinese’ character appearance.
Sex Bony trabeculae may be coarse woven bone or
Both males and females are affected equally. lamellar. As the lesion matures, spicules of
lamellar bone with osteoblastic rimming may Q. 5. Classify odontogenic tumours. Write in detail
be seen. about ameloblastoma and its management.
● Differential diagnosis: Is from ossifying fi-
Ans.
broma, cementifying fibroma, Paget’s disease,
osteosarcoma, etc. The usual course of fibrous [Same as LE Q.1]
dysplasia is slow growth for a decade or so fol-
Q.6. Classify odontogenic tumours of the mandible.
lowed by stabilization and slow return to nor-
How do you manage ameloblastoma involving the ante-
mal. Occlusion and tooth–jaw relation should
rior body portion of the mandible? Give clinical signs
be carefully monitored during the period of
and symptoms of the lesion.
skeletal growth.
Polyostotic fibrous dysplasia (McCune–Albright syn- Ans.
drome)
[Same as LE Q.1]
● The skull and jaws affliction with resultant facial
asymmetry. Q.7. Classify odontogenic tumours of the jaws. Describe

● Simultaneous involvement of both the jaws along the surgical management of ameloblastoma of the lower
with lone bones is seen. jaw.
● ‘Hockey stick’ deformity of the femur is seen with
Ans.
leg length discrepancy.
● Well defined, generally unilateral tan macules on the [Same as LE Q.1]
trunk, thighs and oral mucosa, known as café au lait
Q.8. Define ameloblastoma. How will you evaluate and
(coffee with milk) pigmentations. The margins of
manage a case of ameloblastoma?
these spots are very irregular in contrast to the spots
of neurofibromatosis, which have smooth borders. Ans.
l Sexual precocity, most commonly seen in females is
[Same as LE Q.1]
the common endocrine manifestation.
● Breast development, pubic hair and menstrual Q.9. Describe the differential diagnosis and manage-
bleeding may be seen to occur within first few ment of radiolucent lesions of posterior body and ramus
years of life in affected girls. of mandible.
Management
Ans.
The management of the fibrous dysplasia can be diffi-
cult at times. The treatment plan depends on the extent [Same as LE Q.1]
of involvement, functional disability, danger to func-
tion, neurologic symptoms and aesthetic consideration.
Differentiation should be made between monostotic
SHORT ESSAYS:
and polyostotic form of the lesion. Complete bone Q.1. Myxoma.
scintigraphy can suggest multiple involvement.
Ans.
The treatment ranges from observation for minor le-
sions to radical resection. Myxoma
In case of small lesions, biopsy for confirmation and ● Myxoma is a heterogenous group of soft tissue tu-
follow-up is required. mour, which is benign and does not metastasize, but
it infiltrates the adjacent tissues.
Q.3. Classify odontogenic tumours of the jaw. How do
● It is composed of mucopolysaccharides, mainly hy-
you diagnose ameloblastoma? Outline the method of
aluronidase.
treating tumour involving mandibular third molar area.
● Stellate cells arranged in a loose mucoidstroma are
Ans. seen, which also contains delicate reticulinfibres.

Clinical features
[Same as LE Q.1]
● This appears at any age and there is no definite
Q.4. Differentiate between benign and malignant tu- predilection of gender.

mours. Describe the signs and symptoms and manage- ● Most of the lesions are deeply situated, occurring
ment of an ameloblastoma involving the angle of the in skin, subcutaneous tissues, genitourinary tract,
mandible. gastrointestinal tract or in organs such as liver,
spleen or even parotid glands.
Ans.
Oral manifestations
[Same as LE Q.1] ● It is an extremely rare lesion.
The nerve sheath myxoma is a benign tumour,

● iv. Lesion (mainly unilocular) may be associated
thought to arise from perineural cells of periph- with embedded tooth.
eral nerves and is characterized by occurrence of Histopathology
stellate cells in a prominent mucoid matrix. A locally invasive epithelial characterized by the
Treatment development of intraepithelial structures, probably
● Treatment is surgical, since X-ray is of little benefit. of an amyloid-like nature, may become calcified and
● Recurrence is common. which may be liberated when the cells breakdown.
The areas of calcification of concentric rings are
Q.2. Define tumour and classify odontogenic tumours.
termed as ‘Liesegang rings’. These fuse together to
Ans. form large complex masses.
CEOT shows some potential for recurrence (15%
[Ref LE Q.1]
aggressiveness).
Q.3. Pindborg tumour. Management
Careful excision of the margin of normal tissue and
Ans.
follow-up.
Pindborg tumour
The tumour was first described by Pindborg in 1955. Q.4. Odontoma.
Origin
Ans.
Epithelial elements of the enamel organ.
Incidence Odontoma
It is uncommon, seen 1% of all odontogenic tumours. The term refers to any tumour of odontogenic origin, in
Sex true sense. This is the growth in which both epithelial
There is no specific sex predilection. and ectomesenchymal cells exhibit complete or incom-
Age plete differentiation of tooth formation. This is consid-
It is seen in middle age, i.e. 30–50 years. ered more as a hamartomatous malformation, also as
Site composite lesion, as it contains more than one tissue.
Mandible is most commonly involved in the molar Radiographically and histopathologically, it is recogniz-
region (two-thirds of the turnouts). One-third of the able in two forms:
turnouts are found in the maxilla. Marked predilec- 1. Compound odontoma
tion for the molar region in both the jaws 2. Complex odontoma
Fifty per cent of the turnouts are associated with an Compound composite odontoma
unerupted or embedded tooth. It consists of formed calcified tooth-like struc-
Signs and symptoms tures or miniature dwarfed teeth.
Painless and slow-growing mass. If encroached on Complex composite odontoma
nasal cavity, they produce nasal symptoms like stuff- It is a malformation in which all the dental tissues
iness, epistaxis, etc. are represented with the individual tissues being
Variety well formed, but occurring in a disorderly pattern.
i. Intraosseous Here, the calcified dental tissues are simply found
ii. Extraosseous – nonspecific sessile gingival masses as an irregular mass bearing no morphological
commonly seen in anterior gingiva. similarity to the rudimentary teeth.
Radiographic features ● Most common type of odontogenic lesion
Depending on the stage of development, CEOT pres- (more than 30%).

ents variable radiographic picture. ● Age: First and second decades (10–70
i. Unilocular or multilocular radiolucency with years).

a well-circumscribed border or diffuse lesion. ● Sex: Equal predilection in both sexes.
ii. Multilocular honeycomb appearance: Com- ● Site: Occurs in both the jaws.
bined pattern of radiolucency and radiopacity Complex odontomas are more common in man-
with many small, irregular bony trabeculae dible, i.e. 67%.
traversing the radiolucency in multidirection. Compound odontomas are more common in
iii. Driven snow appearance: Scattered flakes of maxilla.
calcification throughout the radiolucency Compound odontomas are seen in anterior jaw.
can be seen. It can be seen more concen- Complex odontomas are seen in posterior jaw, in
trated around the crown of the embedded third molar region.
tooth. ● Generally asymptomatic
Radiographical features odontoma can be enucleated. Large complex

Compound odontoma appears as a radiopaque of odontoma may be fused to the surrounding bone
calcified structures with an anatomy similar to and is very hard. It should be cut into pieces for
normal teeth. It is seen as a pocket of malformed removal. If excessive force is used to elevate the
dwarfed teeth or tooth-like forms surrounded by a lesion, then the jaw fracture can occur.
narrow radiolucent zone. Sometimes, overlying or Recurrence is not seen.
alongside, an unerupted tooth or between the
Q.5. Adenoameloblastoma.
roots of a deciduous tooth. It prevents eruption of
underlying permanent tooth. Ans.
Cornplexodontoma may be small, large or occa-
Adenoameloblastoma
sionally huge; irregular or ovoid smooth; and,
densely radiopaque mass, often surrounded by a
thin radiolucent zone. It is frequently overlying a {SN Q.2}
displaced unerupted tooth. ● It may be considered as hamartoma.
The radiological picture is variable, depending on ● Incidence: Accounts for 3%–7% of odontogenic
the stage of formation at the time of incidental tumours.
discovery. It will range from complete radiolu- ● Age: Younger age group of 10–20 years (73%). It is
cency in the initial stage to the stage of ‘matura- rarely seen in those above 30 years.
tion’, i.e. complete calcified structure. Mixed ra- ● Sex: Predilection to occur in females (65%).
diolucency and radiopacity can be seen in one ● Site: Morecommon in maxilla (65%) and usually
lesion also. involves the anterior region.
● Asymptomatic – Shows no expansion of the ● Associated with impacted permanent teeth (invari-
bone and facial asymmetry ably canine tooth in about 74%).
● Commonly detected on radiographs ● Painless swelling.
● May show associated unerupted or im- ● Radiologically: Impacted tooth has a unilocular ra-
pacted teeth and associated swelling and diolucency around the crown, resembling a dentiger-
infection ous cyst. Radiolucency may extend apically along
Histological features the root crossing CE junction. More often the radio-
The compound odontoma shows a connective tis- lucency show fine calcification (snow flake). The
sue capsule. The lesion is composed of anatomi- margins are well defined and sclerotic.
cally distinct, small, well-formed or distorted ● Differential diagnosis: Pindborg tumour, CEOC or
teeth with enamel, dentine, pulp and cementum. Gorlin cyst and ameloblastoma.
The complex odontoma lacks anatomical organi- ● Histopathology: The lesion is surrounded by a thick,
zation and consists of calcified dental tissue in a fibrous capsule.
haphazard manner, bound together in a mass of ● Epithelial cells are either polyhedral or even spindle-
cementum and often surrounded by a thin connec- shaped with scanty stroma of connective tissue. Cells
tive tissue capsule. are arranged in sheets, cords or whorled masses,
Management which may form rosette-like structure about a central
Completely calcified complex or compound odon- space. Foci of calcification presumed to be abortive
toma is biologically inert and can be left alone. enamel formation or dentinoid/cementum-like mate-
Reasons for excision rial are seen.
i. Once detected, patient may be psychologically ● Calcification in several forms may be observed.
affected about the diagnosis of the lesion. i. Irregular dystrophic bodies.
ii. To remove the blockade of the favourably ii. Laminated or ring-like calcifications.
placed unerupted tooth underneath or nearby. iii. Large globular masses.
iii. To obtain definite diagnosis between the com- ● Treatment: Conservative excision or enucleation be-
plex odontoma and cementoblastoma or ossi- cause of the capsule is possible. Recurrence is rare
fying fibroma or CEOT, etc. with good prognosis.
Surgical treatment (intraoral approach)
Adequate amount of overlying bone removal
should be done to access the lesion. Compound Q.6. Calcifying epithelial odontogenic tumour.
odontoma is enucleated if the capsule is intact. If
Ans.
the capsule is disrupted, then the individual teeth
forms are removed carefully. Small complex [Same as SE Q.3]
Q.7. Odontomes. 2. Intraluminal unicystic ameloblastoma: It pro-

duces several nodular growth which projects
Ans. from cysts lining into the cyst lumen.
[Same as SE Q.4] 3. Mural type: Neoplastic cells infiltrates into
connective tissue wall of cyst capsule.
Q.8. Adenomatoid odontogenic tumour. Treatment
Ans. a. Enucleation and curettage.
b. Recurrence rate is low compared to CA.
[Same as SE Q.5]
Q.5. Mention various treatment modalities of amelo-
blastoma.
SHORT NOTES:
Ans.
Q.1. Define ameloblastoma. [Same as SN Q.3]
Ans. Q.6. Fibrous dysplasia.
Ameloblastoma is defined as unicentric, nonfunctional, in- Ans.
termittent in growth and anatomically benign tumour that is
clinically persistent. [Same as SN Q.14]
Q.2. Adenomatoid odontogenic tumour. Q.7. Compound odontoma.

Ans.
Ans.
Compound odontoma
[Ref SE Q.5]
● It presents collection of numerous small, discrete and
Q.3. Management of ameloblastona. tooth-like structure of tumour. Most compound

odontoma resembles normal anatomic tooth.
Ans. ● It appears as a radiopaque of calcified structures with
[Ref LE Q.1] an anatomic similarity to normal teeth.

● Seen as a pocket of malformed dwarfed teeth or tooth-
Q.4. Unicystic ameloblastoma. like forms surrounded by a narrow radiolucent zone.
Ans. ● Sometimes overlying alongside an unerupted tooth
or between the roots of a deciduous tooth.

Unicystic ameloblastoma ● It prevents eruption of underlying permanent tooth.
● Unicystic ameloblastoma is a separate entity from
conventional ameloblastoma. Q.8. Saucerization.

● Accounts for about 10%–15% of intraosseous ame-
loblastoma. Ans.
Clinical feature a . Sequestrum is usually lodged within bone.
a. Seen most commonly in younger aged patients. b. Once removed, it leaves behind a hollow cavity, which
b. 90% cases seen in mandibular posterior region. is basically dead space.
c. Lesion is often asymptomatic. c. A large clot will form in this cavity and the clot will
Radiographic features most likely get infected.
a. Well-circumscribed painless swelling of jaw. d. To avoid this reinfection, it is important to eliminate that
b. Radiolucent area that surrounds the crown of an dead space.
unerupted mandibular third molar. e. This is done by procedure called saucerization.
Histopathology f. The margins of the bone which lodge the sequestra are
Three distant types can be seen: trimmed down.
1. Luminal unicystic ameloblastoma: It occurs on g. This creates a saucer-shaped defect instead of a deep
the luminal surface of a cyst. Base of tumour is hollow cavity.
made up of cystic epithelium backed by con- h. This saucer defect accumulates a large clot.
nective tissue. i. The area may be packed with a medicated dressing,
a. Basal layer of columnar or cuboidal cell which is changed repeatedly till healing takes place.
exhibiting reverse polarization of nuclei.
b. Overlying cells are loosely arranged resem- Q.9. Papilloma.
bling stellate reticulum. Ans.
Papilloma These lesions are capable of producing normal appear-

● Papilloma is a common benign neoplasm of the oral ing enamel, dentine, pulp and cement, etc., in an unor-
cavity, arising from the epithelial tissue. ganized fashion.
● It is characterized by an exophytic papillary growth Types of odontomas
with a typical cauliflower-like appearance. 1. Complex odontoma: It consists of completely disor-
● Papilloma is caused by human papilloma virus. ganized and diffuse mass of odontogenic tissue
Clinical features with haphazardly arranged enamel, dentine and
● Most commonly seen in third, fourth and fifth cementum.
decade of life and is equally affected in both 2. Compound odontoma: It presents collection of numer-
sexes. ous small, discrete and tooth-like structure. Most com-
● Sites: Tongue, lips, buccal mucosa, gingival, hard pound odontomas resemble normal anatomic tooth.
and soft palate and so on.
Q.12. What is complex odontoma? Give brief description.
● Papilloma appears as a slow-growing, exo-
phytic, soft, usually pedunclated and painless Ans.

nodular growth with typical cauliflower-like
Complex odontoma
appearance.
● It consists of completely disorganized and diffuse
● It is characterized by numerous finger-like projec-
mass of odontogenic tissue with haphazardly ar-
tion on their surface, which can be either blunt or
ranged enamel, dentine and cementum.
pointed. Because of these projections, it appears
● Here, the calcified dental tissues are simply found as
as an ovoid swelling with a rough, corrugated
an irregular mass bearing no morphological similar-
surface.
ity to the rudimentary teeth.
● The size of the lesion is usually small and varies
● Most common type of odontogenic lesion (more than
from few millimetre to centimetre in diameter.
30%).
● The base of lesion is either sessile or peduncu-
● Age: First and second decades (10–70 years).
lated, but most commonly well circumscribed.
● Sex: Equal predilection in both sexes.
● Lesion is mostly white in colour and is firm in
● Site: Occurs in both the jaws.
consistency, as the surface is highly keratinized.
More common in mandible (about 67%).
● Superficial ulceration and secondary infection
● It may be small, large or occasionally huge; irregu-
may occur.
lar or ovoid smooth; and, densely radiopaque
● Multiple papilloma may coalesce together and
mass, often surrounded by a thin radiolucent zone.
form a large lesion in oral cavity and the condition
● It is frequently overlying a displaced unerupted
is known as papillomatosis.
tooth.
● Papillomatosis of oral mucosa is associated with
● The radiological picture is variable, depending on
skin disorders, e.g. focal dermal hypoplasia, ne-
the stage of formation at the time of incidental
vus uniuslateris, Cowden syndrome, acanthosis
discovery.
nigricans.
● It will range from complete radiolucency in the
Treatment
initial stage to the stage of ‘maturation’, i.e. com-
● Conservative surgical excision of the lesion in-
plete calcified structure.
cluding the base. Recurrence is common.
● Mixed radiolucency and radiopacity can be seen
Q.10. Define odontoma. in one lesion also.

● Asymptomatic – Shows no expansion of the bone
Ans.
and facial asymmetry.
Odontomas are a group of common hamartomatous odon- ● Commonly detected on radiographs.
togenic lesions with limited growth potential. ● May show associated unerupted or impacted teeth
These lesions are capable of producing normal appear- and associated swelling and infection.
ing enamel, dentine, pulp and cement and so on, in an un-
Q.13. Staging of tumour.
organized fashion.
Ans.
Q.11. What are odontomas? Mention its types.
TNM staging
Ans.
T – Primary tumour
Definition TX – Primary tumour cannot be assessed
Odontomas are a group of common hamartomatous T0 – No evidence of primary tumour
odontogenic lesion with limited growth potential. TIS – Carcinoma in situ
T1 – Tumour size 2 cm or less in greatest dimension Monostatic fibrous dysplasia

T2 – Tumour size more than 2 cm but not more than a. When the disease is limited to a single bone, it is
4 cm in greatest dimension termed as monostotic fibrous dysplasia.
T3 – Tumour size more than 4 cm in greatest dimension b. It accounts for 80%–85% of all cases, jaw most
T4 – Tumour invades adjacent structures commonly affected.
N – Regional lymph node c. Most commonly seen in second decade of life.
NX – Regional lymph nodes cannot be assessed. d. Equal predilection for both sexes.
N0 – No regional lymph node metastasis. e. Maxilla more commonly affected than mandible.
N1 – Metastasis in single ipsilateral lymph node, 3 cm Clinical features
or less in greatest dimension. a. Painless swelling of the affected area is the most
N2 – Metastasis in single ipsilateral lymph node, more common feature.
than 3 cm but less than 6 cm in greatest dimension or in b. Growth is slow, sometimes rapid.
bilateral or contralateral nodes (none of them are more c. Maxillary lesion also involves adjacent bone and
than 6 cm in greatest dimension). is not strictly monostotic.
N2a – Metastasis in single ipsilateral lymph node, more d. But unlike maxilla, mandibular lesions are strictly
than 3 cm but less than 6 cm in greatest dimension. monostotic.
N2b – Metastasis in multiple ipsilateral lymph nodes,
none of them are more than 6 cm in greatest dimension. Q.15. Cherubism.
N2c – Metastasis in bilateral or contralateral lymph
Ans.
nodes, none of them are more than 6 cm in greatest
dimension. Cherubism
N3 – Metastasis in lymph node, more than 6 cm in Cherubism is an autosomal dominant, non-neoplastic
greatest dimension. hereditary fibro-osseous lesion of jaw which is similar
M – Distant metastasis to central giant cell granuloma, which affects the jaw of
Mx – Presence of distant metastasis cannot be assessed. children bilaterally.
M0 – No distant metastasis. Clinical feature
M1 – Clinical or radiographic evidence of metastasis. a. It affects children at birth and there is no clinically
or radiographical evidence of the disease until
Q.14. Fibrous dysplasia. 14 months to 3 years of age.
b. Typically, if the lesion appears early, the more
Ans.
rapidly it progress.
Fibrous dysplasia c. When the patient reaches 5 years of age, the self-
Fibrous dysplasia is a tumour-like condition that is limited growth usually begins to slow down and
characterized by replacement of normal bone by an ex- stops by the age of 12–15 years.
cessive proliferation of cellular fibrous tissue inter- d. The lesion begins to regress at puberty.
mixed with irregular bony trabeculae. e. Jaw remodelling continues through the third de-
Aetiology cade of life, at the end of which the clinical abnor-
a. It is caused by a mutation in GNAS-I gene. mality may be subtle.
b. Increased production of melanocytes resulting in f. Depending on the severity of the condition, the
café au lait spots with irregular margins as op- signs and symptoms appear.
posed to the regular outlined spots in neurofibro- g. The jaw lesions are usually painless and symmet-
matosis. ric and have a florid maxillary involvement.
c. cAMP is thought to have an effect on the dif- h. The lesion, which commonly involve the molar to
ferentiation of osteoblasts leading to fibrous coronoid regions are firm to palpation and non-
dysplasia. tender. The condyle always being spared, and are
Clinical feature often associated with cervical lymphadenopathy.
Divided into: Oral manifestation
1. Monostotic form a. Numerous abnormalities have been reported such
2. Polystotic form as agenesis of second and third molars of mandible,
a. Jaffe’s type displacement of the teeth, premature exfoliation of
b. Albright syndrome the primary teeth, delayed eruption of permanent
3. Craniofacial form teeth, and transposition and rotation of teeth.
Treatment b. In some cases, it is associated with condition
Treatment varies on the type of fibrous dysplasia. known as Noonan syndrome.
Grading Treatment
Grade I – Both mandibular ascending rami are in- a. Surgery to correct the jaw deformity.
volved. b. If surgery is indicated, then it is usually under-
Grade II – Both maxillary tuberosities and mandib- taken at puberty when remission phase of the le-
ular ascending rami are involved. sion have been reached.
Grade III – It is characterized by McCune–
Q.16. Monostatic fibrous dysplasia.
Albright syndrome and the whole maxilla and
mandible except the coronoid process and condyle Ans.
are involved.
[Same as SN Q.14]
Topic 11
Diseases of TMJ
LONG ESSAYS:
1 . Describe the aetiology, clinical features and management of ankylosis of temporomandibular joint (TMJ).
2. Enumerate the causes of inability to open the mouth.
3. Differentiate between subluxation dislocation of TMJ and describe the treatment of chronic TMJ dislocation.
4.
Describe the aetiology, signs and symptoms of temporomandibular joint ankylosis. Discuss its management.
[Same as LE Q.1]
5 . Describe the management of ankylosis of TMJ. [Same as LE Q.1]
6. What are the causes for inability to open the mouth? [Same as LE Q.2]
SHORT ESSAYS:
1. Ankylosis treatment protocol.
2. Treatment of temporomandibular joint dysfunction syndrome.
3. Clinical features and management of dislocation. [Ref LE Q.3]
4. Define trismus and enumerate its causes. [Ref LE Q.2]
5. Surgical anatomy of the temporomandibular joint.
6. Subluxation of TMJ.
7. Interposition osteoarthroplasty. [Ref LE Q.1]
8. Internal derangements of TMJ.
9. Enumerate diseases of TMJ.
10. Dislocation of TM joint. [Same as SE Q.3]
11. Acute dislocation of TM joint. [Same as SE Q.3]
12. Acute TMJ dislocation and its causes and treatment. [Same as SE Q.3]
13. Interpositional arthroplasty. [Same as SE Q.7]
SHORT NOTES:
1 . Eminectomy.
2. Articular disc.
3. Mention eight causes that can result in true ankylosis of the TM joint. [Ref LE Q.1]
4. Frey syndrome.
5 . Interposition arthroplasty. [Ref LE Q.1]

6. Risdon’s submandibular approach.
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Describe the aetiology, clinical features and man-
● Condylar fractures: Intracapsular or extracap-
agement of ankylosis of temporomandibular joint
sular
(TMJ).
● Glenoid fossa fracture (rare)
Ans. Infections
● Otitis media
Ankylosis
● Parotitis
● Ankylosis means abnormal immobility of joint
● Tonsilitis
Classification of ankylosis
● Furuncle
i. False ankylosis or true ankylosis
● Abscess around the joint
ii. Extra-articular or intra-articular
● Osteomyelitis of the jaw
iii. Fibrous or bony
● Actinomycosis
iv. Unilateral or bilateral
Inflammation
v. Partial or complete
● Rheumatoid arthritis
● Extra-articular and intra-articular types of TMJ
● Osteoarthritis
ankylosis have been described depending
● Septic arthritis
mainly on the anatomic site of the fusion or
● Polyarthritis
union.
Rare causes
Causes
● Measles
Trauma
● Smallpox
● The definite cause of ankylosis of TMJ
Systemic diseases
● Two main factors predisposing to the ankylosis
● Scarlet fever
are trauma and infection around the joint re-
● Typhoid
gion
● Gonoccocal arthritis
Joint infection
● Scleroderma
● It may occur secondary to septicaemia due to
● Beriberi
osteomyelitis, septic sore throat, scarlet fever,
● Marie–Strumpell disease
tuberculosis, meningitis, etc.
● Ankylosing spondylitis
Direct spread of infection
Other causes
● It may occur from adjacent areas in cases of
● Bifid condyle
otitis media (infection of middle ear), mastoid-
● Prolonged trismus
itis, osteomyelitis of temporal bone or parotid
● Prolonged immobilization
abscess, soft tissue abscess, skin infections or
● Unknown
severe odontogenic submasseteric, infratempo-
● Burns
ral abscesses, etc.
Diseases affecting the joints Clinical manifestations
● Such as rheumatoid arthritis, osteoarthritis and
Clinical manifestations vary according to:
ankylosing spondylitis bring about degenera- a. Severity of ankylosis
tive changes and destruction of the disc fol- b. Time of onset of ankylosis
lowed by the repair process. This can lead to c. Duration
the ankylosis of TMJ. Early joint involvement
● Less than 15 years: Severe facial deformity and loss
{SN Q.3} of function
Aetiopathology of ankylosis of TMJ Late joint involvement
● After the age of 15 years: Facial deformity is mar-
Trauma
● Congenital: At birth, forceps delivery
ginal or nil. But, functional loss is severe.
● Patients with ankylosis developing after full growth
● Haemarthrosis (direct/indirect trauma)
completion have no facial deformity.
Unilateral ankylosis ● Whether it is unilateral or bilateral

Seen in a child or in a person where the onset was usu- ● Associated facial deformity
ally in the childhood. Aims and objectives of surgery
● Obvious facial asymmetry. ● Release of ankylosed mass and creation of a gap to
● Deviation of the mandible and chin on the af- mobilize the joint
fected side. ● Creation of a functional joint
● The chin is receded with hypoplastic mandible on ● To improve patient’s nutrition
the affected side. ● To improve patient’s oral hygiene
● Roundness and fullness of the face on the affected ● To carry out necessary dental treatment
side. ● To reconstruct the joint and restore the vertical
● The appearance of the flatness and elongation on height of the ramus

the unaffected side. ● To prevent recurrence
● Lower border of the mandible on the affected side ● To restore normal facial growth pattern (based on
has a concavity that ends in a well-defined antego- functional matrix theory)

nial notch. ● To improve aesthetics and rehabilitate the patient
● In unilateral ankylosis, some amount of oral open- (cosmetic surgery may be carried out at a later date
ing may be possible. or at second phase)
● Interincisal opening will vary depending on Surgical techniques
whether it is fibrous or bony ankylosis. ● A number of techniques have been advocated by dif-
● Crossbite may be seen. ferent surgeons.

● Class II angles malocclusion on the affected side ● Critical analysis of all, filters only to three basic
plus unilateral posterior crossbite on ipsilateral methods:

side seen. I. Condylectomy
● Condylar movements are absent on the affected II. Gap arthroplasty
side. III. Interpositional arthroplasty
Bilateral ankylosis ● Most surgical procedures can be done through a pre-
● Inability to open the mouth progresses by gradual de- auricular incision alone.
crease in interincisal opening. The mandible is sym- ● The Popowich’s incision is chosen for its obvious
metrical but micrognathic. The patient develops typical advantages.

‘bird face’ deformity with receding chin. ● Whenever required, additional submandibular inci-
● The neck chin angle may be reduced or almost com- sion can be used for fixation of the graft, etc.
pletely absent. I. Condylectomy
● Antegonial notch is well defined bilaterally. ● Condylectomy is advised in cases of fibrous
● Class II malocclusion can be noticed. ankylosis, where the joint space is obliter-
● Upper incisors are often protrusive with anterior ated with deposition of fibrous bands, but,
open bite. Maxilla may be narrow. there is not much deformity of the condylar
● Oral opening will be less than 5 mm or many times head.
there is nil oral opening. ● Radiologically and clinically after surgical ex-
● Multiple carious teeth with bad periodontal health posure, one can see the demarcation between
can be seen. the roof of the glenoid fossa and the head of
● Severe malocclusion and crowding can be seen; and, the condyle.
many impacted teeth may be found on the X-rays. ● The condylectomy procedure can be carried
Diagnosis out via preauricular incision.

Diagnosis is based on the following: ● Horizontal osteotomy cut is carried out with
● History of trauma, infection, etc. the help of the surgical bur at the level of con-
● Clinical findings. dylar neck.
● Radiographic findings are important in arriving at ● Vital structures on the medial surface of the
a final diagnosis. condylar neck should be protected by using

Management of TMJ ankylosis special condylar retractor inserted prior to the
● The treatment of TMJ ankylosis is always surgical bony cut.
correction of the ankylosed joint. ● The condylar head then should be separated
Surgical strategy adopted depends on the following: from the superior attachment carefully.
● Age of onset of ankylosis ● The rest of the stump should be smooth and
● Extent of ankylosis wound closed in layers.

● Unilateral condyle tends to cause deviation of Interpositional materials used are

the mandible towards operated side on oral a. Autogenous
opening; and in bilateral ankylosis, open bite ● Cartilaginous graft
will be caused as a result of the loss of the ● Temporal muscle
vertical rami. ● Temporal fascia
● Therefore, when the site of the fused joint is ● Fascia
treated via condylectomy, then after recontour- ● Dermis
ing, an alloplastic material can be used to b. Heterogenou

maintain space, satisfactory occlusion and ● Chromatized submucosa of pig bladder
joint movements. ● Lyophilized bovine cartilage
II. Gap arthroplasty c. Alloplastic materials

● In the extensive bony ankylosis, a broad, thick Metallic: Tantalum foil/plate, 316L stainless steel,
bone deposition obliterates the entire joint, titanium and gold
sigmoid and coronoid process. Nonmetallic: Silastic, teflon, acrylic, proplast, ce-
● Identification of the previous structure is im- ramic implants, etc.}
possible and mobilization at the level of the
joint becomes difficult, if not impossible. Q.2. Enumerate the causes of inability to open the
● The term gap arthroplasty is used to describe mouth.
the operation in which the level of section is
Ans.
below that of the previous joint space.
● No substance is interposed between the two [SE Q.4]
cut bony surfaces.
● Section consists of two horizontal osteotomy ● {Whenever there is a restriction of normal oral opening
cuts and removal of a bony wedge for creation or inability to open the mouth fully, it is termed as
of a gap between the roof of the glenoid fossa trismus.
and ramus. ● Trismus is also defined as a condition in which muscle
● Here it is recommended to create a minimum spasm or contracture prevents opening of the mouth.
gap of at least 1 cm to prevent re-ankylosis. Causes of trismus
● The width of the bone removed is considered Due to infection
crucial and is not usually possible to remove ● Orofacial infections around the joint area can
the entire block, particularly from the medial bring about trismus or limitation of oral opening.
aspect, which is in close proximity to the inter- Infections include odontogenic acute infections
nal maxillary artery. Hence, bone is removed like pericoronitis, Ludwig angina, submasseteric,
carefully by using a large round bur, until the infratemporal abscess, etc. Chronic infections af-
medial bone is thinned out enough to be read- fecting the jaws also can bring about trismus, e.g.
ily removed by using hand chisel or osteo- tuberculous osteomyelitis of ramus, body and
tome. mandible.
● It is important to create a gap of equal dimen- Trauma
sion both laterally and medially, so that the ● Fracture of the zygomatic arch may impinge on
possibility of medial re-ankylosis due to bone the coronoid process and restrict the oral opening.
contact is avoided. Fracture of the mandible can also bring about
trismus, because of pain and tenderness or muscle
(SE Q.7 and SN Q.6) spasm.
{(III. Interpositional arthroplasty Inflammation
● It is believed that recurrence of ankylosis is ● Myositis or muscular atrophy can bring about
less likely when something is interposed be- trismus.

tween the two cut bony surfaces. Myositis ossificans
● Interpositional arthroplasty involves the cre- ● Following trauma, a haematoma can be formed
ation of a gap, but in addition, a barrier (autog- within the fibres of the masticatory group of
enous or alloplastic) is inserted between the muscles, especially in the masseter, which can
cut bony surfaces. progress into ossification and muscle stiffness.
● This minimizes the risk of recurrence and Clinical and radiographic examination will con-
maintains the vertical height of the ramus. firm the presence of these changes.
Tetany iii. Connective tissue disorders: Hypermobility syn-

● Tetanus following acute infection by Clostridium drome, Ehlers–Danlos syndrome and Marfan syn-
tetani, the typical lockjaw symptom can be seen drome
associated with other symptoms, because of per- iv. Psychogenic causes: Habitual dislocation
sistent tonic muscle spasm. v. Drug-induced: Phenothiazines
Neurological disorders vi. Miscellaneous causes:
● Epilepsy, brain tumour, bulbar paralysis and em- Internal derangement, decreased vertical dimension
bolic haemorrhage in medulla oblongata can bring and occlusal discrepancies
about trismus. Management
Psychosomatic trismus ● Nonsurgical management
● It is also known as trismus hystericus. It is due to ● Chemical capsulorrhaphy
extreme fear and anxiety associated with hysteri- ● Arthroscopic sclerotherapy
cal fits. ● Occlusal correction
Drug-induced trismus ● Physiotherapy
● Strychnine poisoning can bring about spasms Management of dislocation can be divided into two broad
leading to trismus. headings:
Mechanical blockage I. Nonsurgical management
● Elongation, exostosis, osteoma and osteochon- II. Surgical management
droma of coronoid process will cause mechanical Nonsurgical management
blockage and interfere with the normal mandibu- i. Manual reduction of a dislocated condyle:
lar movements. The main aim is to overcome the resistance of
Extra-articular fibrosis the severe muscle contraction that accompanies a
● Chronic cervicofacial sepsis, irradiation therapy, dislocation.
ossification of sphenomandibular ligament, bands ii. Sedatives can be given to reduce the anxiety of the
of scars and burns of the face and neck region and patient.
oral submucous fibrosis will lead towards pro- iii. Pressure and light massage over the coronoid pro-
gressive trismus.} cess intraorally is beneficial.
iv. Johnson has described a simple method by which
Q.3. Differentiate between subluxation dislocation of TMJ injection of local anaesthetic into the glenoid fossa
and describe the treatment of chronic TMJ dislocation. of the dislocated joint cause spontaneous reduction
Ans. of the condyle.
This is probably due to relief of pain and therefore
reduction in muscle spasm and therefore spontane-
[SE Q.3]
ous reduction of dislocation.
{Dislocation v. Most common manual method of reduction:
Dislocation of the condyle refers to the condition in
● Patient is made to sit upright. The doctor puts
which the condyle is placed anterior to the articular his thumbs over the occlusal surface of the lower
eminence with collapse of the articular space. The molars or on the alveolar ridge and pushes the
condyle comes in contact with the anterior slope of mandible downwards, backwards and upwards.
the eminence and is unable to return to the closed vi. Chemical capsulorrhaphy
position It is done in a patient with recurrent dislocations.
Classification Objective is to produce fibrosis and tightening of
● Unilateral or bilateral the capsular ligament, thereby limiting motion and
● Acute or chronic thus preventing dislocation.
● Habitual or recurrent Chemical capsulorrhaphy means injecting a scleros-
Aetiology ing agent into the supporting ligaments of the joint
i. Intrinsic trauma: Overextension injury as in yawn- or into the joint to produce fibrosis.
ing, vomiting, seizures, etc. Surgical management
ii. Extrinsic trauma: Indications
● Trauma to the mandible during a fall or blow to ● Disabling recurrent dislocation
the mandible ● Long-standing dislocation not responsive to closed
● Intubation during General anesthesia (GA) manipulation or other nonsurgical treatment
● Endoscopy Surgical procedures can be divided into three types:
● Dental extraction A. Procedures to limit condylar translation
B. Procedures to eliminate blocking factors in the condylar ii. Mayer advocated the removal of part of the
path of closure articular tubercle and placement of graft
C. Combination procedures to limit condylar translation taken from the zygomatic arch to increase the
and to eliminate blocking factors height of the articular tubercle.
Drawbacks: IMF needed; bone resorption.
A. Procedures to limit condylar translation
iii. Articular eminence can be augmented by
a. Capsulorrhaphy
sectioning it and placing a piece of silastic in
This is a procedure done to tighten the capsule so that
between the sectioned parts.
it prevents the excessive movement of the condyle.
Drawback: Inferior part of the articular emi-
This is done in different ways as described below:
nence is devoid of blood supply and will
i. Removing a wedge of tissue from the capsule
resorb.
and suturing the defect to tighten the capsule.
iv. Dautry’s procedure: The zygomatic arch is
ii. Use of dermal flap from occipital region based
osteotomised and depressed in front of the
on cranial periosteum tunnelled and secured to
condylar head. This serves as an obstacle to
the capsule to augment the capsulorrhaphy.
abnormal translation of the condyle.
iii. Temporal fascia flap can also be used in the
B. Procedures to eliminate blocking factors in the con-
same way.
dylar path of closure
iv. Capsular plication and ligamentopexy.
Operations have been designed to eliminate obstacles in
b. Anchoring sling
the condylar path that may either trigger a dislocation or
● Gordon used fascia lata transplants and secured it
mechanically prevent reduction of the condyle:
to the zygomatic arch and the head of the condyle
i. Discectomy
to prevent excessive anterior movement of the
ii. Eminectomy
condyle.
C. Combination procedures to limit condylar transla-
● This was followed by removal of the disc.
tion and to eliminate blocking factors
c. Ligation of coronoid process
The combined procedures include:
Coronoid process can be ligated to the zygomatic
i. Lateral pterygoid myotomy with discectomy
arch.
ii. Condylotomy
d. Lateral pterygoid myotomy
iii. Condylectomy or high condylectomy}
● Myotomy eliminates action of the superior belly
Chronic/recurrent or habitual dislocation or subluxation
of the lateral pterygoid muscle.
● The term should be reserved for repeated episodes
● Silicon sheet placed over pterygoid fossa prevents
of dislocation, where there is abnormal anterior
reattachment of the muscle.
excursion of the condyles beyond the articular
e. Blocking procedures
eminence. Patient is able to manipulate it back
I. Soft tissue procedures
into position. So, here the condylar head moves
II. Bony or hard tissue procedures
unassisted, forward and backward over the articu-
I. Soft tissue procedures lar eminence.
Creating a closed lock: ● This recurrent, incomplete and self-reducing disloca-
Konjetzny surgically released the posterior tion is termed as hypermobility or chronic subluxation
attachment of the disc and allowed it to of the TMJ.
move anteriorly and inferiorly. It is anchored ● The triad of ligamentous and capsular flaccidity,
vertically in front of the condyle by suturing eminential erosion and flattening and trauma is well
it to the lateral pterygoid muscle and the recognized in the genesis of chronic subluxation.
capsule. This prevents excessive forward ● In such predisposed individuals, yawning or laughing
translation of the condyle. may precipitate subluxation.

Disadvantage: Causes future pain and dis- ● It is also seen in severe epilepsy, dystrophia myotonia
comfort. and Ehlers–Danlos syndrome.

II. Bony or hard tissue procedures
i. Lidermann performed an oblique osteotomy Q.4. Describe the aetiology, signs and symptoms of
of the articular tubercle and turned it down in temporomandibular joint ankylosis. Discuss its man-
front of the condyle head to block movement agement.
of condyle. Ans.
Drawback: IMF needed; bone resorption may
take place. [Same as LE Q.1]
Q.5. Describe the management of ankylosis of TMJ. Q.2. Treatment of temporomandibular joint dysfunc-
tion syndrome.
Ans.
Ans.
[Same as LE Q.1]
● Myofascial Pain dysfunction Syndrome (MPDS) is a
Q.6. What are the causes for inability to open the
pain disorder, which is unilateral and is referred from the
mouth?
trigger points to various muscles of the head and neck.
Ans. ● Pain is constant and dull in contrast to the sudden sharp,
shooting, intermittent pain of neuralgias (chronic pain).

[Same as LE Q.2]
● The pain may range from mild to intolerable.
Treatment of temporomandibular joint dysfunction

syndrome
SHORT ESSAYS: Placebo
Q.1. Ankylosis treatment protocol. ● Placebo effect for treatment of pain/dysfunction
syndrome is by splints and by mock adjustment of

Ans.
the occlusion.
Internationally accepted protocol for the management Reassurance
of TMJ ankylosis ● The quality of doctor–patient relationship is very
● Put forward by Kaban, Perrot and Fisher in 1990. important for the success of treatment, as it may
● Early surgical intervention. help to reduce the emotional problem of the pa-
● Aggressive resection: A gap of at least 1–1.5 cm should tient and they must be reassured that there is no
be created. Special attention should be given to the fu- serious disease. In a few cases, reassurance alone
sion on the medial aspect of the ramus. Old malunited may be sufficient.
condylar fractured piece can be seen attached on the ● Patient’s occupation must be considered, as it may
medial side. be necessary to advice sick leave.

● Ipsilateral coronoidectomy and temporalis myotomy: Occlusal correction
In most of these cases, there is always association of ● Patient should perform bilateral mastication.
elongated coronoid process. After carrying out gap ● Any dental pain, substandard restoration and
arthroplasty, the coronoidectomy on the same side missing teeth should be treated.
should be carried out either separately or in combina- ● Habits can be corrected by exercises.
tion with the gap arthroplasty cut from the same extra- Soft diet
oral incision. The coronoid process is cut from the ● Loading forces on joint reduces.
level of sigmoid notch till the anterior border of the Splints

ramus. The temporalis muscle attachments are severed ● A splint inactivates facial muscles, decompresses
by carrying out temporalis myotomy. The oral opening intracapsular tissue and establishes balanced oc-
is checked after this procedure by the assistant. If clusal plane.
maximum interincisal opening of greater than 35 mm Drugs
is obtained, there is no need to carry out contralateral ● NSAIDs are helpful in reducing pain and inflam-
coronoidectomy. mation.
● Contralateral coronoidectomy and temporalis myot- ● Anti-inflammatory action of corticosteroids is
omy is necessary: If maximum incisal opening is less greater than NSAIDs. Can be given intra-articular
than 35 mm, uninvolved side coronoidectomy and tem- or orally.
poralis myotomy can be carried out through intraoral ● Anxiolytics to reduce anxiety, as anxiety and
incision. muscle tension appear to be related, e.g. diazepam

● Lining of the glenoid fossa region with temporalis 5–10 mg.
fascia. ● Muscle relaxants like methocarbomol and chlo-
● Reconstruction of the ramus with a costochondral roxazone are effective.

graft. ● Antidepressant like tricyclic and MAO inhibitors
● Early mobilization and aggressive physiotherapy for the are effective.

period of at least 6 months postoperatively. Intermaxillary fixation
● Regular long-term follow-up. ● When pain is severe, application of intermaxillary
● To carry out cosmetic surgery at later date, when the fixation relieves symptoms by inducing absolute
growth of the patient is completed. rest.
Thermal agents ● The disc is composed of avascular, aneural and

● They help in decreasing pain, increasing muscle fibrous connective tissue.
relaxation and increasing the range of motions. ● This divides the joint into two separate compart-
● Superficial moist/dry heat: Superficial heat pro- ments:

duces a therapeutic effect by elevating pain ● The superior joint space (between disc and glenoid
threshold, altering nerve conduction velocity and fossa).

decreasing muscle tension. Muscle relaxation ● Inferior joint space (between lower surface of the
may also result from analgesic effects of heating. disc and condylar head).
● Deep ultrasound: They help to increase the elas- ● Functions of the disc:
ticity of soft tissues. It has an anti-inflammatory Probably acts as a shock absorber and also helps in
effect. For TMJ inflammation, pulsed ultrasound lubrication of the joint.
is applied with a 5 cm or smaller sound heard III. Capsule of the joint
at a frequency of 3 MHz and low intensity of ● The capsule is a thin ligamentous structure, which
0.5–0.8 w/cm2 per 5–8 min. Exercise combined extends from temporal portion of glenoid fossa su-
with ultrasound reported a higher percentage of periorly, fuses with margins of the disc in the centre
pain relief. and continues down to attach to the neck of the
condyle inferiorly.
Q.3. Clinical features and management of dislocation. ● Inferior and superior joint spaces which are
Ans. separated by the disc are enclosed within the

capsule.
[Ref LE Q.3] ● Inner aspect of capsule is lined by the synovial
membrane.
Q.4. Define trismus and enumerate its causes.
● This produces the synovial fluid which lubricates
Ans. the joint, helps in smooth movement of the joint and

also acts as a shock absorber.
[Ref LE Q.2]
IV. Ligaments of the TMJ
Q.5. Surgical anatomy of the temporomandibular joint. The ligaments of the TMJ are
a. Lateral ligament or the temporomandibular lig-
Ans.
ament
Components of TMJ b. Sphenomandibular ligament
I. Bony articular components: Condylar head and c. Stylomandibular ligament
glenoid fossa d. Collateral ligaments
II. Intra-articular disc
III. Capsule of the joint a. Lateral ligament
IV. Ligaments of the joint ● Consists of superficial fibres which are
oblique and deep fibres which are more

I. Bony articular components
horizontal.
The temporomandibular joint consists of basically two
● It originates at the root of the zygomatic arch
bony articular components, namely
or the articular tubercle and attaches posteroin-
i. The glenoid fossa of the temporal bone
feriorly to the posterior surface of the condylar
ii. The mandibular condyle
neck.
i. The glenoid fossa of the temporal bone b. Sphenomandibular ligament
This is a smooth concave depression in the tempo- Origin is at the spine of the sphenoid and attaches
ral bone which is thinnest in its deepest part, to the lingula on the medial surface of the ramus
which separates the joint from the middle cranial of the mandible.
fossa. c. Stylomandibular ligament
ii. The mandibular condyle It originates from the styloid process and attaches
This is a paired structure. Condyles on both sides to the angle of the mandible.
being connected by a single continuity of bone Collateral or accessory ligaments make no contri-
which is the mandible. bution to joint activity.
II. Intra-articular disc and its attachments Nerve and blood supply
● The disc is described as a jockey’s cap placed on the Sensory innervation: Auriculotemporal and mas-
condylar head. seteric branch of mandibular nerve.
Vascular supply: Superficial temporal branch of Q.7. Interposition osteoarthroplasty.

external carotid artery supplies the lateral aspect
of the joint. Ans.
Middle meningeal artery and lateral pterygoid
[Ref LE Q.1]
muscle provide an additional vascularity to the
joint. Q.8. Internal derangements of TMJ.
Movements of TMJ
● Depression of the mandible: Contraction of bilateral Ans.
and lateral pterygoid muscles.
Internal derangement of TMJ
● Elevation of mandible:
● Internal derangement is defined as the anteromedial
Contraction of bilateral, masseter contraction, bilat-
displacement of the interarticular disc associated
eral medial pterygoid contraction and bilateral tem-
with the posterosuperior displacement of the condyle
poralis contraction.
in the closed-jaw position.
● Lateral excursion of mandible contraction; unilat-
● It is a progressive disorder which can lead from a
eral, medial and lateral pterygoid (same side) re-
mild clicking sound in the joint to osteoarthritis.
laxation; and opposite side medial and lateral
Aetiology
pterygoid.
● Changes in the joint usually occur as a result of trauma.
● Protrusion of the mandible:
● Trauma may be in the form of microtrauma or mac-
Contraction of bilateral, medial and lateral pterygoid.
rotrauma.
● Retrusion of mandible:
● Microtrauma to the joint maybe in the form of brux-
Contraction posterior fibres of temporalis.
ism, clenching or orthopaedic instability.
● As a result of such insult to the joint, there is elonga-
Q.6. Subluxation of TMJ.
tion of the capsular and discal ligaments and thinning
Ans. of the articular disc.
Clinical features
Chronic recurrent or habitual dislocation or sublux-
● The patients may have relatively normal mouth
ation
opening in early stages of disorder.
● The term should be reserved for repeated episodes
● The restricted mouth opening may be only due to
of dislocation where there is abnormal anterior ex-
pain and not due to a mechanical obstruction.
cursion of the condyles beyond the articular emi-
● Clicking sounds may be palpable on opening or both
nence. Patient is able to manipulate it back into
on opening and closing.
position. So, here the condylar head moves, unas-
● Deviation of the jaw on opening of the mouth may be
sisted, forward and backward over the articular
seen.
eminence.
Management
● This recurrent, incomplete and self-reducing disloca-
Nonsurgical management
tion is termed as hypermobility or chronic sublux-
I. Anterior repositioning appliances
ation of the TMJ.
● This is an appliance placed on the occlusal
● The triad of ligamentous and capsular flaccidity,
surface in an attempt to recapture the disc to
eminential erosion and flattening and trauma is well
its normal position.
recognized in the genesis of chronic subluxation.
II. Supportive therapy
● In such predisposed individuals, yawning or laugh-
● Decrease loading of the joint, NSAID to con-
ing may precipitate subluxation.
trol pain and heat application are advised.
● It is also seen in severe epilepsy, dystrophia myoto-
● In case of orthopaedic instability, dental ther-
nia and Ehlers–Danlos syndrome.
apy for occlusal correction may be useful.
Chronic subluxation with pain
● Excessive excursive movement or hypermobility Q.9. Enumerate diseases of TMJ.
of the mandibular condyle is not necessarily
Ans.
painful.
● But in some of the patients, sudden sharp and se- Disorders due to extrinsic factors
vere pain occurs when the mouth is opened widely. Masticatory muscle disorders
Occasionally, the problem is of such a magnitude ● Protective muscle splinting
that, the patient becomes reluctant to masticate ● Masticatory muscle spasm (MPD) syndrome
food. ● Masticatory muscle inflammation (myositis)

Temporomandibular disorders due to intrinsic factors It is important to remove medial-most part of the
●
1. Trauma eminence.
● Dislocation or subluxation ● It does not interfere with the internal structure of the
● Haemarthrosis joint.
● Intracapsular fracture or extracapsular fracture Complications
2. Internal disc displacement ● Pneumatization of eminence and dural tear during its
● Anterior disc displacement with reduction removal.

● Anterior disc displacement without reduction ● Formation of postoperative osteophytes.
3. Arthritis ● Crepitus and pain.
● Osteoarthrosis (degenerative arthritis, osteoarthri-

Q.2. Articular disc.
tis)
● Rheumatoid arthritis Ans.
● Juvenile rheumatoid arthritis
● TMJ is a diarthroidial synovial paired joint.
● Infectious arthritis
● The disc is biconcave in sagittal section. The superior
4. Developmental defects
surface is concavoconvex to match the anatomy of the
● Condylar agenesis or aplasia – Unilateral/bilateral.
glenoid fossa and inferior surface is concave to fit over
● Bifid condyle
the condylar head.
● Condylar hypoplasia
● The disc is composed of avascular, aneural and fibrous
● Condylar hyperplasia
connective tissue.
5. Ankylosis
● This divides the joint into two separate compartments:
6. Neoplasms
● The superior joint space (between disc and glenoid
● Benign tumours: Osteoma, osteochondroma and
fossa).
chondroma
● Inferior joint space (between lower surface of the
● Malignant tumours: Chondrosarcoma, fibrosar-
disc and condylar head).
coma and synovial sarcoma
● Functions of the disc:
Q.10. Dislocation of TM joint. Probably acts as a shock absorber and also helps in lu-
brication of the joint.
Ans.
[Same as SE Q.3] Q.3. Mention eight causes that can result in true anky-
losis of the TM joint.
Q.11. Acute dislocation of TM joint.
Ans.
Ans.
[Ref LE Q.1]
[Same as SE Q.3]
Q.4. Frey syndrome.
Q.12. Acute TMJ dislocation and its causes and treat-
ment. Ans.
Ans. Frey syndrome
● This auriculotemporal nerve syndrome may follow
[Same as SE Q.3]
the surgery of the parotid gland and TM joint, a fa-
Q.13. Interpositional arthroplasty. cial wound or parotid abscess.
● It is characterized by pain in the auriculotemporal
Ans.
nerve distribution.
[Same as SE Q.7] ● Associated gustatory sweating and occasionally ery-
thema is seen.
● There is flushing on the affected side of the face ac-
SHORT NOTES: companied by sweating within the hairline, the peri-
Q.1. Eminectomy. auricular region and beneath the pinna.
● A minor starch – iodine test is positive in these pa-
Ans.
tients.
Eminectomy Treatment options for Frey syndrome
● Eminectomy involves reduction of height of emi- ● Topical agents.
nence to allow free forward and backward move- ● Commercial antiperspirants are effective only for
ments of condyle. milder symptoms.

Submandibular (Risdon) approach

Surgical procedures
● In Risdon’s method, the incision is taken about 1 cm
● Skin excision for localized and relative areas.
below the angle of the mandible.
● Auriculotemporal nerve section results are perma-
● It extends forward, parallel to the lower border of the
nent.
mandible and curves backward slightly behind the
● Tympanic neurectomy is a safe procedure on outpa-
angle.
tient basis.
● Approach to the neck of the condyle and ramus is
Q.5. Interposition arthroplasty. achieved by sharply incising through the pterygo-
masseteric sling and reflecting the masseter muscle
Ans.
laterally to expose the neck of the condyle and sig-
[Ref LE Q.1] moid notch.
● Poor access to the condylar head region. Procedures
Q.6. Risdon’s submandibular approach.
involving the articular portion of the head and the
Ans. meniscus cannot be performed by this approach.
Topic 12
Diseases of Salivary Gland
LONG ESSAYS:
1 . Describe signs and symptoms, diagnosis and management of sialolith in Wharton’s duct.
2. Describe the sialography of parotid gland in an adult.
3. Classify tumours of salivary glands and discuss in detail about pleomorphic adenoma.
4. Describe the clinical features and treatment of salivary calculus of Warton’s duct. [Same as LE Q.1]
5. Enumerate salivary gland disorders and discuss the management of sialolith in Warton’s duct. [Same as LE Q.1]
6. What is sialography? Describe its technique. How will you remove a sialolith from the right Wharton’s duct?
[Same as LE Q.2]
SHORT ESSAYS:
1. Sialadenitis.
2. Salivary fistula.
3. Sialolith. [Ref LE Q.1]
4. Classify salivary gland tumours and how do you investigate them?
5. Ranula.
6. Mucocoele.
7. Adenocarcinoma of minor salivary gland in palate.
8. Mumps.
9. Pleomorphic adenoma. [Ref LE Q.3]
10. Sjogren syndrome.
11. Surgical anatomy of submandibular gland.
12. Investigations in salivary calculus. [Same as SE Q.3]
13. Submandibular salivary calculi and its management. [Same as SE Q.3]
14. Surgical removal of salivary stone from submandibular duct. [Same as SE Q.3]
15. Sialolithiasis and management. [Same as SE Q.3]
16. Mixed tumour of parotid gland. [Same as SE Q.9]
SHORT NOTES:
1. Mumps and its clinical features. [Ref SE Q.8]
2. Sialogram. [Ref LE Q.2]
3. Indications of sialography. [Ref LE Q.2]
4. Sialolithiasis. [Ref LE Q.1]
5. Sjogren syndrome. [Ref SE Q.10]
6. What is Wharton’s duct? What is Bartholin’s duct?
7. Pleomorphic adenoma. [Ref LE Q.3]
8. Ranula. [Ref SE Q.5]
9. Mucocoele. [Ref SE Q.6]
10. Sialolith. [Same as SN Q.4]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Describe signs and symptoms, diagnosis and man- (SE Q.3 and SN Q.4)
agement of sialolith in Wharton’s duct.
Ans. {(Sialolithiasis
● The sialolith is a calcified mass with laminated
Classification of salivary gland diseases layers of inorganic material. It results from the
I. Developmental crystallization of salivary solutes.
1. Aplasia – Absence of the gland ● The sialolith is yellowish white in colour; single
2. Atresia – Absence of the duct or multiple; and may be round, ovoid, or elon-
3. Aberrancy – Ectopic gland gated having the size of 2 cm or more in diameter.
II. Enlargement of the gland ● The minerals are forms of calcium phosphate like
A. Inflammatory hydroxyapatite, octacalcium phosphate, etc. Cal-
1. Viral: Mumps cium and phosphorus ions are deposited on the
2. Bacterial organic nidus, which may be, desquamated epi-
3. Allergic thelial cell, bacteria, foreign particle or product of
B. Noninflammatory bacterial decomposition.
1. Autoimmune ● Sialolith frequently occurs in the Wharton’s duct
2. Diabetes mellitus due to the following reasons:}
3. Nutritional deficiency
4. HIV associated
III. Cysts [SE Q.3]
1. Extravasation cysts i. {The long, curved Wharton’s duct has increased
2. Retention cysts chance of entrapment of organic debris.
3. Ranula ii. The secretion of this gland is higher in calcium
IV. Tumours of salivary glands content and thick in consistency.
A. Benign tumours iii. The position of the gland increases the chances
1. Pleomorphic adenoma for the stagnation of the saliva.
2. Warthin tumour Signs and symptoms
B. Malignant tumours ● Patients complain of periodic painful swelling when
1. Mucoepidermoid carcinoma eating, interspersed with periods of remission.
2. Adenoid cystic carcinoma ● Spontaneous extrusion of small calculi from the
V. Necrotising sialometaplasia ducts.
VI. Salivary gland dysfunction ● Point tenderness in the region of the hilum or,
1. Xerostomia near Wharton’s duct of the submandibular gland.
2. Sialorrhoea ● Salivary secretion may be affected only slightly.
A gelatinous, cloudy mucopurulent material is

● ● The stone is removed using small forceps. In case
seen in basically clear and adequate saliva. This the stone is large, it can be crushed with the help
mucopurulent material is derived from the inflam- of the forceps.
matory ductal changes caused by calculus block- ● Following this, a cannula may be passed to aspi-
age and salivary stagnation. rate the pieces of stone, mucin, etc.
● If treatment not instituted early, pronounced exac- ● The patency of the duct anterior to the surgical
erbations are seen, characterized by an acute area should be ensured by passing a probe.
suppurative process with attendant systemic man- ● Sutures are placed at the level of the mucosa.
ifestations. Submandibular gland excision

● Pus may exude from the duct orifice. ● If stone in the submandibular gland is not acces-
● The mucosa around the duct is inflamed, particu- sible, then in such cases submandibular gland
larly in the floor of the mouth where swelling, excision is one.
redness and tenderness are present along the ● This procedure is performed under GA.
course of Wharton’s duct. Incision

● The glands are enlarged, tender and dense. ● An incision of 5 cm is made in the skin crease of
● Palpation of the gland and the duct causes pain the neck approximately 2–3 cm below inferior
and flow of pus. border of mandible.
Diagnosis ● Incision is done through the platysma.
Radiographs: AP view, lateral, lateral oblique or oc- ● Care is taken to protect the marginal mandibular
clusal view. branch of the facial nerve.

Sialography: The radiographs demonstrate the pres- ● The facial vein is located, ligated and cut.
ence of salivary calculi, which can be appropriately ● The cervical branch of the facial nerve is identi-
located by the sialography. fied and protected.

Management ● Beneath the deep cervical fascia, the submandibu-
A suitable procedure is selected depending upon the lar gland is found encapsulated.
number, size and site of the stone in the duct or the ● The gland and the surrounding structure are freed
gland; and age of the patient, etc. from the under surface of the mandible.
● The smaller sialoliths which are located periph- ● The facial artery is ligated and divided, as it ap-
erally near the ductal opening may be removed proaches the lower border of the mandible.
by manipulation called milking the gland. ● The inferior portion of the gland is dissected from
● Larger sialoliths are surgically removed. the digastric muscle.

● Sometimes the stones which are not impacted ● The facial artery will be encountered again in this
may be extracted through the intubation of the region inferiorly near its origin from the ECA. It
duct with fine soft plastic catheter and applica- is ligated again.
tion of the suction to the tube. ● The gland is retracted laterally to expose the my-
● Multiple stones or stones in the gland require lohyoid muscle.

the removal of the gland. ● The mylohyoid muscle is dissected free and re-
● Modern techniques like piezoelectric shock- tracted medially.

wave lithotripsy to fragment the salivary stones ● This helps in exposing the hypoglossal nerve infe-
can be used. riorly, lingual nerve superiorly at the point of

The fragments pass through the duct, as the sali- emergence of the submandibular duct.
vary flow is stimulated and enhanced by the use of ● Once these three structures are positively con-
sialogogues.} firmed, the duct is ligated and transected with the

Transoral sialolithotomy of Warton’s duct submandibular ganglion.
● It is a surgical procedure to remove submandibu- ● The specimen is removed.
lar duct stones. ● Drains are placed. Wound is sutured in layers and
● The exact site of the stone is located by X-rays dressing is done.

and palpation. Complications
● Incision is made in the mucosa parallel to the duct. i. Facial nerve injury
● Care should be taken not to injure the lingual ii. Haematoma formation
nerve and sublingual glands. iii. Sialocoele (salivary fistula)
● After incision, blunt dissection is carried out. iv. Frey syndrome
● The tissues are displaced to locate the duct. ● Also known as auriculotemporal syndrome
● Once the part of the duct lodging the stone is identi- ● Common long-term complication of parotid
fied, a longitudinal incision is made over the stone. gland

Results from inappropriate autonomic rein-

● high radiographic density, so that it produces a very
nervation of sweat glands of the skin from clear ductogram and excellent acinar opacification.
parotid parasympathetics Technique
Treatment It can be divided into three phases:
● Glycopyrrolate or scopolamine I. Preliminary film evaluation – To rule out any
● Dermal grafting, fat grafting, sub-SMAS dissec- obvious radiopaque pathosis
tion, etc. II. Injection or filling phase – Involves injection of
Q.2. Describe the sialography of parotid gland in adult. contrast material to outline the ductal system
III. Parenchymal phase (if water-soluble medium is
Ans. used) or evacuation phase (if fat-soluble medium
is used)
{SN Q.2} ● Evacuation and post-evacuation phases are
more helpful in the presence of inflammation

Sialography or an obstruction.
● Sialography is a specialized radiographic proce-
● Delayed or incomplete evacuation may be as-
dure performed for detection of disorders of the sociated with process that causes parenchymal
major salivary glands (usually parotid and sub- destruction such as autoimmune disorders,
mandibular glands). chronic infection and irradiation.
● It involves cannulation and filling with a radi-
● The amount of secretion and the functioning
opaque/contrast agent to make them visible on a capacity of the gland can be determined by
radiograph. observing the clearance of the contrast media
● The procedure indicates the changes in the inter-
during sialography.
nal architecture and thus reveals the location and Equipment
integrity of salivary glands. i. Polyethylene tubing with a special blunt metallic tip
with side-holes for parotid gland injection. Similar
tubing for injection into submandibular gland with
{SN Q.3} an end terminal hole
Indications ii. A 5–10 mL syringe
● Detection of calculi iii. Lacrimal dilator
● Recurrent swelling of salivary gland iv. Contrast medium
● Recurrent sialadenitis v. Lemon slices or artificial lemon extract in a plastic
● Pain of unknown cause container
● Dryness of mouth Procedure
● Detection of residual stones. i. Identification of the location of duct orifices: The
parotid duct is located at the base of the papilla in
the buccal mucosa opposite maxillary first and sec-
Contraindications ond molar teeth. The area of the mucosa in the vi-
i. Acute infection of salivary gland cinity of the orifice is dried with a small sponge.
ii. Patients sensitive to iodine containing compounds The application of gentle pressure over the area
iii. Calculus present at the entrance of the duct overlying the gland would lead to expression of
Two types of contrast media are available: saliva, in case the gland has some degree of func-
i. Water-soluble tion. The submandibular duct orifice is situated on
ii. Fat-soluble the summit of a papilla by the side of the lingual
Water-soluble media: These are principally iodinated frenulum.
benzene or pyridine derivatives. They have a low ii. Exploration of the duct with a lacrimal probe: In
viscosity and lower surface tension and are more view of the tortuous course of the parotid duct, pa-
miscible with salivary secretions. These characteris- tient’s cheek must be turned outward prior to the
tics permit filling of the finer ductal system under insertion of the probe into the duct. This eversion of
low pressure and facilitate prompt drainage. cheek reduces the chances of penetration of the duct
Fat-soluble media: There are two types present. They at the sharp angles in its course. In case of the sub-
are (i) iodized oil and (ii) water-insoluble organic io- mandibular duct, the probe should pass through the
dine compounds. Iodized oil compounds are ethiodized considerable length of the floor of the mouth to the
poppy (ethiodol) and iodized poppy seed oil (lipi- level of the posterior border of mylohyoid muscle,
odol). Ethiodol is a contrast medium of choice be- approximately 5 cm. In both the ducts, the probe
cause of its low viscosity and least irritability than the should slide easily back and forth and also rotate
other oil-based media. It contains 37% iodine and has freely without dragging.
Cannulation of parotid duct ● Acinic cell adenocarcinoma

● The orifice of the parotid duct is located on the buc- ● Malignant mixed tumours
cal mucosa opposite to the maxillary second molar. ● Polmorphous low-grade adenocarcinoma
● The duct passes laterally and posteriorly through the ● Monomorphic adenocarcinomas
buccinator. ● Adenocarinoma
● Cannulation is facilitated by pulling the cheek for-
(SE Q.9 and SN Q.7)
ward, thereby straightening the right-angle bend in
the parotid duct. {Pleomorphic adenoma
● Once the duct is cannulated, a syringe is used to in- ● It can affect both the major and minor salivary
ject the contrast material with gentle pressure. glands. It commonly affects the parotid gland. It is
● The parotid duct system can painlessly accommo- believed that the tumour arises from the myoepithe-
date 0.5–0.75 mL of contrast material. lial cell of the salivary gland.
● For the parotid, most common views taken are an- ● The different tissue types of both epithelial and con-
teroposterior, anteroposterior with jaw open, antero- nective tissue elements are seen in the tumour giving
posterior with cheek in blowout position, lateral or the name ‘mixed tumour’.
orthopantomogram (OPG). Clinical features
Technique ● Pleomorphic adenoma most commonly affects the
● The orifice of the submandibular duct is smaller and parotid gland, followed by minor salivary glands
it opens into a papilla called sublingual caruncle, of the palate and lip. It less frequently affects the
located on the floor of the mouth just lateral to the submandibular gland.
frenulum of the tongue. It may also open onto the ● Majority of the lesions are seen between fourth to
side of the papilla. sixth decades.

● Lemon juice may be required to stimulate the gland ● More commonly seen in females.
and help in identification of the orifice. The duct ● The tumour starts as a small painless nodule, ei-
opening appears as a tiny black spot when it opens to ther at the angle of the mandible or beneath the
deliver saliva. ear lobe.
● Submandibular duct angles posteriorly and down- ● The nodule slowly increases in size, which may
ward. Approximately 1–2 cm below its orifice, the characteristically show intermittent growth.
duct becomes more horizontal in direction. Accord- ● The tumour is well circumscribed, encapsulated,
ingly, the direction of the probe should also be firm in consistency and may show areas of cystic
changed. degeneration.
● The cannula should be advanced fully until the ori- ● The tumour is readily movable without fixity to
fice is obturated. The contrast material is then in- the deeper tissues or to the overlying skin. The
jected. The submandibular gland will hold 0.5 mL. tumour can grow to a very large size, but does not
● Once the contrast material is injected, radiographs ulcerate.
are taken. ● Tissue destruction, pain or facial paralysis is not
● Common views for the submandibular gland are lat- seen.
eral oblique, OPG and occlusal. ● The intraoral pleomorphic adenomas which affect
the minor salivary glands of the palate are noticed

Q.3. Classify tumours of salivary glands and discuss in early, because of the difficulties in mastication,
detail about pleomorphic adenoma. talking, etc. The palatal pleomorphic adenoma
may show fixity to the underlying bone, but does
Ans.
not invade the bone.
Tumours of salivary gland ● Pleomorphic adenoma should be differentiated
Benign from other benign tumours and hyperplastic

● Pleomorphic adenoma lymph nodes.
● Warthin tumour ● Though the painless, nodular, firm growth with no
● Canalicular adenoma ulceration of the overlying skin is suggestive of

● Basal adenoma this tumour, it can be confirmed by biopsy.
● Oncocytoma ● In case of minor salivary gland lesions, which are
● Ductal papillomas usually not more than 2 cm in diameter, it is better

Malignant to perform excisional biopsy.
● Mucoepidermoid carcinoma Differential diagnosis
● Adenoid cystic carcinoma i. Warthin tumour
ii. Lipoma been kept without food or fluids, and has received
iii. Hyperplastic lymph nodes atropine during the surgical procedure.
iv. Neurilemmoma of the facial nerve ● Medications that produce xerostomia as a side effect.
Treatment ● Noninfectious causes of salivary inflammation
● Pleomorphic adenomas are treated by surgical include Sjogren syndrome, sarcoidosis, radiation
excision. therapy and numerous allergens.
● The parotid tumours are removed with adequate Clinical features
margins, whereas the intraoral lesions can be ● Most common in the parotid gland and is bilateral
treated little more conservatively. in few cases.

● In case of submandibular tumours, excision of the ● The affected gland is swollen and painful, and the
gland with the tumour is performed.} overlying skin may be erythematous in colour.
● An associated low-grade fever may be present
Q.4. Describe the clinical features and treatment of sali-
along with trismus.
vary calculus of Warton’s duct.
● A purulent discharge is often observed from the
Ans. duct orifice when the gland is massaged.

● Recurrent or persistent ductal obstruction most
[Same as LE Q.1]
commonly caused by sialoliths can lead to a
Q.5. Enumerate salivary gland disorders, and discuss chronic sialadenitis.
the management of sialolith in Warton’s duct. ● Periodic swelling and pain occur within the af-
fected gland, usually developing at mealtime

Ans.
when salivary flow is stimulated.
[Same as LE Q.1] ● Sialography often demonstrates sialectasis (ductal
dilatation) proximal to the area of obstruction.

Q.6. What is sialography? Describe its technique. How
● Subacute necrotizing is a form of salivary inflam-
will you remove a sialolith from the right Wharton’s
mation that occurs most commonly in young
duct?
adults. The lesion usually involves the minor sali-
Ans. vary glands of palate, presenting as a painful
nodule that is covered by intact, erythematous
[Same as LE Q.2]
mucosa. Unlike necrotizing sialometaplasia, the
lesion does not ulcerate.
SHORT ESSAYS: ● In patients with acute sialadenitis, accumulation
Q.1. Sialadenitis. of neutrophils is observed with the ductal system

and acini. Chronic sialadenitis is characterized by
Ans.
scattered or patchy infiltration of the salivary pa-
Sialadenitis renchyma by lymphocytes and plasma cells.
Sialadenitis is the inflammation of the salivary glands that Treatment
can arise from various infectious and noninfectious causes. ● Initial treatment of acute sialadenitis includes ap-
Causes propriate antibiotic therapy and rehydration of the

● The most common viral infection is mumps, al- patient to stimulate salivary flow.
though a number of other viruses can also involve ● Surgical drainage may be needed if there is ab-
the salivary glands, including coxsackie A virus scess formation. Mortality rate because of the in-
and ECHO virus. fection and sepsis is less.
● Most bacterial infections arise as a result of ductal ● Surgical management of chronic sialadenitis de-
obstruction or decreased salivary flow caused by pends on the severity and duration of the condi-
Staphylococcus aureus, allowing retrograde tion. Early cases that develop secondary to ductal
spread of bacteria throughout the ductal system. blockage may respond to removal of the sialoliths
Blockage of the duct can be caused by sialolithia- or other obstruction.
sis, congenital strictures or compression by an ● If sialectasia is present, dilated ducts can lead to
adjacent tumour. Decreased flow can result from stasis of secretions and predispose the gland to
dehydration, debilitation or medications that in- further sialolith formation.
hibit secretions. ● If sufficient inflammatory destruction of the sali-
● Recent surgery after which an acute parotitis (sur- vary tissue has occurred, then surgical removal of
gical mumps) may arise because the patient has the affected gland may be necessary.
● Subacute necrotizing sialadenitis is a self-limiting the oral cavity through the mucous membrane
condition that usually resolves within 2 weeks and is retained with sutures.
even without treatment. ● This allows the salivary flow in the oral cavity
through an artificial outlet. After 3–4 weeks,
Q.2. Salivary fistula.
tube may be removed so that saliva passes
Ans. through the tissue passages which were cre-
ated by polythene tube. Suitable diet may be
Salivary fistula
prescribed which will not displace the tube.
● Salivary fistula can be defined as leakage of saliva or
pus through the opening. It occurs either in the duct Q.3. Sialolith.
or gland itself.
Ans.
● These fistulas commonly occur in parotid gland. The
cause for fistula is commonly due to: [Ref LE Q.1]

i. Traumatic injury
Q.4. Classify salivary gland tumours and how do you
ii. During surgery in the area of gland or duct
investigate them?
iii. Infections of gland or duct and subsequent break
down of abscess Ans.
iv. Can also occur at the site of incision
Tumours of salivary gland
Clinical features
Benign
i. Leaking of saliva and pus through the fistula
● Pleomorphic adenoma
ii. No signs of saliva passing through the natural
● Warthin tumour
orifice of the duct
● Canalicular adenoma
iii. Patient complains of dry mouth
● Basal adenoma
Treatment
● Oncocytoma
I. Nonsurgical
● Ductal papillomas
● Conservatively fistulas can be managed by
Malignant
controlling infections with antibiotics.
● Mucoepidermoid carcinoma
● Arresting the flow of saliva by administration
● Adenoid cystic carcinoma
of atropine in divided repeated doses allows
● Acinic cell adenocarcinoma
fistula to heal by itself.
● Malignant mixed tumours
● X-ray irradiation was also tried which can lead
● Polmorphous low-grade adenocarcinoma
to atrophy of the gland leading to spontaneous
● Monomorphic adenocarcinomas
healing of the fistula.
● Adenocarinoma
II. Surgical
● Includes excision of the orifice of the fistula Methods of investigating salivary gland tumours are as
and fistulous tract is completely dissected out. follows:
One or two sutures may be given in the subcu- Diagnostic imaging
taneous tissue. The skin incision is closed with Diagnostic imaging plays an important role in the evalu-
sutures. ation of various disorders of major salivary glands. The
● Fistulas were also treated with ligation of the modalities used for imaging include:
duct distal to the opening, thus arresting free 1. Conventional radiography
flow of saliva through the fistulous tract. 2. Sialography
III. Transplantation 3. Ultrasonography
● This can be done by locating the duct from the 4. Computerized tomography
fistulous area after surgical exploration. 5. Radionuclide imaging
● The duct is neatly freed by sharp and blunt 6. Magnetic resonance imaging (MRI)
instrument and all the strictures and fibrous
The abnormalities which can be evaluated by diagnostic
tissue are dissected out. Then, a small poly-
imaging can be divided into:
thene tube is inserted, which is biologically
i. Developmental
viable to the tissues and to the distal part of the
ii. Inflammatory
duct.
iii. Autoimmune
● This is tried with nylon atraumatic sutures and
iv. Metabolic
the wound is closed with interrupted sutures.
v. Traumatic
The end of the polythene tube is drawn into
vi. Neoplastic
Conventional radiography
{SN Q.8}
● It is useful in detecting the calcification within the
glands to know the presence of metastasis to the Ranula

salivary glands. But radiographs are not useful to ● Ranula is a term used for retention cysts of sali-
know the extent of rapid, destructive, invasive le- vary gland origin, occurring in the floor of the
sions, because the changes can appear in the ra- mouth. The name is due to its resemblance to a
diographs only after 30% of the mineral content is frog’s translucent underbelly.
removed. ● Formation of ranula occurs by two mechanisms,
● The posteroanterior, lateral, lateral oblique and namely, partial obstruction of the distal end of the
frontal views may be used for the radiography of duct with dilation resulting is an epithelial lined
the salivary glands. cyst (mucous retention cyst) or disruption of the
Sialography duct with formation of a connective tissue line
● The technique is employed for examination of space (mucous extravasation or pseudocyst).
both parenchymal (acinar) and ductal abnormali- ● The source of the cystic fluid is believed to be the
ties. sublingual glands in the most common form of

● It involves cannulation and filling with a radi- ranula.
opaque/contrast agent to make them visible on a
radiograph. Clinical features
● The procedure indicates the changes in the inter-
● Two varieties of cysts are seen (simple ranula and
nal architecture and thus reveals the location and plunging ranula) that have different clinical behaviours
integrity of salivary glands. and appearances and require different methods of treat-
Radionuclide salivary imaging ment. Simple ranulas are true retention cysts.
● Radionuclide scanning is a valuable diagnostic
● An unusual clinical variant, the plunging or cervical
tool for major salivary glands. It is useful for ranula is a cyst that occurs beyond the mucous mem-
evaluation of physiology as well as pathology. branes of the oral cavity into the floor of the mouth,
● It is particularly indicated in patients with sus-
through a hiatus of the mylohyoid muscle and into
pected obstructive sialadenitis, in whom, the con- the facial planes of the neck. This occurs when the
trast sialography is either contraindicated or can- spilled mucin dissects through the mylohyoid muscle
not be performed due to anatomical or technical and produces swelling within the neck.
reasons. ● Ranula appears as a blue, dome-shaped fluctuant
● Radionuclide scans differentiate between acute
swelling in the floor of the mouth. They are usually
obstructive and nonobstructive sialadenitis. It painless and unilateral with increasing size. They can
shows the presence of parenchymal masses cause deviation of the tongue and can cross the mid-
greater than 1 cm in diameter and identifies spe- line submucosally at times, and they may rupture
cific types of tumour. spontaneously with extrusion of a thick, translucent
CT and MRI fluid into the mouth. The wall then rapidly heals and
Computerized tomography (CT) and MRI studies the cyst subsequently reforms.
provide excellent soft tissue details. They show (i) Treatment
lesions and also (ii) involvement of the adjacent ● Ranulas do not regress spontaneously and require
structures. MRI is especially helpful in showing definitive surgical therapy. Marsupialization is the
early extension along various neurovascular path- treatment of choice. If recurrence is seen, exclusion in
ways. continuity with the sublingual gland of origin is done.
Ultrasound evaluation ● Marsupialization involves excision of the superior
The submandibular gland and larger portion of pa- wall of the lesion and suturing of the inner wall to the
rotid gland, because of their superficial location, can mucosa of the floor of the mouth.
be readily examined with high resolution ultrasound.
Ultrasound: (i) differentiates between intraglandular Q.6. Mucocoele.
and extraglandular masses and (ii) demonstrates the Ans.
presence of solid, cystic and complex masses and
sialoliths. {SN Q.9}
Mucocoele (mucous extravasation phenomenon or
Q.5. Ranula. mucous escape reaction)
● Mucocoele results from rupture of a salivary
Ans. gland duct and subsequent spillage of mucin into
● Symptoms of facial pain and swelling character-

the surrounding soft tissues. This spillage is due
ize the ACC of maxillary antrum
to local trauma in many cases. Mucocoeles are not
● Radiograph is necessary for assessing the extent
true cysts, because they lack an epithelial lining.
of osseous destruction
● In Minor salivary glands (SG), palate is most
common followed by tongue, cheek, upper lip,

Clinical features
floor of mouth, oropharynx and lower lip
● Mucocoele typically appears as dome-shaped muco-
● In the tongue, it is the third most common tumour
sal swelling ranging from one to several centimetres
following squamous cell carcinoma (SCC)
in size.
Investigations
● They are most common in children and young adults.
1. Fine Needle Aspiration Cytology (FNAC)
● The spilled mucin below the mucosal surface often
● Aspiration biopsies consist of round or ovoid
imparts a bluish translucent hue to the swelling. How-
basophilic cells arranged in branching structures
ever, deeper mucocoeles may be normal in colour.
● Amorphous, hyaline globoid structures with
● The lesion characteristically is fluctuant, but some
tumour cells are characteristic features of ACC
long-standing mucocoeles feel firmer to palpation.
2. Immunohistochemistry
● Lower lip is the most common site for the muco-
● It reveals the presence of two cell population:
coeles. Mucocoeles usually are found lateral to the
i. Ductal cells and
midline. Less common sites include the buccal mu-
ii. Myoepithelial cells
cosa and anterior ventral tongue, and are known as
ranula when occurring in the floor of mouth.
● Polmorphous low-grade adenocarcinoma
Treatment
● Salivary duct carcinoma
● Some mucocoeles are short-lived lesions that rupture
● Pleomorphic adenoma
and heal by themselves.
● Many lesions, however, are chronic in nature and lo-
● Surgical excision is the treatment of choice.
cal surgical excisions are necessary.
● As it is very much prone to local recurrence, even-
● To minimize the risk of recurrence when the area is
tual distant metastasis adjunct radiotherapy will
excised, adjacent minor salivary glands should be
improve patient survival.
removed as it may be feeding into the lesion.
● The excised tissue should be submitted for micro- Q.8. Mumps.
scopic examination to confirm the diagnosis and rule
Ans.
out the possibility of a salivary gland tumour.
● The prognosis is excellent, although occasional mu-
cocoeles will recur, prompting re-excision, espe- {SN Q.1}

cially if the feeding glands are not removed.
Mumps
Q.7. Adenocarcinoma of minor salivary gland in palate. ● Mumps is the most common nonsuppurative,
Ans. acute sialadenitis of viral origin. It is a conta-

gious, generalized disease that presents as a pain-
Adenoid cystic carcinoma (ACC) ful enlargement of the salivary glands.
● Adenoid cystic carcinoma is a clinically and patho-
● The virus of mumps causes an acute febrile illness
logically well-defined entity and occurs primarily in with prodromal period of 2–3 weeks.
the major salivary glands and relatively frequently in Clinical features
the oral accessory salivary glands, particularly the ● Mumps primarily infects young adults and classi-
palate. cally 6–8 years of age.
Clinical features ● Mumps virus has an incubation period of 2–3
● Occur in older individuals. Show equal sex predi-
weeks and is transmitted by contact or in droplets
lection of saliva.
● Slow-growing tumour
● The onset is sudden fever, headache and painful
● Pain and tenderness occur during tumour growth
swelling of the parotids.
● Fixation to skin and surrounding structures de-
● Usually one gland is infected first and then the
velop in later stages other. In some cases there is bilateral involvement.
● Cause paralysis of facial nerve
● Swelling occurs rapidly, reaches a maximum size
● Presents as a swelling or mass in minor salivary
within 1–3 days.
glands
Clinical features
● Trismus may be present, with some difficulty in
● Predominantly women over 40 years of age are af-
chewing.
fected. However, it may occur in men and young adults.
● Stensen’s duct orifice is swollen and erythema-
● Parotid gland is more frequently involved.
tous, but there is no purulent material in the saliva.
● Typical features of the disease are the dryness of
The symptoms subside in 3–7 days.
mouth and eyes, which often results in painful and
burning sensation.
Investigations ● Apart from this, various secretory glands of larynx,
Diagnosis is usually made on a clinical basis during pharynx and vagina are involved with this dryness.
epidemics. Serum antibodies to the mumps S and V Treatment
antigens with a titre of greater than 1:192, indicates in- ● Treatment of the patient with Sjogren syndrome is
fection. mostly supportive.

Complications ● The dry eyes are best managed by use of artificial
● Parotid gland sialectasia with recurrent chronic and tears. In addition, attempts can be made to conserve
acute suppuration. the tear film through the use of sealed glasses to pre-
● Complications of mumps result from generalized vent evaporation. Sealing the lacrimal punctum pack
viraemia and include pancreatitis, architis, mumps in the inner margin of the eyelids also can be helpful
and meningitis (meningoencephalits). blocking of the normal drainage of any lacrimal se-
● Other sequelae include sensory neural hearing loss cretions into the nose.
(frequently unilateral), diabetes secondary to pancre- ● Artificial saliva is available for the treatment xerosto-
atic fibrosis and sterility secondary to gonadal in- mia. Sugarless candy or gum can help to keep mouth
volvement. The condition resolves spontaneously in moist.
5–10 days. Symptomatic relief of pain and fever is ● Oral hygiene products that contain lactoperoxidase,
necessary and prevention of dehydration is essential. lysozyme and lactoferrin are used. Sialagogue such
as pilocarpine and cevimeline can be useful to stimu-
Q.9. Pleomorphic adenoma. late salivary flow if enough functional salivary tissue
Ans. still remains.
● Because of the increased risk of dental caries, daily
[Ref LE Q.3] fluoride applications may be indicated in dentulous
Q.10. Sjogren syndrome. patients. Antifungal therapy often is needed to treat
secondary candidiasis.
Ans.
Q.11. Surgical anatomy of submandibular gland.
{SN Q.5}
Ans.
Sjogren syndrome
● Sjogren syndrome is a chronic, systemic autoim-
Submandibular gland
● Submandibular gland is the second largest of the
mune disorder that principally involves the sali-
vary and lacrimal glands, resulting in xerostomia salivary gland weighing 10–15 g. It contains both
and xerophthalmia. serous and mucous secreting glandular elements.
● This gland lies below and in front of the angle of the
● Two forms of the disease are recognized:
i. Primary Sjogren syndrome (Sicca syndrome mandible. It is situated in digastric triangle.

● It is J-shaped. The largest portion of the gland lies
alone; no other autoimmune disorder is present.)
ii. Secondary Sjogren syndrome (the patient below the mylohyoid muscle. It extends as far ante-
manifests Sicca syndrome in addition to an- riorly as the anterior belly of digastric and posterior
other associated autoimmune disease.) to the stylomandibular ligament which keeps it sepa-
rate from the parotid gland.
● At the posterior border of the mylohyoid muscle, a
● The cause of Sjogren syndrome is unknown. Although process of the gland curves upwards around the
it is not a hereditary disease, there is evidence of a ge- muscle and extends medially towards the genioglos-
netic influence. sus muscle to lie in lateral sublingual space.
● It has also been suggested that viruses, such as Epstein– ● It is divided into superficial and deep parts by mylo-
Barr virus (EBV) or human T-cell lymphotrophic virus, hyoid.
may play a pathogenetic role in Sjogren syndrome, but Superior part
evidence for this is speculative. ● Inferiorly covered by skin and platysma
● Laterally covered by submandibular fossa and Q.15. Sialolithiasis and management.

medial pterygoid muscle
Ans.
Medial surface
● Anterior part – Mylohyoid muscle, artery and vein [Same as SE Q.3]
● Medial – Hyoglossus, styloglossus and lingual nerve
Q.16. Mixed tumour of parotid gland.
● Posterior – Styloglossus, stylohyoid ligament and
wall of pharynx Ans.

Deep part [Same as SE Q.9]
● Small
● Lies deep to mylohyoid and superficial to hyo-
glossus SHORT NOTES:

● Posteriorly continuous with superficial part
Q.1. Mumps and its clinical features.
● Anteriorly extends up to sublingual gland
Submandibular duct Ans.

Submandibular duct emerges at anterior end of deep [Ref SE Q.8]
part. It is 5 cm long and runs forward between the my-
lohyoid and hyoglossus muscle and then on to the ge- Q.2. Sialogram.
nioglossus muscle opening on floor of mouth on the Ans.
summit of lingual papilla at the side of frenulum of
tongue. [Ref LE Q.2]
Blood supply Q.3. Indications of sialography.
The arterial supply to the gland is from the lingual
and facial arteries. The venous drainage is the ante- Ans.
rior facial vein. [Ref LE Q.2]
Nerve supply
The parasympathetic nerve supply is via the chorda Q.4. Sialolithiasis.
tympani nerve, which carries preganglionic fibres to Ans.
the submandibular ganglia. Post-ganglionic fibres
originate in this ganglion and pass to the gland. The [Ref LE Q.1]
sympathetic nerve fibres are carried along the lingual
Q.5. Sjogren syndrome.
artery to the gland.
Lymphatic drainage Ans.
The lymphatic drainage is into the submaxillary
[Ref SE Q.10]
nodes and then to the jugular chain.
Applied anatomy
Q.6. What is Wharton’s duct? What is Bartholin’s duct?
The tortuous course of the submandibular duct leads
to stagnation of saliva and thus helps in the formation Ans.
of salivary stone.
Submandibular duct (Wharton’s duct)
Submandibular duct emerges at anterior end of deep
Q.12. Investigations in salivary calculus.
part. It is 5 cm long and runs forward between the my-
Ans. lohyoid and hyoglossus muscle and then on to the ge-
nioglossus muscle opening on floor of mouth on the
[Same as SE Q.3]
summit of lingual papilla at the side of frenulum of
Q.13. Submandibular salivary calculi and its manage- tongue.
ment. Sublingual gland duct (Bartholin’s duct)
There are around 20 small sublingual ducts known as
Ans.
ducts of Ravinus opening into floor of mouth. Main duct
[Same as SE Q.3] known as Bartholin’s duct opens into submandibular
duct.
Q.14. Surgical removal of salivary stone from subman-
dibular duct. Q.7. Pleomorphic adenoma.
Ans. Ans.
Q.8. Ranula. Q.10. Sialolith.

Ans. Ans.
[Ref SE Q.5] [Same as SN Q.4]
Q.9. Mucocoele.
Ans.
[Ref SE Q.6]
Topic 13
Diseases of Maxillary Sinus
LONG ESSAYS:
1 . Discuss the surgical anatomy, clinical features and management of root in the maxillary sinus.
2. Write about the embryology and surgical anatomy of maxillary sinus and describe the causes, signs and symp-
toms of oroantral fistula. Give the treatment for closure of chronic oroantral fistula.
3. Clinical features and management of acute maxillary sinusitis. Add a note on nasal antrostomy.
4. What are the causes of fracture of tooth during extraction? How do you manage a case of root pushed in maxil-
lary antrum? [Same as LE Q.1]
5. What are the causes for pushing a tooth or a root into a sinus? How do you diagnose to treat such cases?
[Same as LE Q.1]
6. Removal of fractured root from the maxillary sinus. [Same as LE Q.1]
SHORT ESSAYS:
1 . Caldwell–Luc procedure. [Ref LE Q.1]
2. Clinical features and management of acute maxillary sinusitis.
3. Chronic maxillary sinusitis.
4. Anatomy of maxillary sinus. [Ref LE Q.2]
SHORT NOTES:
1. Definition of oroantral fistula. [Ref LE Q.2]
2. Whitehead’s varnish.
3. Define Caldwell–Luc operation. [Ref LE Q.1]
4. Cause of root displacement into maxillary sinus. [Ref LE Q.1]
5. Medical management of acute sinusitis. [Ref LE Q.1]
6. Mucormycosis involving maxillary antrum.
7. Palatal flap closure for oroantral fistula. [Ref LE Q.2]
8. Mention in brief about causes of failure of closure of oroantral fistula.
9. Mention any four clinical features of acute maxillary sinusitis. [Ref LE Q.3]
10. Transillumination test.
11. Describe in brief the technique of intranasal antrostomy. [Ref LE Q.3]
12. Von Rehrmann’s flap.
13. Oroantral fistula. [Same as SN Q.1]
14. Write four indications of Caldwell–Luc operation. [Same as SN Q.3]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Discuss the surgical anatomy, clinical features and
A. Recently created communication
management of root in the maxillary sinus.
● Attempted extraction of maxillary molar root,
Ans. which disappears as soon as force is applied

with an elevator. It also denotes its inadvertent
Anatomy of the maxillary antrum
displacement into maxillary sinus and the pres-
● Maxillary antrum or sinus is also called the Antrum
ence of coexistent communication.
of Highmore as it was described in detail by an Eng-
● Attempted extraction of a partially erupted upper
lish anatomist Nathaniel Highmore.
third molar. The root(s) of such a tooth are adja-
● It is the largest of the paranasal sinuses.
cent to maxillary sinus, and the application of
Structure of maxillary antrum
extraction force results in its displacement into
● The antrum is roughly pyramidal in shape.
maxillary sinus. This is more likely to occur if
● Base of the pyramid is formed by the lateral nasal wall.
the roots of the partially erupted third molar are
● Apex is pointing laterally at the zygomatic process.
conical.
● Roof of the antrum: The floor of the orbit forms the
Confirmation of the presence of oroantral com-
roof of the antrum.
munication/fistula
● Floor of the sinus: Alveolar process of the maxilla
● If the fistula is large, it can be assessed from
forms the floor of the sinus.
inspection; in case, if its patency is not obvi-
● It is closely related to the root apices of the maxillary
ous, the nose blowing test is useful.
premolars and molars. Some of the roots may even
● Compression of anterior nares followed by
penetrate into the antrum.
gentle blowing of nose (with mouth open)
● Anterior wall: Formed by the facial surface of the maxilla.
causes a rise in intranasal pressure exhibited by
● Posterior wall: Sphenomaxillary wall
the whistling sound, as air passes down the
● Medial wall: Lateral wall of the nasal cavity.
open passage.
● Escape of air bubbles, blood, etc. may appear
{SN Q.4} at the oral orifice.

● A wisp of cotton wool held just below the al-
Causes of tooth displacement into maxillary sinus veolar opening will usually be deflected by the
● Lack of bone that can be because of pneumatiza-
air stream.
tion or erosion of bone due to apical pathology Management
● Indiscrimination and aggressive instrumentation
A. Treatment of early cases
● Maxillary molars – Solitary and isolated
In cases where oroantral communication is recent
● Shape of root
and formation of fistula is not established, then the
Diagnosis treatment is as follows:
● Head-shaking test
1. Ideal treatment
● Radiographs – IOPA, oblique occlusal view, PNS
i. Immediate surgical repair to achieve pri-
view and lateral sinus view mary closure
Treatment ii. Simultaneous antibiotic prophylaxis to
● Nozzle connected to powerful suction kept at
prevent sinus infection
fistulous opening – Root can be removed ● The immediate primary closure is done
● Long roller gauze packed into antrum through
by a simple reduction of the buccal and
tooth socket and withdrawn in a jerky motion the palatal socket walls, to allow coap-
● Roots are likely to come out along with gauze,
tation of buccal and palatal soft tissue
if lying in antrum flaps to close over the defect.
● A protective acrylic denture or splint can
Oroantral communication can be divided into: be used to provide a barrier to the inadver-
A. Recently created communication tent entry of food particles.
B. Treatment of delayed cases Supportive measures
In a situation where it is not complicated by dis-

●
{SN Q.5}
placement of a tooth or a root into the antrum, it
i. Antibiotics can be closed by buccal flap sutured under local
Penicillin and its derivatives: anaesthesia.
● It can be started with i.v. route, and later Treatment of cases seen more than 24 h of accident
switched over to oral route. Penicillin V 250– ● When a period of 24 h has elapsed, the tissue mar-
500 mg every 6 hourly is adequate. gins of fistula often get infected.

● In case the organisms are resistant to penicil- ● It is preferred to defer the surgical closure, until
lin, a broad-spectrum antibiotic is prescribed. gingival edges sound healing, i.e. approximately
ii. Nasal decongestants 3 weeks.
i. Ephedrine nasal drops (0.5%) are instilled intra- ● As a prophylactic measure, antibiotics, analgesics
nasally every 2–3 h. and decongestants should be prescribed.

ii. Steam inhalations: When the nose is clear subse- Treatment of oroantral fistula of long duration (more than
quent to the use of decongestant drops or sprays, 1 month)
steam inhalations are helpful in encouraging ● In these cases, the fistulous tract is usually epithe-
drainage. It also helps in thinning down the mu- lialized. Surgical closure is also required.
cous, pus and has a soothing effect.
iii. Benzoin and menthol inhalations: A teaspoonful Management of tooth or fractured root pushed in to the
is added to a pint of hot (not boiling) water and maxillary sinus
the vapours are inhaled for 10 min twice a day,
after covering the head. (SE Q.1 and SN Q.3)
iii. Analgesics
Nonsteroidal anti-inflammatory agents: {Caldwell–Luc operation
i. Aspirin 500 mg 1–3 tablets four times daily Caldwell–Luc operation is defined as a method of
ii. Paracetamol 500 mg three times daily gaining entry into maxillary sinus via canine fossa
iii. Ibuprofen 400 mg three times daily with nasal antrostomy.
Indications
● Open procedure for removal of root fragment or
foreign body or an antrolith (stone) from the max-

Provisional or temporary measures which effect satis- illary sinus.
● To treat chronic maxillary sinusitis with hyperpla-
factory repair
i. Whitehead’s varnish pack sial lining and polypoid degeneration of the
ii. Denture plate mucosa.
● Removal of cysts or benign growths from the
i. A strip gauze or ribbon gauze dipped in White- maxillary sinus.

● Management of haematoma in the maxillary sinus
head’s varnish is used to pack over the socket
and secured with sutures. Superficially, the pack and to control post-traumatic haemorrhage in the
is further supported by a horizontal mattress sinus.
● Zygomatic maxillary complex fractures involving
suture.
ii. Denture plate is indicated when surgical repair floor of the orbit and anterior wall of the maxillary
of fistula is to be deferred. The purpose of the sinus.
● Removal of impacted canine or impacted third
appliance is to provide a barrier to prevent entry
of food particles into the antrum. molar.
● Along with closure of chronic oroantral fislula
The orifice in the socket is covered with a piece of
gauze or tulle grass; a well-fitting denture plate is associated with chronic maxillary sinusitis.}
constructed to entirely cover the opening. [SE Q.1]
B. Treatment of delayed cases
Treatment of oroantral fistula seen within 24 h of {Surgical procedure
accident ● The surgical procedure can be performed under LA
● If the case of oroantral communication is seen with sedation or under GA, which is the preferred
within 24 h of its occurrence, and if the edges of method.
the wounds are cleaned. They should be closed ● A semilunar incision is made in the buccal vestibule
immediately. Usual postoperative treatment of from canine to second molar area just above the gin-
antibiotics and nasal inhalations are prescribed. gival attachment.
A mucoperiosteal flap is elevated with the help of

● ● The other end of the ribbon gauze is then used to
periosteal elevator till the infraorbital ridge. Care is systematically pack the maxillary sinus cavity in
taken to prevent injury to infraorbital nerve. multiple folds, after achieving proper haemostasis
● An opening or window is created in the anterior wall (after Caldwell–Luc operation).
of the maxillary sinus with the help of chisels, ● An antrostomy can be performed by removing ap-
gouges or dental drills. proximately 1 cm of the medial wall of the antrum,

● The opening is enlarged carefully in all directions which bulges into the sinus below the level of the
with Rongeur forceps, to permit the inspection of the inferior turbinate.
sinus cavity. ● This antrostomy should be extended to the level of
● The size obtained should be about the size of the in- the floor of the nose.
dex finger. This is to facilitate the palpation of the The nasal mucosa is then incised from the antral
sinus lining with the introduction of index finger into surface on three sides and the nasal mucosal flap thus
the sinus cavity. created is reflected into the antrum.
● The opening or window created should be well away
from the apices of the roots of the maxillary teeth. Q.2. Write about the embryology and surgical anatomy
● Pus should be sucked away from the sinus and a of maxillary sinus and describe the causes, signs and
thorough irrigation of the maxillary sinus is carried symptoms of oroantral fistula. Give the treatment for
out with copious saline wash. closure of chronic oroantral fistula.
● Inspection of the maxillary sinus is done and re-
Ans.
moval of root, tooth gauze, cotton or stone or bone
wax, etc., can be done at this stage. Embryology/development of maxillary sinus
● The thickened, infected lining of the maxillary sinus ● It is the first among the paranasal sinuses to develop.
can be elevated with Howarth’s periosteal elevator and It starts as a shallow groove on the medial surface of
removed and sent for histopathological examination. the maxilla during the 4th month of intrauterine life.
● If there is profuse bleeding, then the sinus can be ● At birth, it is a small cavity which is usually fluid-filled.
packed with ribbon gauze soaked in adrenaline ● Growth is usually biphasic with growth occurring
1:1000 for 1 or 2 min. during the age of 0–3 years and again between 7 and
● The antral cavity again is irrigated and can be packed 8 years.
with iodoform ribbon gauze. The end of the same can ● It attains its maximum size at adulthood at around 18
be removed through the nasal antrostomy or through years of age.

the small incision in the buccal vestibule. ● During the later phase, pneumatization proceeds more
● The incision is closed with 3-0 silk. inferiorly as the permanent teeth develop completely.
Postoperative management
[SE Q.4]
● Antibiotics, analgesics and anti-inflammatory drugs
for 5 days. {Anatomy of the maxillary antrum

● Pack removal on the 5th day. Tincture of benzoin ● Maxillary antrum or sinus is also called sinus maxil-
inhalation three times a day, followed by nasal drops. laris.
Patient is instructed not to blow the nose, have soft ● It is called the antrum of Highmore as it was de-
diet and no vigorous gargling.} scribed in detail by an English anatomist Nathaniel

Intranasal antrostomy Highmore.
● It is performed to facilitate the drainage at the con- ● It is the largest of the paranasal sinuses.
clusion of an operation performed: (i) to close an Structure of maxillary antrum

oroantral fistula or (ii) to remove a tooth or a root ● The antrum is roughly pyramidal in shape
from sinus. ● Base of the pyramidal is formed by the lateral nasal wall
Surgical procedure for intranasal antrostomy ● Apex is pointing laterally at the zygomatic process.
● A small-sized osteotome or gouge is pushed through Capacity of the maxillary antrum is around 15 mL
the inferior meatus in the nasal cavity into the maxil- ● Dimensions are
lary sinus. ● Height 3.5 cm and width 2.5 cm
● Then a big curved artery forceps is passed through ● Anteroposterior depth is 3.2 cm on an average
this opening and an iodoform impregnated ribbon Roof of the antrum

gauze pack’s end is grasped into its beak and pulled ● The floor of the orbit forms the roof of the antrum.
out into the nostril. ● It is the thin plate of the orbital process of the maxilla.
● Here a single knot, which is put in the ribbon gauze, ● It lodges the infraorbital canal and groove, which
will help to keep it secured in the nostril. lodge the infraorbital nerve.
Floor of the sinus Aetiology

● Alveolar process of the maxilla forms the floor of the Oroantral fistula can result from several causes:
sinus. ● Extraction of teeth
● Its level is lower than the level of the floor of the nose. ● Destruction of the portion of the floor of the sinus
● It is closely related to the root apices of the maxillary by periapical lesions

premolars and molars (some of the roots may even ● Perforation of the floor of the sinus and sinus
penetrate into the antrum). membrane with injudicious use of instruments

Anterior wall ● Forcing a tooth or a root into the sinus during
● Formed by the facial surface of the maxilla. attempted removal

● The canine fossa is an important structure on this wall. ● Extensive trauma to face
● The infraorbital foramen located in the mid-superior ● Surgery of maxillary sinus: Removal of large cys-
portion is present on this wall and the infraorbital tic lesions encroaching on the sinus cavity
nerve exits from the foramen. ● Chronic infection of maxillary sinus, such as
● The thinnest portion of the anterior wall is just above osteomyelitis

the canine tooth called the canine fossa. ● Teratomatous destruction of maxilla, such as
Posterior wall gumma involving palate

● Sphenomaxillary wall ● Infected maxillary implant dentures, and malig-
● A thin plate of bone separates the antral cavity from nant diseases such as malignant granuloma
the infratemporal fossa A. Fresh oroantral communication
Medial wall Symptoms
● Lateral wall of the nasal cavity. Remember five Es.
● The opening of the maxillary antrum or the ostium i. Escape of fluids from mouth to nose on extrac-
lies in the middle meatus at the lower part of the hia- tion. This happens when the patient gargles the
tus semilunaris. mouth following extraction.
● The opening of the sinus is closer to the roof and is ii. Epistaxis (unilateral): It is due to blood in the
at a higher level than the floor. Therefore the location sinus escaping through ostium into the nostril. It
of this opening requires that there be a good drainage may or may not be associated with frothing at the
with the individual in upright position. nostril on the affected side.
Antral lining iii. Escape of air from mouth into nose, on sucking,
● The sinus is lined by respiratory mucosa, which is inhaling or drawing on a cigarette or puffing the
formed by ciliated columnar epithelium. The ciliary cheeks (inability to blow cheeks and passage of
movements help in removal of mucous secretions air into mouth on sucking).
towards the ostium. iv. Enhanced column of air causes alteration in vocal
Arterial supply resonance and subsequently change in the voice.
● Facial artery, infraorbital artery and greater palatine v. Excruciating pain in and around the region of the
artery affected sinus, as the local anaesthesia begins to
Nerve supply wear off.
● Infraorbital nerve; anterior, middle and posterior In late stage established oroantral fistula
superior alveolar nerves Symptoms
Venous drainage Remember five Ps.
● Facial vein which then drains into pterygoid venous i. Pain previously a dominant feature is now negli-
plexus gible, as the fistula is established. It allows free
Lymphatic drainage escape of fluids.
● Submandibular lymph nodes and then to deep cervi- ii. Persistent, purulent or mucopurulent foul unilat-
cal lymph nodes.} eral nasal discharge from the affected nostril,
especially when head is lowered down. Unilat-
{SN Q.1} eral foul or foetid taste and smell.
iii. Postnasal drip: The tricking of the nasal dis-
Oroantral fistula charge from the posterior nares down the
● An oroantral perforation is an unnatural communi-
pharynx. The continuous swallowing of the
cation between the oral cavity and maxillary sinus. foul mucopurulent discharge may lead to un-
● An oroantral fistula is an epithelialzed, pathologi-
pleasant taste. This is accompanied by noctur-
cal and unnatural communication between these nal cough, hoarseness, earache or catarrhal
two cavities. deafness.
iv. Possible sequelae of general systemic toxaemic ● In case if antral pathology is present, then
condition – Fever, malaise, morning anorexia, Caldwell–Luc procedure should be carried out
frontal and parietal headaches and in extreme before the final closure of fistula.
cases anosmia and cacosmia. ● Arrest of haemorrhage:
v. Popping out of an antral polyp: The persistent ● Complete arrest of haemorrhage to avoid for-
infection in the antrum may lead to establish- mation of haematoma.

ment of chronic long-standing or antral fistula, ● Closure of wound:
which may be occluded by an antra polyp. This ● The mucoperiosteal flap is sutured into posi-
can be seen as a bluish-red lump extruding tion across fistula with interrupted sutures.
through the fistula.
Treatment {SN Q.7}
i. Buccal flap/Von Rehrmann’s flap ii. Palatal flaps
ii. Palatal flap/Ashley flap a. Palatal flap (Ashley’s flap)
iii. Combination technique ● Palatal flap is also known as Ashley’s flap.
● Palate gets blood supply from greater pala-

i. Buccal flap/Von Rehrmann’s flap
● Injection of LA in the mucobuccal fold:
tine arteries, which emerge from greater
● It reduces local capillary bleeding by vasocon-
palatine foramen.
● Local anaesthesia is administered. The fis-
striction at the time of operation and reduces
the risk of formation of postoperative haema- tulous tract is excised. The outline of the
toma. palatal flap should be marked.
● An incision is made along the mid-palatal
● Excision of fistulous tract:
● An incision is made around the fistulous tract

line from just anterior to the junction of
3–4 mm marginal to the orifice. As the soft tis- hard and soft palate and curved laterally
sue aperture of the communication is almost towards the affected side.
● It then passes back about 4 mm palatal to
always smaller than the diameter of bony de-
fect. The entire epithelialized tract along with the crest of the edentulous ridge or gingival
associated antral polyps is dissected out and margin of the fistula when excised.
● The palatal flap should be elevated carefully
excised gum margins are freshened with blade
no. 11. preserving the greater palatine artery.
● Buccal vestibular height is unaffected.
● Incision making:
● The palatal flap is rotated across fistula, so
● Two divergent incisions are taken with blade
no. 15, from each side of orifice into buccal that the suture line rests on the sound bone
sulcus for a distance of 2.5 cm. These incisions on the buccal side of the orifices.
are made down till the bone. While extending
the incisions towards cheek, care must be taken b. Palatal island flap
to avoid injury to papillae and duct of parotid ● This procedure dissects out an island of palatal
salivary gland. Mucoperiosteal flap is reflected mucosa, but it retains its connection to the
carefully. Inspection of bony margins of the greater palatine artery.
alveolar ridge is done. Reduction and smooth- ● Variations in technique are that by dissecting
ening of the same is carried out. the greater palatine neurovascular bundle back
● Advancement of buccal flap: to the palatal foramen, some extension can be
● In situations, where the buccal mucoperiosteal provided and the flap can be transferred as a
flap falls short of covering the fistula, the flap well-nourished, full thickness flap to a palatal
can be advanced. A horizontal incision is made or a buccal site.
in the periosteum as high as possible. This will iii. Combination flap
allow advancement of buccal flap. ● Both buccal and palatal flaps are used for closure
● Inspection of maxillary sinus: Maxillary sinus of fistulous tract.
should be carefully inspected for evidence of ● Buccal flap is elevated and reversed, which is
infection, either through fistula or by illumina- sutured with palatal margins.
tion or with a fiberoptic light. Any polypoidal ● Palatal flap is rotated and placed in usual manner.
masses or other diseased tissues should be re- ● It is sutured using 3-0 chromic catgut.
moved. Antrum is gently irrigated with warm ● In this raw surface, both the flaps are used against
normal saline. each other which ensure double layered closure.
● An acrylic splint is given to afford protection dur- ● In case the organisms are resistant to penicil-
ing mastication. lin, a broad-spectrum antibiotic is prescribed.
The closure of oroantral fistula should be followed ii. Nasal decongestants
by Caldwell–Luc operation. ● Ephedrine nasal drops (0.5%) are instilled in-
tranasally every 2–3 h.

Q.3. Clinical features and management of acute maxil-
● Steam inhalations: When the nose is clear
lary sinusitis. Add a note on nasal antrostomy.
subsequent to the use of decongestant drops
Ans. or sprays, steam inhalations are helpful in
encouraging drainage. It also helps in thin-
Maxillary sinusitis
ning down the mucous, pus and has a sooth-
Maxillary sinusitis is the inflammation of maxillary sinus
ing effect.
due to various causes.
● Benzoin and Menthol inhalations: A teaspoon-
ful is added to a pint of hot (not boiling) water

{SN Q.9} and the vapours are inhaled for 10 min twice a
day, after covering the head.
Signs of acute sinusitis iii. Analgesics
● Tenderness over the maxilla, especially in the in-
● Nonsteroidal anti-inflammatory agents:
fraorbital region. i. Aspirin 500 mg 1–3 tablets four times daily
● Mild oedema of cheek in infraorbital soft tissues.
ii. Paracetamol 500 mg three times daily
● Rarely, patient gets earache as a referred pain from
iii. Ibuprofen 400 mg three times daily
antrum. This is attributed to acute otitis media. Provisional or temporary measures which effect satis-
● Percussion of maxillary premolars and molars
factory repair
related to affected sinus will lead to pain. Exami- i. Whitehead’s varnish pack
nation of nose with a speculum shows nasal con- ● A strip or ribbon gauze is used to pack over
gestion (red, shiny and swollen mucous mem- the socket and secured with sutures. Superfi-
brane around ostium). cially, the pack is further supported by a hori-
● Presence of pus or mucopurulent discharge in
zontal mattress suture.
middle meatus. This comes from sinus, through ii. Denture plate
ostium and from over inferior conchae onto floor ● Denture plate is indicated when surgical re-
of nose. pair of fistula is to be deferred. The purpose
● Oropharynx: Mucopurulent discharge trickling
of the appliance is to provide a barrier to pre-
down posterior wall of pharynx. vent entry of food particles into the antrum.
The orifice in the socket is covered with a
Treatment of early cases piece of gauze or tulle grass. A well-fitting
In cases where oroantral communication is recent and for- denture plate is constructed to entirely cover
mation of fistula is not established, then the treatment is as the opening.
follows:
Ideal treatment
i. Immediate surgery repair to achieve primary closure {SN Q.11}
ii. Simultaneous antibiotic prophylaxis to prevent
Intranasal antrostomy
sinus infection
● It is performed to facilitate the drainage at the
● Immediate primary closure is done by a simple
conclusion of an operation performed: (i) to close
reduction of the buccal and the palatal socket
an oroantral fistula or (ii) to remove a tooth or a
walls to allow coaptation of buccal and palatal
root from sinus.
soft tissue flaps to close over the defect.
● A protective acrylic denture or splint can be
used to provide a barrier to the inadvertent

entry of food particles. Drawbacks
Supportive measures ● It cannot drain the sinus satisfactorily, as the point
i. Antibiotics created for drainage is not at the point of dependent

Penicillin and its derivatives: drainage, due to the fact that antral floor is about
● It can be started with i.v. route and later 1.5 cm below nasal floor.
switched over to oral route. Penicillin V 250– ● It also interferes with ciliary pathways. Thus, im-
500 mg 6 hourly is adequate. pedes normal physiological drainage of sinus.

Maxillary sinusitis
{SN Q.11}
Maxillary sinusitis is inflammation of maxillary sinus
Surgical procedure for intranasal antrostomy due to various causes.
● A small-sized osteotome or gouge is pushed Signs of acute sinusitis
through the inferior meatus in the nasal cavity into ● Tenderness over maxilla, especially in the infraor-
the maxillary sinus. bital region.

● Then a big, curved artery forceps is passed ● Mild oedema of cheek in infraorbital soft tissues.
through this opening and an iodoform impreg- ● Rarely, patient gets earache as a referred pain from
nated ribbon gauze pack’s end is grasped into its antrum. This is attributed to acute otitis media.
beak and pulled out into the nostril. ● Percussion of maxillary premolars and molars re-
● Here a single knot, which is put in the ribbon lated to affected sinus will lead to pain. Examination
gauze, will help to keep it secured in the nostril. of nose with a speculum shows nasal congestion
● The other end of the ribbon gauze is then used to (red, shiny and swollen mucous membrane around
systematically pack the maxillary sinus cavity in ostium).
multiple folds after achieving proper haemostasis ● Presence of pus or mucopurulent discharge in middle
(after Caldwell–Luc operation). meatus. This comes from sinus, through ostium and
● An antrostomy can be performed by removing from over inferior conchae onto floor of nose.
approximately 1 cm of the medial wall of the an- ● Oropharynx: Mucopurulent discharge trickling down
trum, which bulges into the sinus below the level posterior wall of pharynx.
of the inferior turbinate. Medical management
● This antrostomy should be extended to the level i. Antibiotics
of the floor of the nose. Penicillin and its derivatives:
● The nasal mucosa is then incised from the antral ● It can be started with i.v. route, and later switched
surface on three sides and the nasal mucosal flap over to oral route. Penicillin V 250–500 mg 6 hourly
thus created is reflected into the antrum. is adequate.
● In case the organisms are resistant to penicillin, a
broad-spectrum antibiotic is prescribed.

Q.4. What are the causes of fracture of tooth during ii. Nasal decongestants
extraction? How do you manage a case of root pushed in ● Ephedrine nasal drops (0.5%) are instilled intra-
maxillary antrum? nasally every 2–3 h.
● Steam inhalations: When the nose is clear subse-
Ans.
quent to the use of decongestant drops or sprays,
[Same as LE Q.1] steam inhalations are helpful in encouraging
drainage. It also helps in thinning down the mu-
Q.5. What are the causes for pushing a tooth or a root
cous, pus and has a soothing effect.
into a sinus? How do you diagnose to treat such cases?
● Benzoin and Menthol inhalations: A teaspoonful
Ans. is added to a pint of hot (not boiling) water and
the vapours are inhaled for 10 min twice a day,
[Same as LE Q.1]
after covering the head.
Q.6. Removal of fractured root from the maxillary sinus. iii. Analgesics
● Nonsteroidal anti-inflammatory agents:
Ans.
i. Aspirin 500 mg 1–3 tablets four times daily
[Same as LE Q.1] ii. Paracetamol 500 mg three times daily
iii. Ibuprofen 400 mg three times daily
iv. Hot fomentation
SHORT ESSAYS: ● Local heat application is smoothening to inflamed
Q.1. Caldwell–Luc procedure. sinus.
Surgical management
Ans.
Antral lavage
[Ref LE Q.1] ● This procedure assists in drainage of the sinus.
● It involves inserting a cannula into the maxillary

Q.2. Clinical features and management of acute maxil-
sinus through inferior meatus.
lary sinusitis.
● Irrigation of sinus with lukewarm water, which
Ans. drains out through ostium along with sinus exudate.
Q.3. Chronic maxillary sinusitis. ● A semilunar incision is placed in the buccal vestibule
from canine to second molar area just above the gin-
Ans.
gival attachment.
Chronic maxillary sinusitis ● A mucoperiosteal flap is reflected.
● Infection of the sinus that lasts for months or years is ● An opening or window is created in the anterior wall
called chronic sinusitis. It most commonly is an ex- of the maxillary sinus with the help of chisels,
tension of an acute sinusitis, which failed to resolve gouges or dental drills.
completely. ● The opening is enlarged carefully in all directions
Pathophysiology with Rongeur forceps to permit the inspection of the

● After an acute infection, the ciliated epithelium gets sinus cavity.
destroyed and prevents drainage of secretions from ● The size obtained should be about the size of the in-
the sinus. dex finger. This is to facilitate the palpation of the

● Thus, there is pooling and stagnation of mucopuru- sinus lining with the introduction of index finger into
lent discharge within the sinus, which further causes the sinus cavity.
progress of the infective process. ● Pus should be sucked away from the sinus and a
● Further, mucosal changes, ciliary damage and oedema thorough irrigation of the maxillary sinus is carried
follow. Mucosa may become thick and polypoidal. out with copious saline wash.
Clinical features ● The thickened, infected lining of the maxillary sinus
● Symptoms are nonspecific unlike acute sinusitis. can be elevated with Howarth’s periosteal elevator and
Patient may not complain of any pain or tenderness. removed and sent for histopathological examination.
● Pain may be the only presenting symptom of an ● The antral cavity again is irrigated and can be packed
acute exacerbation. with iodoform ribbon gauze.

● Purulent nasal discharge. ● The incision is closed with 3-0 silk.
● Blocking of nose and change in voice due to loss of Postoperative management

resonance. ● Antibiotics, analgesics and anti-inflammatory drugs
● Anosmia. for 5 days.

Causative organisms ● Pack removal on the 5th day. Tincture of benzoin
● Mixed aerobic and anaerobic organisms. inhalation three times a day, followed by nasal drops.
Investigations ● Patient is instructed not to blow the nose, have soft
● Water’s view radiograph. diet and no vigorous gargling.

● Thickening of mucosa and opacity of involved sinus.
Q.4. Anatomy of maxillary sinus.
● Culture of discharge from the sinus.
Management Ans.
● Complete workup to identify aetiological factors, [Ref LE Q.2]
which obstruct the drainage system of the sinus and
identification of allergic agents. SHORT NOTES:
Medical management
Q.1. Definition of oroantral fistula.
● Antibiotics, antihistamines and decongestants.
Surgical management Ans.

● Any dental infection if present is treated.
[Ref LE Q.2]
● Antral lavage: If more than three successive punc-
tures have purulent fluid, then the treatment should Q.2. Whitehead’s varnish.
be more radical. Ans.
● Intranasal antrostomy: A window or opening is created
Whitehead’s varnish
in the inferior meatus to facilitate drainage of the sinus.
● Benzoin 10 parts 44 g
● Caldwell–Luc operation.
● Storax 7.5 parts 33 g
Caldwell–Luc Operation
● Balsam of tolu 5 parts 22 g
● Caldwell–Luc operation is defined as a method of
● Iodoform 10 parts 44 g
gaining entry into maxillary sinus via canine fossa
● Solvent ether 1 fl oz or 100 parts
with nasal antrostomy.
Procedure Q.3. Define Caldwell–Luc operation.
● The surgical procedure can be performed under LA
with sedation or under GA, which is the preferred Ans.

method. [Ref LE Q.1]
Q.4. Cause of root displacement into maxillary sinus. ● The results of a normal sinus – A definite infraorbital
crescent of light and a brightly lit and glowing pupil.
Ans.
● In case the antral cavity contains mucus, polyps,
[Ref LE Q.1] blood and thickened lining, fibro-osseous lesions or

a tumour, it will not light up as in normal circum-
Q.5. Medical management of acute sinusitis.
stances.
Ans. ● The result will be false negative in cases where there
is a large abscess over maxillary sinus.

[Ref LE Q.1]
● Transillumination is certainly, a less accurate than
Q.6. Mucormycosis involving maxillary antrum. conventional radiography; but still is a useful method
of examination, if the facilities are available.
Ans.
Q.11. Describe in brief the technique of intranasal an-
Mucormycosis
trostomy.
● It is the fungal infection involving maxillary sinus.
● It is seen in chronic maxillary sinusitis. Ans.

● Patients are put on antifungal drugs such as ampho-
[Ref LE Q.3]
tericin B and nystatin.
● Oral mouthwash preparation is also available for Q.12. Von Rehrmann’s flap.
nystatin.
Ans.
● Treatment is done by Caldwell–Luc operation fol-
lowed by nasal antrostromy. Buccal flap/Von Rehrmann’s flap

● Most common flap used for closure of oroantral fistula
Q.7. Palatal flap closure for oroantral fistula.
● Performed under LA
Ans. ● Incision making:
● Two divergent incisions are taken with blade no. 15,

[Ref LE Q.2]
from each side of orifice into buccal sulcus for a
Q.8. Mention in brief about causes of failure of closure distance of 2.5 cm. Mucoperiosteal flap is reflected
of oroantral fistula. carefully.
● Advancement of buccal flap:
Ans.
● A horizontal incision is made in the periosteum, as
Causes of failure of closure of oroantral fistula are high as possible. This will allow advancement of
i. Postoperative infection buccal flap.
ii. Inadequate flap design ● Maxillary sinus should be carefully inspected for
iii. Inadequate flap volume evidence of infection, either through fistula or by

iv. Postoperative failure to maintain proper oral hygiene by illumination or with a fiberoptic light. Any polypoi-
patients dal masses or other diseased tissues should be
removed. Antrum is gently irrigated with warm nor-
Q.9. Mention any four clinical features of acute maxil-
mal saline.
lary sinusitis.
● Attain complete haemostasis.
Ans. ● Closure of wound:
● The mucoperiosteal flap is sutured into position

[Ref LE Q.3]
across fistula with interrupted sutures.
Q.10. Transillumination test.
Q.13. Oroantral fistula.
Ans.
Ans.
Transillumination test
[Same as SN Q.1]
● Transillumination is one of the methods of examina-
tion, and can be carried out because of relative thin- Q.14. Write four indications of Caldwell–Luc operation.
ness of the walls of the maxillary sinus.
Ans.
● It can be carried out by placing a strong light in cen-
tre of mouth of the patient with the lips closed. [Same as SN Q.3]
Topic 14
Inflammatory Lesions of Jaw and Orofacial Infections
LONG ESSAYS:
1. Define osteoradionecrosis. Describe the clinical features, radiographic picture and management of osteoradio-
necrosis.
2. Define osteomyelitis. Describe the pathology and the management of chronic osteomyelitis of mandible.
3. Write the clinical features, aetiology and management of Ludwig angina and note on systemic complications.
4. Describe the mode of spread of infection from mandibular third molar region. Discuss the line of treatment in
such a case.
5. Give the boundaries of pterygomandibular space.
6. What are the boundaries of infratemporal space? How will you manage a case of infection of infratemporal
space?
7. Describe the pathophysiology, clinical features and management of osteoradionecrosis. [Same as LE Q.1]
8. Define osteoradionecrosis. Describe in detail the ill effects of radiation therapy of oral and perioral structures
and how do you manage them? [Same as LE Q.1]
9. Define and classify osteomyelitis of jaw bones. How will you manage a case of chronic suppurative osteomyeli-
tis of mandible in an adult? [Same as LE Q.2]
10. Define Ludwig angina. Mention clinical features and management of Ludwig angina. [Same as LE Q.3]
11. Describe clinical features, diagnosis and surgical treatment as well as antibiotic regime for a case of Ludwig
angina. [Same as LE Q.3]
12. Describe the pathway of spread of mandibular third molar and give its management. [Same as LE Q.4]
13. Define space infection. Enumerate the tissue that offers resistance to spread of infection. How does the infection
spread from the lower last molar periodontal flap and its management? [Same as LE Q.4]
14. Mention the microorganisms and various ways by which odontogenic infection can spread. Describe the boundaries,
clinical signs and symptoms and management of involvement of the pterygomandibular space. [Same as LE Q.5]
15. Describe the boundaries and contents of pterygomandibular space. Write the causes for spread of infection to
the pterygomandibular space and give the clinical features and management. [Same as LE Q.5]
SHORT ESSAYS:
1. Write in detail the clinical features and management of acute suppurative osteomyelitis.
2. Classify fascial spaces around the jaws.
3. I and D (incision and drainage).
4. Antibiotics for oral infection.
5. Principles of antibiotic therapy.
6. Pericoronitis.
7. Acute alveolar abscess.
8. Hyperbaric oxygen therapy.
9. Infratemporal space infection. [Ref LE Q.6]
10. Garre osteomyelitis.
11. Submasseteric space infection.
12. Cellulitis.
13. Acute osteomyelitis.
14. Spread of infections from lower first molar and its management.
15. Incision and drainage. [Same as SE Q.3]
16. What do you mean by massive antibiotic therapy? What are the conditions in maxillofacial surgery? Where it
is used? [Same as SE Q.5]
1 7. Pericoronitis and its management. [Same as SE Q.6]

18. HBO. [Same as SE Q.8]
SHORT NOTES:
1. Actinomycosis.
2. Garre osteomyelitis. [Ref SE Q.10]
3. Masticatory space.
4. Acute osteomyelitis. [Ref SE Q.13]
5. Mention in brief the predisposing factors for acute alveolar osteitis (dry socket).
6. Mention any eight clinical signs and symptoms of acute osteomyelitis. [Same as SN Q.4]
7. Give the boundaries and contents of sublingual space.
8. Mention boundaries and contents of pterygomandibular space. [Ref LE Q.5]
9. Mention boundaries and contents of submental space.
10. State the factors affecting spread of infection of odontogenic origin.
11. Quinsy.
12. Abscess.
13. Lumpy jaw.
14. Submental space. [Same as SN Q.9]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Define osteoradionecrosis. Describe the clinical then an area of denuded bone may be seen on al-
features, radiographic picture and management of os- veolar process which may be viable.
teoradionecrosis. ● The mucosa may show sloughing and the area of
exposed bone shows tendency to become larger.

Ans.
● There is slow sequestration, because not only the
Osteoradionecrosis osteoblastic, but also osteoclastic activity is de-
● Osteoradionecrosis (ORN) is an exposure of nonvi- stroyed.
able, nonhealing and nonseptic lesion in the irradi- ● When sequestration occurs, generally, a large
ated bone, which fails to heal without intervention. piece of bone is separated from unaffected vital
● It is a sequelae of irradiation-induced tissue injury in part of mandible.
which hypocellularity, hypovascularity and hypoxia ● Involvement of fascial spaces of face and neck
are the underlying causes. leading to deep cellulitis.
Clinical features: ORN has various clinical and radio- ● There may be sloughing of adjoining skin and
graphic presentations and there are no diagnostic signs mucosa.
or tests. ● Clinically, ORN may appear as a sequestrum of
● ORN is a painful and debilitating condition, dead bone, osteopenic and fibrotic in nature.
which is frequently refractory to treatment. ● Microorganisms are not the causative factors, but
● Severe, deep and boring pain, which may con- they create complication in the process and they
tinue for weeks or months. extend the treatment.
● Swelling of face when infection develops. ● Exposed bone is not necessarily radiation-
● Soft tissue abscesses and persistently draining compromised or dead. It may be due to the soft
sinuses. tissue envelope insult and if conservatively sup-
● Exposed bone in association with intraoral or ported, may heal without bone debridement.
extraoral fistulae. Radiographic features
● Trismus. ● In the early stage, there is little change.
● Foetid odour. ● It may appear as a radiolucent modelling with in-
● Pyrexia. definite nonsclerotic borders and occasional areas of
● Pathological fracture may be present. radiopacity associated with bony sequestrum.
● The signs and symptoms would vary depending ● Sequestra and involucrum occur late or not at all,
upon the cause. If extraction of tooth is the cause, because of severely compromised blood supply.
● Initial blood flow assays with nuclear isotope viii. Hyperbaric oxygen (HBO) therapy:
technetium-99 methylene diphosphate scanning It is a useful adjunct to other treatment mo-
can be of some benefit in assessing regional per- dalities.
fusion of the afflicted areas. ● Rationale for the use of HBO in association
Treatment with surgery in irradiated tissues is to in-

● There is no universally accepted treatment for ORN. crease blood to tissue oxygen tension, which
● The management of ORN remains controversial and will enhance the diffusion of oxygen into the
both radical and conservative treatments have been tissues.
reported. ● This revascularizes the irradiated tissue
Conservative treatment and also improves the fibroblastic cellu-

● It includes systemic antibiotics, selective rinsing lar density, thus further limiting the
with topical antiseptics, selective removal of seques- amount of nonviable tissue to be surgi-
tra, curetting and local debridement and burring it cally removed.
out until normal bleeding from the bone appears.
Radical treatment Q.2. Define osteomyelitis. Describe the pathology and
It is indicated where acute progressive ORN is refrac- the management of chronic osteomyelitis of mandible.
tory to conservative treatment. Ans.
In general the treatment comprises of
i. Debridement Osteomyelitis
ii. Control of infection: ● Osteomyelitis may be defined as an inflammatory
● Antibiotics are administered to control acute condition of bone that begins as an infection of med-
infection, if present. ullary cavity and Haversian systems of the cortex,
iii. Other supportive treatment: and extends to involve the periosteum of the affected
(i) Hydration: fluid therapy, (ii) high protein and area.
vitamin diet ● The inflammation may be acute, subacute or chronic.
iv. Analgesics: ● It may be localized or may involve a larger portion
● Narcotic and non-narcotic analgesics of bone.

v. Bupivacaine (Marcaine), alcohol nerve blocks, ● It may be suppurative or nonsuppurative.
nerve avulsion and rhizotomy Aetiology

Good oral hygiene: Osteomyelitis of the jaws is caused by the following:
● Oral rinses, such as 1% sodium fluoride gel, 1. Odontogenic infections:
1% chlorhexidine gluconate and plain water It includes primarily, odontogenic infections
help to prevent radiation-induced caries from originating from pulpal or periodontal tissues,
the xerostomia pericoronitis, infected socket, infected cyst,
vi. Frequent irrigations of wounds: tumour, etc.
● Exposed dead bone and small pieces of bone 2. Trauma:
may become loose and can be removed easily. It is the second leading cause: (a) Especially,
vii. Sequestrectomy: compound fracture and (b) surgery-iatrogenic.
It is preferably performed intraorally, because 3. Infections of orofacial regions derived from:
of skin and vascular damage resulting from ir- a. Periostitis following gingival ulceration
radiation. b. Lymph nodes infected from furuncles
● Pathological fractures are not so common. c. Lacerations and
● The best form of treatment is excision of d. Peritonsillar abscess
necrotic ends of both the fragments and re- 4. Infections derived by haematogenous route:
placement with a large graft. It includes furuncle on face, wound on the
● Reconstruction of bone defects usually war- skin, upper respiratory tract infection, middle
rants major soft tissue flap revascularization ear infection, mastoiditis and systemic tuber-
support. culosis.
● Bone resection is performed if there is The infections from the last two groups ac-
persistent pain, infection or pathological count for a small percentage of cases.
fracture. It is preferably done intraorally to Chronic osteomyelitis
avoid possibility of orocutaneous fistula in It can be (a) primary, resulting from organisms which
radiation-compromised skin. are less virulent and (b) secondary, occurring after acute
Osteomyelitis, when the treatment does not succeed in ● Supportive therapy

eliminating the infection. ● Pain control
Clinical features ● I.v. antimicrobial agents
● Pain and tenderness: The pain is minimal. ● Blood transfusion
● Nonhealing bony and overlying soft tissue wounds ● Postoperative care
with induration of soft tissues. ● HBO therapy
● Intraoral or extraoral draining fistulae. B. Surgical management

● Thickened or ‘wooden’ character of bone. ● Extraction of teeth involved
● Enlargement of mandible, because of deposition ● Incision and drainage
of subperiosteal new bone. ● Continuous or intermittent closed catheter
● Pathological fractures may occur. irrigation

● Sterile abscess (Brodie abscess) common to long ● Sequestrectomy, saucerization and decorti-
bones is rare in jaws. cations

● Teeth in the area tend to become loose and sensi- ● Resection of jaw with or without immediate
tive to palpation and percussion. delayed reconstruction with bone graft

Diagnosis ● Postoperative care
It is made on the basis of: Recommended antibiotic regimens for OML of jaws
i. Presence of sequestra 1. Regimen I (first choice): As empirical therapy,
ii. Areas of suppuration involving the tooth bearing penicillin (penicillin-V) is given.
area of jaw bone, not responding to debridement a. Aqueous penicillin 2 million units given intra-
and conservative therapy venously every 4 hourly.
iii. Compromised immune response, either re- b. Oxacillin 1 g i.v. every 4 hourly.
gional or systemic or microvascular decom- When the patient has been asymptomatic for
pensation or both 48–72 h, then switch to oral Penicillin V 500 mg
Treatment every 4 hourly with cloxacillin 250 mg orally
● The treatment measures remain the same for acute every 4 hourly for 2–4 weeks.
as well as for chronic Osteomyelitis. 2. Regimen II is based on culture and sensitivity re-
● In certain circumstances, after performing the neces- sults.
sary surgical procedures where the soft tissues can- Penicillinase-resistant penicillin, such as oxacil-
not be closed without leaving dead space or because lin, cloxacillin, dicloxacillin or flucloxacillin may
of rigid fibrosis, the wound may be dressed with 2" be given.
ribbon gauze soaked with Whitehead’s varnish. In case of allergy to penicillin, the following anti-
● A differentiation has to be made between the biotics are used:
types of bone encountered. i. Clindamycin 300–600 mg orally every
● The necrotic but unsequestrectomised bone has 6 hourly.
dirty white colour cortex, while the living cortical ii. Cephalosporin: (a) Cefazolin 500 mg ev-
bone has a yellowish hue. ery 8 hourly, or (b) Cephalexin 500 mg
● The viable cortex shows tiny red bleeding spots every 6 hourly.
on cut surfaces. iii. Erythromycin 2 g every 6 hourly i.v. then
Chronic external sinuses require irrigation. 500 mg every 6 hourly orally.
i. Resection: It is rarely required. When full Second choice: Clindamycin
thickness of segment of jaw is involved and a ● It is effective against penicillinase produc-
conservative approach has failed to cure, resec- ing Staphylococci, Streptococci and anaero-
tion of the involved part should be considered. bic bacteria including Bacteroides.
ii. Secondary bone grafting: This should be con- ● It is used because of its ability to diffuse
sidered when the wound has healed com- widely in bone. It is not recommended as
pletely and is free of infection. first choice, as it is bacteriostatic and
Management causes diarrhoea due to pseudomembra-
The management includes: nous colitis.
A. Conservative method of treatment and 3. Third choice: Cefazolin or Cephalexin
B. Surgical treatment It is effective against most cocci including
penicillinase-producing Staphylococci, Gram-
A. Conservative management negative aerobic bacilli such as E. coli, Klebsiella
● Advised to take complete bed rest and Proteus.
Cephalosporins are not recommended as first 7 . Miscellaneous causes: It includes rare causes such as:
choice. a. Infection in the tonsils or pharynx such as purulent
4. Fourth choice: Erythromycin tonsillitis, etc.
These drugs cannot be used as first choice, as b. Foreign bodies such as fish bone, etc.
these are (i) bacteriostatic and (ii) rapidly develop c. Oral soft tissue lacerations
resistant strains. 8. Cervical lymphoid tissues
The dose and duration of antimicrobial therapy is Pathology
dependent upon severity of infection and its re- ● The condition is a diffuse inflammation of soft
sponse to treatment. tissues which is not circumscribed or confined to

Q.3. Write the clinical features, aetiology and management one area, but in contrast to the abscess, tends to
of Ludwig angina and note on systemic complications. spread through tissue spaces and along fascial
planes.
Ans.
● Such type of spreading infection occurs in the pres-
Ludwig angina ence of organisms that produce significant amounts

Ludwig angina is a massive, firm, brawny cellulitis/ of hyaluronidase and fibrnolysins, which act to break
induration; acute and toxic stage involving simultane- down or dissolve, respectively, hyaluronic acid and
ously submandibular, sublingual and submental spaces fibrin.
bilaterally. ● Streptococci, being the potent producers of hyal-
Aetiology uronidase are always associated with classical or true

1. Odontogenic: This is the cause in majority of cases. Ludwig angina.
The most common teeth involved are mandibular sec- Clinical features
ond and third molars. It can cause infections in various The following signs and symptoms are present with
other forms: varying degree of severity.
a. Acute dentoalveolar abscess. General examination
b. Acute periodontal abscess: Deep abscess may in- General constitutional symptoms
volve sublingual spaces. i. Patient looks toxic, very ill and dehydrated.
c. Pericoronal abscess: In relation to erupting mandible ii. There is pyrexia, anorexia, chills and malaise.
third molars, which can extend to the following iii. Marked pyrexia.
spaces: iv. Difficulty in swallowing (dysphagia).
i. Submandibular space v. Impaired speech and hoarseness of voice.
ii. Buccal space Clinical examination
iii. Sublingual space ● Firm/hard brawny (board-like, woody hard)
iv. Pterygomandibular space swelling in the bilateral submandibular and sub-

d. Infected mandibular cyst also can spread to form mental regions, which soon extends down the an-
Ludwig angina. terior part of the neck to the clavicles.
2. Iatrogenic: Use of a contaminated needle for giving lo- ● Swelling is nonpitting, minimally or nonfluctuant
cal anaesthesia. associated with severe tenderness.
3. Traumatic injuries to orofacial region: These can be in ● It shows ill-defined borders with induration.
the form of: ● Severe muscle spasm may lead to trismus with
a. Mandibular fractures – The chances of developing restricted mouth opening and also jaw move-
Ludwig angina are more, if the fracture is com- ments.
pounded and comminuted. ● Typically mouth remains open due to oedema of
b. Deep lacerations or penetrating injuries such as sublingual tissues leading to raised tongue almost
punctured wounds. touching the palatal vault.
4. Osteomyelitis secondary to compound mandibular frac- ● In extreme circumstances, tongue may actually
tures or acute exacerbation of chronic osteomyelitis of protrude from the mouth. The tongue movements
mandible may develop into Ludwig angina. may be raised.
5. Submandibular and sublingual sialadenitis: Acute or ● Breathing being shallow with accessory muscles
chronic infection from these glands. of respiration being used.

6. Secondary infections of oral malignancies: The associ- ● Cyanosis may occur due to progressive hypoxia.
ated malignancies of the region may give rise to second- ● Death may occur in untreated case of Ludwig
ary infection leading to the condition. angina within 10–24 h due to asphyxia.
● Intraorally, the swelling develops rapidly, which Use of cuffed endotracheal tube
involves the sublingual tissues and involves: ● Avoid sedatives and narcotic agents that may de-
i. Distends or raises the floor of mouth and teriorate respiration.

woody oedema of the floor of the mouth and ● Degree of respiratory obstruction can be better
tongue. evaluated using pulse oximeter and evaluating

ii. Tongue may be raised against palate. blood gases.
iii. Increased salivation, stiffness of tongue move- Anaesthesia
ments and difficulty in swallowing. It is always better to use local anaesthesia for surgi-
iv. Backward spread of infection leads to oedema cal intervention.
of glottis resulting in respiratory obstruction/ Local infiltration with 2% lidocaine with adrenaline
embarrassment. into skin and superficial tissues of neck is sufficient
● Stridor being the alarming sign of this fatal exten- to fulfil the need for surgical intervention.
sion needing emergency intervention to keep air- In patients who are already intubated, GA can be
way patent. considered after evaluating its advantages over local
● There is reduced control of muscles and jaw anaesthesia.
posture. ● I.v. analgesics can be supplemented to relieve
● Salivation is excessive and saliva may be even pain.

seen drooling. ● Surgical intervention: It has two aims: (i) re-
● Part of the tongue may get pushed backward mak- moval of cause and (ii) surgical decompression:
ing swallowing of even liquid, very difficult or decompression of the spaces involved.
even impossible. Surgical decompression
● Oral opening and jaw movements may be As Ludwig angina is in fact cellulitis, the aggressive
reduced. surgical intervention is debatable.
Principles of treatment Advantages of early surgical decompression
The treatment is based on the combination of the fol- i. It reduces pressure of oedematous tissue on
lowing factors: airway, reducing respiratory embarrassment.
1. Early diagnosis ii. It allows prompt drainage.
2. Maintenance of patent airway iii. It allows obtaining specimens or samples for
3. Intense and prolonged antibiotic therapy staining, culture and sensitivity for identifica-
4. Extraction of offending teeth tion of micro-organisms; and, accordingly
5. Surgical drainage or decompression of fascial adjustment of antibiotics later on.
spaces iv. It allows placement of drains, may be to drain
Airway maintenance pus collection as time progresses and irriga-
● This condition is considered to be fatal. tion of the tissues at regular interval.
● Death can occur from asphyxia rather than the Care should be taken to preserve or avoid trauma to:
infection itself, leading to septicaemia and ● Facial vessels near angle
shock. ● Lingual nerve
● Hence, it is advisable to observe the patient for ● Jugular vein, laterally below angle region
respiratory obstruction and restlessness. Antibiotic therapy

● In case of respiratory embarrassment, the follow- ● Antibiotics: Antibiotics play a vital role in manag-
ing points should be considered for using artificial ing Ludwig angina. Usually, i.v. antibiotics with
airway: proper dosage and frequency are necessary.
i. Intubation of the patient a. Penicillin and its derivatives:
ii. Surgical airway i. Penicillin is the first line of antibiotics in treat-
Intubation of the patient ing such infection, as it covers the majority of
● Blind intubation should be avoided. aerobic Gram-positive microbial flora com-
● Nasoendotracheal intubation is far more reliable monly associated with this infection. It is ad-
and almost predictable and should be preferred. ministered in the form of aqueous penicillin
Surgical airway G, 2–4 million units, i.v. every 4–6 hourly; or
● It may be required in case of severe upper respira- 500 mg every 6 hourly orally.
tory obstruction. ii. Semisynthetic derivatives of penicillin:
● Laryngotomy and cricothyroidotomy (tracheot- Ampicillin/amoxicillin: 500 mg every 6 and
omy) are always preferred over tracheostomy. 8 hourly, i.v. and orally, respectively.
iii. Cloxacillin: 500 mg orally, every 8 hourly. ● Posteriorly, this space communicates with the lateral
iv. In case of allergy to penicillin: Erythromycin pharyngeal space.
600 mg every 6–8 hourly. ● An infection from a third molar can also pass directly
v. Gentamicin has activity against some resistant into the parapharyngeal space by extension medial to
Staphylococci and Pseudomonas. 80 mg. 1 M b.d. the pterygoid muscle.
vi. Clindamycin i.v. 300–600 mg every 8 hourly, ● A patient with pterygomandibular space infection
orally and intravenously. Its spectrum of activity will show no external evidence of swelling.
includes Gram-positive cocci including penicil- ● Intraoral examination reveals an anterior bulging
linase resistant Staphylococci, and Bacteroides. of half the soft palate and the anterior tonsillar pil-
vii. Metronidazole: It is a useful antibiotic against lar with deviation of the uvula to the unaffected
anaerobic flora found in infections. It is admin- side.
istered in the form of 400 mg every 8 hourly, ● The patient will have severe trismus and difficulty.
orally or intravenously. ● Despite the limitation in opening, depression of the
viii. Cephalosporins: These are closely related to tongue blade usually permits inspection of the soft
penicillin and have similar spectrum of their palate and pharyngeal wall.
activity. These are usually reserved for resis- ● The pterygomandibular space abscess must be distin-
tant infections. guished from the peritonsillar abscess.

● Usually, a combination of antibiotic therapy ● With the latter, there is less trismus and no dental
is indicated for aggressive management of involvement.

Ludwig angina, penicillin or its derivative ● Occasionally, an infection from third molar can in-
along with metronidazole or gentamicin. volve the submasseteric space.

● Antibiotics should be changed subsequent ● Usually this is the result of pericoronitis, but this
to the result of bacterial culture and sensi- can arise from a periapical infection when lin-
tivity testing. guoversion of the tooth or an extreme curvature
● The therapy should also be changed, if of the root brings the apex closer to the buccal
favourable results are not observed after surface.
48–72 h of therapy. ● The submasseteric space is bounded laterally by the
masseter muscle and medially by the larteral surface

Q.4. Describe the mode of spread of infection from man- of the mandibular ramus.
dibular third molar region. Discuss the line of treatment ● The anterior boundary is the facial extension of the
in such a case. paratideomasseteric fascia, and the posterior bound-
Ans. ary is the parotid fascia and retromandibular portion
of the parotid gland.
Mandibular third molar ● Superiorly, the space extends to the level of the zy-
● The mandibular third molar is generally positioned gomatic arch and communicates with the infratem-
medially to the vertical plane of the ramus. There- poral space.
fore, its apex is much closer to the lingual than to the ● A submasseteric space infection can be distin-
buccal cortical plate. guished from buccal space infection by the fact
● In this region, the mylohyoid muscle is attached near that its anterior boundary ends at the anterior bor-
the alveolar margins and its posterior border is just der of the masseter muscle, whereas the posterior
behind the tooth. border of the buccal space swelling ends at that
● Because of the relationship, infection from vertically point.
positioned third molar will extend below the mylohy- Management
oid muscle and localize in the submandibular space. ● The management of the acute infection involves
● With mesioanugular or horizontal positioned teeth, both supportive and surgical therapy.
the infection will extend to the mylohyoid muscle, ● Surgical therapy consists of extraction of the
localizing in the pterygomandibular space. offending tooth or teeth, incision and drainage.
● This region is bounded laterally by the medial sur- ● Supportive therapy involves administration of an-
face of ramus of the mandible and medially by the tibiotics, hydration of the patients, administering
lateral aspect of the medial pterygoid muscle. an analgesic for pain, bed rest, application of heat
● It is the space into which the needle is passed in per- in the form of moist packs and/or mouth rinses
forming an inferior alveolar nerve block injection. and opening the tooth for drainage.
Q.5. Give the boundaries of pterygomandibular space. ● Pus is evacuated. Drain is inserted from an in-
traoral approach and left in position.
Ans.
Q.6. What are the boundaries of infratemporal space?
How will you manage a case of infection of infratempo-
{SN Q.8} ral space?
Surgical anatomy Ans.
Boundaries
[SE Q.9]
● Lateral: Medial surface of ramus of mandible
● Medial: Lateral surface of medial pterygoid {Infratemporal space

muscle ● Infratemporal space is also called ‘retrozygomatic
● Posterior: Parotid gland (deep portion) space’ as it is partly situated behind the zygomatic
● Anterior: Pterygomandibular raphae bone.
● Superior: Lateral pterygoid muscle forms roof ● The space is continuous with upper part of pterygo-
to the pterygomandibular space. The space just mandibular space anteriorly.
below the lateral pterygoid muscle communi- ● However, it is separated from it by lateral pterygoid
cates with the pharyngeal spaces muscle posteriorly.
● Contents: Lingual nerve, mandibular nerve, ● Thus, the infratemporal fossa forms the upper ex-
inferior alveolar or mandibular artery, mylohy- tremity of pterygomandibular space.
oid nerve and vessels and loose areolar con- Involvement
nective tissue. i. Infections of the infratemporal space arise
from the infection of the buccal roots of the
maxillary second and third molars, particularly
Clinical features from unerupted third molars.
● Even the established cases of pterygomandibular ii. Local anaesthesia injections with contaminated
space infections do not cause much swelling of face needles in the area of tuberosity.
over the submandibular region. iii. Spread from the other spaces infection.
● There is severe degree of limitation of mouth opening. Surgical anatomy
● Tenderness can be elicited over the area of wall tis- i. Boundaries
sues medial to anterior border of ramus mandible. Infratemporal space is bounded:
● Dysphagia is present. ● Laterally, by ramus of mandible, temporalis
● Medial displacement of the lateral wall of the phar- muscle and its tendon.
ynx, and redness and oedematous area around the ● Medially, by medial pterygoid plate, lateral
third molar. pterygoid muscle, medial pterygoid muscle,
Management lower part of temporal fossa of the skull and
Incision and drainage lateral wall of pharynx.
The abscess tends to point at the anterior border of ● Superiorly, by infratemporal surface of
the ramus mandible and drainage can be easily done greater wing of sphenoid and zygomatic
by intraoral route. arch.
a. Intraoral drainage ● Inferiorly, by lateral pterygoid muscle
● A vertical incision, approximately 1.5 cm forms the floor of the fossa and its lower
length is made on the anterior and medial as- head is said to mark the border between
pect of the ramus of mandible. pterygomandibular and infratemporal
● A sinus forcep inserted in the abscess cavity is spaces.
opened and closed and withdrawn. ● Anteriorly, infratemporal surface of
● The pus is evacuated and a rubber drain intro- maxilla.
duced is secured in position with a suture. ● Posteriorly, by parotid gland.
b. Extraoral drainage ii. Contents
● An incision is made on the skin at the angle of ● The fossa contains origins of medial pterygoid
the mandible. and lateral pterygoid muscles.
● A sinus forceps is inserted towards the medial ● The lower head of lateral pterygoid muscle
side of the ramus in an upward and backward borders the pterygomandibular and infratem-
direction. poral spaces.
● It contains pterygoid venous plexus of veins. Q.9. Define and classify osteomyelitis of jaw bones. How
● It is traversed by maxillary artery, mandibular will you manage a case of chronic suppurative osteomy-
nerve and middle meningeal artery. elitis of mandible in an adult?
Clinical features
a. Extraoral Ans.
● Trismus: Marked limitation of oral opening. [Same as LE Q.2]
● Bulging of temporalis muscle.
● Marked swelling of the face on the affected

Q.10. Define Ludwig angina. Mention clinical features
side in front of the ear overlying the area of the and management of Ludwig angina.
temporomandibular joint behind the zygomatic Ans.
process.
● The eye is often closed and is proptosed. [Same as LE Q.3]
b. Intraoral Q.11. Describe clinical features, diagnosis and surgical
● Swelling in the tuberosity area; elevation of
treatment as well as antibiotic regime for a case of
temperature up to 104°F. Ludwig angina.
Incision and drainage
a. Intraoral approach Ans.
If the trismus is not marked and fluctuation is
[Same as LE Q.3]
detected early, an intraoral incision is given in the
buccal vestibule opposite the second and third Q.12. Describe the pathway of spread of mandibular
molars. third molar and give its management.
The exploration is carried out medial to coronoid
process and temporalis muscle upwards and back- Ans.
wards with a sinus forceps or a curved haemostat. [Same as LE Q.4]
The space is entered and drained; and a small
piece of corrugated rubber drain is kept and se- Q.13. Define space infection. Enumerate the tissue that
cured with a suture. offers resistance to spread of infection. How does the
b. Extraoral approach infection spread from the lower last molar periodontal
● In severe intractable infections, extraoral inci-
flap and its management?
sion is the only method of drainage. Incision is Ans.
made at the upper and posterior edge of tempo-
ralis muscle within the hairline. [Same as LE Q.4]
● A sinus forceps is then directed upwards and
Q.14. Mention the microorganisms and various ways by
medially. which odontogenic infection can spread. Describe the
● Pus is evacuated. Rubber drain is inserted and
boundaries, clinical signs and symptoms and manage-
suture secured. Dressing is given. ment of involvement of the pterygomandibular space.
● Despite appropriate and prompt treatment, the
lesion takes long-time to resolve. Ans.

● The restriction of opening persists for long-
[Same as LE Q.5]
time over a few weeks and improves in due
course of time with active physiotherapy with Q.15. Describe the boundaries and contents of pterygo-
jaw exercises.} mandibular space. Write the causes for spread of infec-
tion to the pterygomandibular space and give the clini-
Q.7. Describe the pathophysiology, clinical features and cal features and management.
management of osteoradionecrosis.
Ans.
Ans.
[Same as LE Q.5]
[Same as LE Q.1]
Q.8. Define osteoradionecrosis. Describe in detail the ill SHORT ESSAYS:
effects of radiation therapy of oral and perioral struc-
tures and how do you manage them? Q.1. Write in detail the clinical features and manage-
ment of acute suppurative osteomyelitis.
Ans.
Ans.
[Same as LE Q.1]
Acute suppurative osteomyelitis ● Pathologic fracture occasionally occurs because

● Acute suppurative osteomyelitis of the jaw is a seri- of weakening of the jaw by the destructive
ous sequel of periapical infection that often results in process.
a diffuse spread of infection throughout the medul-
Q.2. Classify fascial spaces around the jaws.
lary spaces with subsequent necrosis of a variable
amount of bone. Ans.
● Dental infection is the most frequent cause of acute
Fascial spaces
osteomyelitis of the jaw.
Classification
● It may be either well-localized infection of one in-
A. Based on mode of involvement
volving a great volume of bone.
i. Direct involvement
● It is usually a polymicrobial infection.
a. Primary spaces
● Different types of organisms such as, Staphylococcus
b. Maxillary spaces
aureus, Staphylococcus albus and various Strepto-
c. Mandibular spaces
cocci are involved.
ii. Indirect involvement
● Anaerobes such as Bacteroides, Porphyromonas or
Secondary spaces
Prevotella species also predominate.
Spaces involved in odontogenic infections
Clinical features
Primary spaces of maxilla – Canine, buccal and
● Acute or subacute osteomyelitis involves either
infratemporal spaces
maxilla or mandible.
Primary spaces of mandible – Submental, buccal,
● In maxilla, the disease usually remains well local-
submandibular and sublingual spaces
ized to the area of infection.
a. Secondary fascial spaces – Masseteric, pter-
● In mandible, bone involvement tends to be more
ygomandibular, superficial and deep tempo-
diffuse and widespread.
ral, lateral pharyngeal, retropharyngeal, pre-
● The disease may occur at any age.
vertebral spaces and parotid spaces
● A particular form of osteomyelitis referred to as
B. Based on clinical significance
neonatal maxillitis in infants and young children
i. Face – Buccal, canine, masticatory and parotid
is a well-recognized entity, which is nowadays
ii. Suprahyoid – Sublingual, submandibular,
uncommon because of use of antibiotics.
pharyngomaxilary and peritonsillar
● The adult afflicted with acute suppurative osteo-
iii. Infrahyoid – Anterovisceral (pretracheal)
myelitis usually has a severe pain, trismus and
iv. Spaces of total neck – Retropharyngeal and
paraesthesia of the lips in case on mandibular in-
space of carotid sheath
volvement, and manifests an elevation of temper-
ature with regional lymphadenopathy. Q.3. I and D (incision and drainage).
● The white blood cell count is elevated.
Ans.
● The teeth in the area of involvement are loose and
sore. Incision and drainage helps in the following ways:

● Pus may exude from the gingival margin. i. Getting rid of toxic purulent material
● Until periostitis develops, there is no swelling or ii. Decompressing the oedematous tissues
reddening of the skin or mucosa. iii. Allowing better perfusion of blood containing antibiot-
Treatment ics and defensive elements
● General principle of management includes de- iv. Increasing oxygenation of the infected area
bridement, drainage and antimicrobial therapy. ● The abscess is then drained surgically and simultane-
● If sequestrum is small, it gradually exfoliates ously dental treatment must also be instituted for
through mucosa. achieving quick resolution.
● If large, surgical removal may be necessary, since ● It involves the blunt exploration of the entire anatomic
its removal by normal processes of bone resorp- space or the abscess cavity, along with the opening up
tion would be extremely slow. of all the tissue planes within the abscess cavity.
● Sometimes an involucrum form when the ● Irrigation of the abscess cavity is then done with
sequetrum becomes surrounded by new living betadine and saline solution.

bone. ● Thereafter, a drain is inserted into the depth of the
● Unless proper treatment is instituted, acute sup- space.

purative osteomyelitis may proceed to the devel- ● It may simply pass through a single incision and even
opment of periostitis, soft tissue, abscess or cel- remain in the depth of the space, or it may be a
lulitis. through and through drain.
● The drain is secured to one of the margins of the inci- Q.5. Principles of antibiotic therapy.
sions with a suture or to itself in case of a through
Ans.
and through intraoral to extraoral drains and are left
in situ, which can again be in the same fascial space. General principles of antibiotic therapy:
Q.4. Antibiotics for oral infection. 1. Empirical antibiotic therapy has a limited role in the
prevention and the management of infections.
Ans. 2. If no response is forthcoming within 3 days of therapy,
Antibiotics used for oral infections based on type of organ- then organisms must be identified so that the antibiot-
isms involved are as follows: ics can be chosen to act against susceptible organ-
isms. No single antibiotic is effective against the
Infecting pathogens. Once the causative organisms are isolated,
organisms Antibiotic Alternative it becomes critical to identify the appropriate antibi-
Actinomyces israelii Penicillin G Tetracycline
otic therapy.
3. The most common organisms are Streptococci, Staph-
Bacteroides fragilis Clindamycin Chlorampheni- ylococci and bacteroides.
col
4. Culture of the organisms and antibiotic sensitivity test
Bacteroides melanino- Penicillin G Tetracycline assume greater importance in patients with:
genicus
a. Compromised defences like diabetes
Candida albicans Amphotericin B - b. Immunosuppressed patients
(Nystatin c. Those who are vulnerable to infections like sub-
topically)
acute bacterial endocarditis
Clostridium organisms Penicillin G Tetracycline d. Patients on dialysis
Diphtheroids Penicillin G Add Vancomycin e. Patients who are on chemotherapy for malignancy
f. In geriatric patients
Escherichia coli Kanamycin Cefamandole
5. For the drug to be therapeutically effective, the antibi-
Haemophilus influenza Ampicillin Cefaclor otics must be given in proper dose at proper intervals
Klebsiella organisms Kanamycin Colistimethate through appropriate route, so that blood concentration
Mycoplasma Erythromycin Tetracycline
of the drug is maintained at the desired level.
pneumonia 6. The drug which is least toxic, most economical and
most effective must be chosen for the therapy.
Peptococcus organism Penicillin G Clindamycin
7. To avoid the development of resistant strains, the drug
Peptostreptococcus Penicillin G Clindamycin with least spectrum must be chosen.
organism
8. The patient must be warned about the possibility of the
Proteus mirabilis Ampicillin Kanamycin side effects and complications. If any such untoward
Proteus organism Gentamicin Kanamycin reactions develop, then the patient must discontinue
the therapy henceforth.
Pseudomonas Gentamicin Carbenicllin
aeruginosa
9. Caution must be exercised in using newer drugs. Pref-
erence must be given to use the known drug with
Serratia marcescens Kanamycin Ampicillin
proven effectiveness.
Saphylococcus albus Cephalothin Vancomycin 10. Wherever possible, judicious methods to accentuate
Staphylococcus aureus Penicillin G Cephalothin the efficacy of antibiotics must be utilized.
(nonpenicillinase
producing) Q.6. Pericoronitis.
Staphylococcus aureus Dicloxacillin Methicilliin Ans.
(penicillinase
producing) Pericoronitis
● An erupting tooth is covered by a soft tissue flap of
Staphylococcus Cephalothin Vancomycin
epidermidis the alveolar mucosa; and when tooth is partially
erupted, sometimes there may be inflammation or
Staphylococcus Ampicillin and Vancomycin
faecalis gentamicin
infection of the soft tissue flap covering the tooth.
● This is known as pericoronal infection or pericoro-
Streptococcus Penicillin G Cephalothin nitis.
pyogenes
● Usually seen in erupting mandibular third molar, but
Streptococcus viridians Penicillin G Cephalothin can be associated with any erupting tooth.
(alpha-haemolytic)
Aetiology Rapid extension to adjacent bone marrow spaces

●
● A partially erupted tooth covered partially by a frequently occurs, producing an actual osteomy-
pericoronal flap may get infected by accumulation elitis.
of food debris between the flap and the surface of ● In such cases, clinical features may be severe and
the crown. serious with swelling of the tissue.

● Eruption of tooth itself may produce some amount ● It generally presents with no clinical features,
of inflammation of the pericoronal region. since it is essentially a mild, well-circumscribed

● Trauma to the inflamed swollen flap may aggra- area of suppuration that shows little tendency to
vate the problem. spread from the local area.
● Inadequate attached gingival in the region of the Radiographic features
erupting third molar may lead to pocket formation ● Slight thickening of periodontal ligament space
around the erupting tooth. can be seen.

● Inflammation of this periodontal pocket may also Treatment and prognosis
spread to a pericoronal infection. ● Principle of the treatment is drainage.
Clinical features ● This can be done by opening pulp chamber or
● Pain and swelling in involved region. extracting the tooth.

● May be associated with trismus, if a lower molar ● Sometimes, tooth may be retained and root canal
is involved. therapy carried out if the lesion can be sterilized.

● Indentation from the upper tooth trauma may be If not treated, abscess can lead to serious compli-
seen on the pericoronal flap. cations through the spread of infection.
● Pus discharge from under the pericoronal flap.
● Regional lymph node enlargement. Q.8. Hyperbaric oxygen therapy.

● Tooth may be tender on percussion.
Ans.
Management
● Analgesics and antibiotics. Hyperbaric oxygen therapy
● If infection has spread to adjacent vestibule, then Method of delivery
incision and drainage. ● Hyperbaric oxygen therapy involves the intermit-
● Adequate irrigation of the pericoronal flap. Dilute tent, usually daily, inhalation of 100% humidified
hydrogen peroxide can be used to irrigate this oxygen under pressure, greater than one atmo-
region. spheric absolute pressure (ATA).
● Warm saline mouth rinses in future help to reduce ● Patient is placed in a chamber; and O2 is given by
the acute condition. mask or by hood.

● Once the acute condition subsides, the impacted ● Each dive is 90 min in length.
tooth may either be extracted or the pericoronal ● The treatment is given 5 days per week for 30, 60
flap may be exicised. or more dives in monoplace chamber at 2.4 ATA

for 90 min, while breathing 100% oxygen twice
Q.7. Acute alveolar abscess. daily.
● It is a potent alternative to surgical reperfusion
Ans
and is an adjunctive enhancement to host immune
Acute alveolar abscess response.
● Also known as dentoalveolar abscess or periapical ● Its use has increased in the treatment of OML and
abscess. ORN.
● Periapical abscess is an acute or chronic suppurative ● HBO therapy increases a dose of oxygen dis-
process of dental periapical region. solved in the plasma and also that which is deliv-
● It may develop either from acute periapical, peri- ered to the tissues.
odontal or more commonly from a periapical ● It results in reduction of hypoxia within the af-
granuloma. fected tissues which in turn stimulates angiogen-

Clinical features esis in the hypovascular tissues.
● It presents an acute inflammation of the apical Mechanism of action of HBO
periodontium. ● Regular, periodic, but not sustained elevation
● Initially it produces tenderness of the tooth, which of the oxygen within hypoxic tissue has been
is relieved by application of pressure. shown.
● Enhances the killing ability of leucocytes. ii. Compensatory thickening of bone as a mechani-
● Stimulates fibroblast growth and increased colla- cal adaptation for reinforcing the area weakened
gen formation. due to disease and
● Promotes growth of capillaries. iii. An exuberant attempt of repair
● Toxic to aerobic and anaerobic bacteria.
● Inhibits bacterial toxin formation.

{SN Q.2}
Q.9. Infratemporal space infection.
Treatment
Ans. It is directed towards removing sources of inflamma-
[Ref LE Q.6] tion:
a. Removal of infected tooth and curettage of
Q.10. Garre osteomyelitis. socket
Ans. b. Surgical recontouring: This is done to recon-
tour the cortical expansion of the jaw. This is
attempted only if there is obvious expansion
{SN Q.2}
c. Endodontic therapy
Garre osteomyelitis d. Antibiotics: If signs of infection are present
Garre sclerosing OML is also known as chronic nonsup- e. Follow-up
purative sclerosing chronic OML with proliferative peri-
ostitis and periossificans.
It is a nonsuppurative inflammatory process, where there Q.11. Submasseteric space infection.
is peripheral subperiosteal bone deposition caused by Ans.
mild irritation and infection.
Submasseteric space infection
Pathogenesis ● Masseter consists of three layers which are fused
● The aetiological agents can be a carious tooth or the anteriorly, but can be easily separated posteriorly.
overlying soft tissue infection. ● There is potential space in the substance of the
● The infectious process localizes in periosteum or muscle between the middle and the deep heads,
beneath the periosteal covering of cortex, spreading while the bony insertion is firm above and below.
slightly into the interior of bone. The intermediate fibres will have only a loose at-
● It generally involves mandible. tachment.
● The disease primarily occurs in children and young ● It is possible for these fibres to be separated from
adults; and occasionally in older individuals. bone relatively easily by the accumulation of pus at
this site.
● A submasseteric space abscess is produced when the
{SN Q.2} pus accumulates between the ramus of the mandible
Clinical features and the masseter muscle.
It is characterized by: Involvement
● Localized hard, nontender bony swelling of Infection usually originates from the lower third mo-
lateral and inferior aspects of mandible lars, either resulting from
● Lymphadenopathy, hyperpyrexia and leucocy- i. Pericoronitis related to vertical and distoan-
tosis are usually not found. gular third molars or
ii. If a periapical abscess spreads subperiosteally
Radiography in a distal direction
● A focal area of well calcified bone proliferation may Surgical anatomy
be seen that is smooth and that often has a laminated Boundaries
or ‘onion skin’ appearance. ● Anteriorly: Masseter muscle (anterior border)
● The radiographic appearance is typical. and buccinator.

● There is cortical bone condensation and overgrowth ● Posteriorly: Parotid gland and posterior part of
of bony tissue beneath the periosteum. masseter.

● The increase in mass of bone is due to several factors ● Inferiorly: Attachment of the masseter muscle
as follows: to the lower border of mandible.

i. Mild toxic stimulation of fibroblasts by attenu- ● Medially: Lateral surface of the ramus of
ated infection mandible.

● Laterally: Medial surface of the masseter mandible to open the abscess by Hilton’s
muscle. method.
● Contents: Masseteric nerve, superficial tempo- ● A rubber drain is inserted and secured in posi-
ral artery and transverse facial artery. tion with a suture. Dressing is applied.
● It contains muscles of mastication – Masseter,
Q.12. Cellulitis.
lateral and medial pterygoids and insertion of
temporalis muscle. Also contains ramus and Ans.
posterior part of mandible, and branches of
Cellulitis
mandibular division of trigeminal nerve.
Cellulitis is a diffuse inflammation of the soft tissues,
● These branches include: Buccal, lingual and
which is not circumscribed or confined to one area, but
inferior alveolar nerves.
which, in contrary to abscess, tends to spread through
Clinical features
tissue spaces along fascial planes.
● External facial swelling is moderate in size; and
Clinical features
is confined to the outline of the masseter mus-
● Patient with cellulitis of face originating from
cle, i.e. the swelling is seen extending from the
dental infection may be moderately ill and has
lower border of the mandible to the zygomatic
elevated temperature and leukocytes.
arch, anteriorly to the anterior border of masse-
● Painful swelling of the soft tissue involved, the
ter and posteriorly to the posterior border of the
skin is inflamed and has an orange peel appear-
mandible.
ance and is even purplish sometimes.
● There is tenderness over the angle of the mandible.
● Regional lymphadenitis is present.
● There is almost complete limitation of mouth
● Infection arising in maxilla perforates the outer
opening. Fluctuation may be absent; and if pres-
cortical layer of the bone above buccinators at-
ent, cannot be elicited, because the muscle lies
tachment and causes swelling, initially of the up-
between the pus and the surface.
per half lip of the face.
● There is pyrexia and malaise.
● When infection in mandible perforates the outer
● The ramus of the mandible is more dependent
cortical plates below the buccinators attachment,
upon blood supply from the overlying muscle
there is a diffuse swelling of the lower half of the
than the body of the mandible, which is supplied
face, which is seen as a superior as well as cervi-
by inferior alveolar artery.
cal spread.
● As a result, ischaemic changes may take place in
● Spread to cervical tissue can cause respiratory
that part of bone denuded by periosteum by a
discomfort.
submasseteric abscess, so that a low-grade osteo-
myelitis of lateral cortical plate may occur with
● Antibiotics including antianaerobes and also the
sequestrum formation.
removal of the cause of infection.
● Often submasseteric infection leads to subperios-
teal new bone deposition beneath the periosteum. Q.13. Acute osteomyelitis.
● Necrosis of the muscle can also occur.
Ans.
Incision and drainage
There are two approaches:
Intraoral approach
● An incision is made vertically over the lower {SN Q.4}
part of anterior border of the ramus of the man-
Acute osteomyelitis
dible extending deep to the bone.
● Acute osteomyelitis is a sequel of periapical infec-
● Along the lateral surface of the ramus, a sinus
tion that often results in a diffuse spread of infection
forceps is passed downwards and backwards
throughout the medullary spaces with subsequent
and the pus is drained. The drain is inserted
necrosis of a variable amount of bone.
and secured with a suture.
Clinical features
● The abscess is usually situated below the level
● In maxilla, the lesion remains well localized to the
of incision and not at a point of dependent
area of initial infections.
drainage, and hence the drainage may be inef-
● In mandible, bone involvement tends to be more
ficient.
diffuse and widespread.
Extraoral approach
● Deep intense pain.
● When the mouth cannot be opened, an incision
● Abscess.
is placed in the skin behind the angle of the
● Surgical therapy consists of extraction of the of-

High intermittent fever.
●
fending tooth or teeth, incision and drainage.
● Pus discharge.
● Supportive therapy involves administration of an-
● Trismus.
tibiotics, hydration of the patients, administration
● Paraesthesia or anaesthesia of lip.
of analgesic for pain, bed rest, application of heat
● Diffuse swelling.
in the form of moistpacks and/or mouth rinses and
● Loosening of tooth.
opening the tooth for drainage.
Treatment
General principle of management Q.15. Incision and drainage.
● Debridement, drainage and antimicrobial Ans.
therapy.
● If lesion is large, surgical removal may be nec-
[Same as SE Q.3]
essary. Q.16. What do you mean by massive antibiotic therapy?
● Unless proper treatment is instituted, can prog- What are the conditions in maxillofacial surgery?
ress to periostitis, soft tissue abscess or cellulitis. Where it is used?
● Pathological fractures may occur because of
weakening of the jaw by destructive process. Ans.

[Same as SE Q.5]
Q.17. Pericoronitis and its management.
Q.14. Spread of infections from lower first molar and its Ans.
management.
[Same as SE Q.6]
Ans.
Q.18. HBO.
Spread of Infections from lower first molar
Ans.
● Spread of infection from lower first molar can give
rise to buccal space infection, if the infection exits [Same as SE Q.8]

from the buccal aspect of the bone below the attach-
ment of the buccinators muscle.
● The oblique line of buccinators attachment on the
SHORT NOTES:
mandible generally results in the root apices being Q.1. Actinomycosis.
above the origin of the muscle, thereby causing lo-
Ans.
calization of the infection within the oral vestibule.
● On the lingual aspect of mandible, the attachment of the Actinomycosis
mylohyoid muscle roughly parallels the oblique down- ● Actinomycosis is a chronic granulomatous disease
ward and forward course of the buccinators muscle. caused by anaerobic or microaerophilic Gram-posi-
● The apices of the premolar and first molar are always tive nonacid fast and branched filamentous bacteria.
located above the attachment of this muscle. ● The most commonly isolated organism is Actinomy-
● Boundaries of this space: ces israeli.
● It is bounded inferiorly by mylohyoid muscle, ● Actinomycosis bovis produces lumpy jaw in cattle,
laterally and anteriorly by lingual aspect of man- but is seldom found to be a pathogen in humans.
dible, superiorly by the mucosa of the oral cavity, ● Actinomycosis can be classified anatomically ac-
posteriorly at the midline by the body of the hyoid cording to the location of the lesion:
and medially by geniohyoid, genioglossus and a. Cervicofacial
styloglossus muscles. b. Abdominal
● Because of the loose connective tissue interspersed c. Pulmonary forms
between the latter muscles as well as between the in- Clinical features
trinsic muscle of the tongue, infection of the sublin- ● In cervicofacial actinomycosis, the organism may
gual space usually spreads across the midline to the enter the oral mucous membranes and may re-
opposite side as well as into the body of the tongue. main localized in the subjacent soft tissue or
● Such sublingual infections are also known as Ludwig spread to involve the salivary glands, bones or the
angina. skin of the face and neck, producing swelling and
Management induration of the tissue.
● The management of the acute infection involves ● The soft tissue swelling eventually develops into
both supportive and surgical therapy. one or more abscesses, which discharge upon a
skin surface liberating pus containing the typical Dry socket

‘sulphur granules’. Dry socket is defined as failure of approximate healing
● Abdominal actinomycosis is an extremely serious after extraction due to disruption of initial clot with the
form of the disease and carries high mortality rate. eventual lack of organization by granulation tissue.
● It presents with fever, chills, nausea and vomiting. Causes
● Pulmonary actinomycosis produces similar find- ● Traumatic extraction – Smoking after extraction
ing of fever and chills accompanied by a produc- ● Excessive rinsing after extraction
tive cough and pleural pain. ● Food impaction in socket
● The organisms may spread beyond the lungs to ● Limited local blood supply
involve adjacent structures. ● Excessive use of vasoconstrictor in LA
● Previous radiotherapy
Q.2. Garre osteomyelitis.
Q.6. Mention any eight clinical signs and symptoms of
Ans. acute osteomyelitis.
[Ref SE Q.10] Ans.
Q.3. Masticatory space. [Same as SN Q.4]
Ans. Q.7. Give the boundaries and contents of sublingual
space.
Masticatory space
i. Comprise pterygomandibular, submasseteric, superfi- Ans.
cial temporal and deep temporal or temporal spaces.
Sublingual space
ii. All these spaces are well differentiated and communi-
The sublingual space is a V-shaped trough lying later-
cate with other fascial spaces, buccal, submandibular
ally to muscles of tongue including hyoglossus, genio-
and parapharyngeal space infection from one compart-
glossus and geniohyoid.
ment may spread to the other compartments.
Involvement
iii. Amongst the muscles of mastication, only the outer
The teeth which frequently give rise to involvement
surface of masseter and inner face of medial pterygoid
of sublingual space are the mandibular incisors, ca-
muscles are covered by fascia.
nines, premolars and sometimes first molars. The
Masticatory spaces are divided into two by the ramus of
apices of these teeth are superior to the mylohoid
mandible: (a) Lateral compartment and (b) Medial
muscle. The infection perforates lingual plate below
compartment.
the level of the mucosa of the floor of the mouth and
iv. Masticatory space is formed by splitting of investing
passes into the sublingual space.
fascia into superficial and deep layers, which define the
It is a paired space, but the two sides communicate
lateral and medial extent of space.
anteriorly. This space communicates with subman-
v. The superficial layer lies along lateral surfaces of mas-
dibular space around the posterior border of mylohy-
seter and lower half of temporalis muscles. Superiorly,
oid muscle.
the superficial layer fuses with periosteum of zygoma
Surgical anatomy
and temporalis fascia. The deep layer passes along the
Boundaries
medial surface of pterygoid muscles, before attaching
● Superiorly, by the mucosa of floor of the mouth
to base of skull superiorly.
● Inferiorly, by mylohyoid muscle
vi. The masticatory space borders the number of other
● Laterally, by medial side of the mandible above
spaces, which include:
the mylohyoid muscle
Posteriorly, the parotid space; medially, the parapha-
● Medially, by hyoglossus, genioglossus and ge-
ryngeal space; and inferiorly, the submandibular and
niohyoid muscles
sublingual spaces.
● Posteriorly, by hyoid bone
Q.4. Acute osteomyelitis. ● Laterally and inferiorly, by mylohyoid muscle
and lingual side of mandible

Ans.
Contents
[Ref SE Q.13] Major contents include: Geniohyoid and genio-
glossus muscles and the hyoglossus muscle com-
Q.5. Mention in brief the predisposing factors for acute
plex. It also contains:
alveolar osteitis (dry socket).
i. Deep part of the submandibular salivary
Ans. gland and its duct anteriorly
ii. Sublingual salivary gland Involvement

iii. Lingual nerve i. Infection coming from the depth of the tonsillar
iv. Hypoglossal nerve crypt or supratonsillar fossa.
ii. As a complication of acute pericoronal abscess
Q.8. Mention boundaries and contents of pterygoman-
in which case, the abscess points near the lower
dibular space.
pole of the tonsil.
Ans. Clinical features
i. Patient looks ill, anoxic and dehydrated.
[Ref LE Q.5]
ii. Pain on one side of the throat radiating to the
Q.9. Mention boundaries and contents of submental ear.
space. iii. Dysphagia.
iv. Limitation of mouth may not be pronounced.
Ans.
v. Speech is difficult, especially in bilateral cases
Boundaries and contents of submental space and a peculiar muffled ‘hot potato in mouth’
Boundaries voice is characteristic.
● Lateral: Lower border of mandible and anterior vi. Drooling of saliva.
bellies of digastric muscle. vii. When the abscess is fully developed, a large
● Superior: Mylohyoid muscle. tense swelling of anterior pillar of fauces and a
● Inferior: Suprahyoid portion of the investing layer bulge in the soft palate on the affected side
of deep cervical facia, which is in turn covered by which in extreme cases reaches the midline;
the platysma, superficial fascia and skin. and pushes the uvula downwards and forwards,
Contents until it impinges against the opposite tonsil.
● Submental lymph nodes and anterior jugular viii. Coated tongue with marked foetor oris.
veins. The lymph nodes lie embedded in adipose Incision and drainage
tissue, and hence submental abscesses tend to re- It can be achieved by using a guarded knife and sinus
main well circumscribed. forceps which are inserted into the most prominent part
of the soft palate where the fluctuation is the maximal.
Q.10. State the factors affecting spread of infection of
Spread
odontogenic origin.
Oedema may eventually affect the base of the tongue,
Ans. epiglottis and aryepiglottic fold. In three to 5 days
duration, the mass becomes fluctuant and ruptures by
Factors affecting spread of infection of odontogenic origin
pointing usually through the anterior tonsillar pillar.
A. General factors
1. Host resistance Q.12. Abscess.
2. Virulence of microorganisms
Ans.
3. Compromised host defences
4. Combination of both Abscess
B. Local factors ● A circumscribed collection of pus in a pathological
Intact anatomical barriers tissue space is known as an abscess.

● Alveolar bone: As the infection progresses ● A true abscess is a thick-walled cavity containing pus.
within the bone, it spreads in the radical man- ● The suppurative infections are characteristic of
ner and extends to the cortical plates. Staphylococci, often with anaerobes, such as Bacte-
● Periosteum: It is next to local barrier. It does not roides; and are usually associated with large accumu-
provide much resistance and the infection spreads lation of pus, which require immediate drainage.
into the adjacent surrounding soft tissues. ● These microorganisms produce coagulase, an en-
● Adjacent muscles and fascia: It is next site of zyme that may cause fibrin deposition in citrated or
localization. oxalated blood.
Q.11. Quinsy. Q.13. Lumpy jaw.
Ans. Ans.
Peritonsillar abscess (quinsy) Lumpy jaw
It is a localized infection in the connective tissue bed ● Actinomycosis is a chronic granulomatous infection
between the tonsil and the superior constrictor muscle, caused by anaerobic or microaerophilic Gram-positive
and between the anterior and posterior pillars of fauces. nonacid fast and branched filamentous bacteria.
● The most commonly isolated organism is Actinomy- . Abdominal

b
ces israeli. c. Pulmonary forms
● Actinomycosis bovis produces lumpy jaw in cattle,
Q.14. Submental space.
but is seldom found to be a pathogen in humans.
● Actinomycosis can be classified anatomically ac- Ans.
cording to the location of the lesion:
[Same as SN Q.9]
a. Cervicofacial
Topic 15
Facial Neuropathology
LONG ESSAYS:
1 . Nerve injuries in oral surgery.
2. Describe signs and symptoms and management of trigeminal neuralgia.
3. Classification of injuries of trigeminal nerve. [Same as LE Q.1]
4. What is trigeminal neuralgia? Describe the various medical and surgical treatments. [Same as LE Q.2]
SHORT ESSAYS:
1. Trigeminal neuralgia. [Ref LE Q.2]
2. Aetiology and clinical features of Bell palsy.
3. Infraorbital neurectomy. [Ref LE Q.2]
4. Atypical facial pain.
5. Trigger zones. [Ref LE Q.2]
6. Analgesics for orofacial pain. [Ref LE Q.2]
7. Cryosurgery.
8. Clinical features and medical management of trigeminal neuralgia. [Same as SE Q.1]
9. Any four clinical characteristics of trigeminal neuralgia. [Same as SE Q.1]
10. Management of trigeminal neuralgia. [Same as SE Q.1]
11. Facial palsy. [Same as SE Q.2]
12. Cryosurgery – Principles and indications in oral lesions. [Same as SE Q.7]
SHORT NOTES:
1 . Bell palsy.
2. What are trigger zones? Name their location on the face with the relevant nerve. [Ref LE Q.2]
3. Cryosurgery. [Ref SE Q.7]
4. Pathways of pain.
5. Tinnel’s sign.
6. Bell’s sign. [Same as SN Q.1]
7. What is cryosurgery? [Same as SN Q.7]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Nerve injuries in oral surgery. ● The discontinuity gap between proximal and
distal nerve stumps becomes filled up with scar
Ans.
tissue, and proximal axonal sprouts are pre-
● Injuries to peripheral branches of the fifth (trigeminal) vented from recannulating distal endoneurial
nerve is an ever-present risk during surgical procedures tubules.
performed in the oral cavity and associated maxillofa- ● No recovery is expected without surgical inter-
cial region. vention.
Classification of mechanical nerve injuries ● Sunderland’s classification is based on patho-
● Classification of nerve injuries helps the clinician in physiology and anatomy of the injured nerve.
making a diagnosis, developing a rational plan of ● It also incorporates the features of Seddon’s
management, determining the need for and timing scheme that includes the amount of nerve tissue
of surgical intervention and estimating the prognosis damaged and tissue still intact.
of an injury. 1. Neuropraxia (Seddon)/first-degree lesion (Sunder-
Seddon (1943) and Sunderland (1978) have proposed land)
nerve injury classifications. ● It is characterized by a conduction block, the
● It is applied to both motor as well as sensory rapid and virtually complete return of sensation or
nerves. function with no degeneration of axon.
Seddon’s classification ● There are three types of first-degree nerve injuries
1. Neuropraxia based on the proposed mechanism of conduction
● Mild, temporary injury caused by compression or block.
retraction of the nerve. a. First-degree type-I injury: It may be the result
● There is no axonal degeneration distal to the area of nerve trunk manipulation, mild traction or
of injury. mild compression, such as during sagittal split
● There is a temporary conduction block – Sensory ramus osteotomy, inferior alveolar nerve repo-
loss. sitioning or lingual nerve manipulation during
● Spontaneous recovery usually occurs within excision of sublingual or submandibular sali-
4 weeks or less time. vary gland.
● No surgical intervention is required. b. First-degree type-II injury: It may be caused by
2. Axonotmesis moderate manipulation, traction or compres-
● More significant injury – There is disruption or sion of a nerve.
loss of continuity of some axons. Trauma of sufficient magnitude to injure the
● Undergo Wallerian degeneration distal to the site endoneurial capillaries cause intrafascicular
of injury. oedema and results in a conduction block.
● The general structure of the nerve remains intact. Normal sensation or function returns within
● There is prolonged conduction failure. 1–2 days following the resolution ofintrafas-
● Initial signs of recovery of nerve function do not cicular oedema, generally 1 week following
appear for 1–3 months after injury. nerve injury.
● Eventual recovery is often less than normal (pare- c. First-degree type-III injury: It results from
sis and hypoaesthesia). severe nerve manipulation, traction or com-
● Sensory nerve injuries may develop persistent pression pressure on the nerve, which may
painful sensation (dysaesthesias). result in segmental demyelination or mechani-
3. Neurotmesis cal disruption of the myelin sheath. Sensory
● It is the complete severance or internal physio- and functional recoveries are complete within
logic disruption of all layers of the nerve. 1–2 months.
● Wallerian degeneration of all axons occurs distal The psychophysical response to this type of
to the injury. injury is paraesthesia.
● There is a total permanent conduction block of all Surgery is not indicated for first-degree nerve
impulses (paralysis and anaesthesia). injuries.
a. Axonotmesis (Seddon)/second-degree Sunder- Q.2. Describe signs and symptoms and management of
land nerve injury trigeminal neuralgia.
● It is characterized by axonal injury with subse-
Ans.
quent degeneration and regeneration.
● Traction and compression are the usual mecha-
[SE Q.1]
nisms of this type of nerve injury and may
cause severe ischaemia, intrafascicular oedema {Trigeminal neuralgia
or demyelination. ● Trigeminal neuralgia (TN) is defined as sudden, usu-
● Even though the axons are damaged, there is ally unilateral, severe, brief, stabbing, lancinating
no disruption of the endoneurial sheath, peri- and recurring pain in the distribution of one or more
neurium or epineurium. Within 2–4 months branches of fifth cranial nerve.
following injury there are signs of sensation or Clinical features
function, which continue to improve over the ● Trigeminal neuralgic pain typically arises in persons,
next 8–10 months. who have no abnormal neurologic deficit such as loss
b. Axonotmesis (Seddon)/third-degree Sunder- of corneal reflexes, anaesthesia, paraesthesia or mus-
land nerve injury cular atrophy or weakness, etc.
● The aetiology of a third-degree nerve injury is ● TN typically manifests as a sudden, unilateral, inter-
typically traction or compression. mittent paroxysmal, sharp, shooting, lancinating,

● Not only is the axon damaged, but the endo- shock-like pain, which is elicited by slight touching
neurial sheath is breached resulting in intrafas- superficial ‘trigger points’ and radiates from that
cicular disorganization, while the perineurium point across the distribution of one or more branches
and epineurium remain intact. of the trigeminal nerve.
● The first signs of sensation or function are evi- ● Pain is usually confined to one part of one division of
dent within 2–5 months and may take another trigeminal nerve – Mandibular or maxillary, but may
10 months or so. occasionally spread to an adjacent division or rarely
● Recovery is never complete. involve all three divisions.
c. Axonotmesis (Seddon)/fourth-degree Sunder- ● Pain rarely crosses the midline.
land nerve injury ● The pain is of short duration and lasts for a few sec-
● The aetiology of a fourth-degree nerve injury onds, but may recur with variable frequency. Even
may include traction, compression, injection though there is a refractory period (complete lack of
injury and chemical injury. pain) between the attacks, some patients report a dull
● The injection of chemical agents into the nerve ache in-between the attacks.
trunk may cause irreversible damage to the ● During an attack, the patient grimaces with pain,
axons and connective tissue components of the clutches his hands over the affected side of the face
nerve trunk. stopping all the activities and holds or rubs his face,
● Fourth-degree nerve injuries are characterized which may redden the eyes or the eyes water until the
by disruption of the axon, endoneurium and attack subsides.
perineurium with preservation of the continu- ● Male patients avoid shaving. The oral hygiene is
ity of the epineurium, resulting in severe fas- poor, as patient avoids brushing of teeth.
cicular disorganization. ● The paroxysms occur in cycles, each cycle lasting for
● There is poor prognosis for recovery and a weeks or months and with time, the cycle appears
high probability of development of central closer and closer. With each attack, the pain seems to
neuroma incontinuity. become more intense and unbearable.
● In extreme cases, the patient will have a motionless
Neurotmesis (Seddon)/fifth-degree Sunderland nerve face – The ‘frozen or mask-like face’.}

injury
(SE Q.5 and SN Q.2)
● It is characterized by severe disruption of connective
tissue components of the nerve trunks with compro-

mised sensory and functional recovery. ● {(Presence of an intraoral or extraoral trigger point
● There is also a considerable amount of tissue loss.
that is provokable by obvious stimuli is seen in TN.
● The mechanisms of this injury include laceration,
It may be brought on by touching face at a particular
avulsion and chemical injury. site or by chewing or even by speaking or smiling,
● There is damage to all components of the nerve
brushing, shaving or even washing the face, etc.
● The location of the trigger points depends on
trunk: axon, endoneurium, perineurium and epi-
neurium. which division of trigeminal nerve is involved.
● Such as bupivacaine with or without corti-

i. In V2, the points are located on the skin of the
costeroids may be injected at the most
upper lip, ala nasi, cheek or on the upper gums.
proximal possible nerve site.
ii. In V3, this is the most frequently involved
● The selective nerve blocks can be given as
branch.
an emergency measure where the patient is
Trigger points are seen over the lower lip, and
suffering quite a lot, but the pain-free period
teeth or gums of the lower jaw. Tongue is
will be very short-lived.
rarely involved.
● The injection can be repeated, when the
iii. In V4, the trigger zone usually lies near the
pain recurs.
supraorbital ridge of the affected side.
b. Alcohol injections
● It is a characteristic of the disorder that attacks do
Peripheral branches of trigeminal nerve can
not occur during sleep.
be blocked by the intraoral injection of
● Many patients will lead a very poor quality of life,
95% absolute alcohol in small quantities
because of excruciating pain.
(0.5–2 mL).
● It is very common for these patients to undergo
● This produces anaesthesia of the region sup-
indiscriminate dental extractions on the affected
plied by the branch.
side without any relief from pain, because the
● Repeated alcohol injections should be avoided,
pain of the trigger zone and the pain fibre distribu-
as it causes local tissue toxicity, inflammation
tions, often mimic pain of odontogenic origin.)}
and fibrosis.
● It can also cause a complication of burning al-
[SE Q.1] cohol neuritis. The results are variable.
● Extraoral injections into maxillary and man-
{Management
Treatment can be divided into: dibular division of the trigeminal nerve at the
I. Medicinal level of the base of the skull also can be
II. Surgical given.
● Peripheral injections – infraorbital, mental and
I. Medicinal management inferior alveolar nerve blocks can be given
● This is the first-line approach for most of the patients. depending on the involvement.
● TN does not respond to analgesics including Peripheral neurectomy (nerve avulsion)
opiates.} ● Simple, oldest and most effective technique which
can be repeated and is a relatively reliable method of

(SE Q.1 and SE Q.6)
nerve avulsion.
● {(Carbamazapine 100 mg three times a day ● It acts by interrupting the flow of a significant
● When carbamazepine is contraindicated, clonaz- number of afferent impulses to central trigeminal
epam 15 mg day can be used apparatus.
● Tab. Phenytoin: Dose – 100 mg three times a day ● Indicated in patients in whom craniotomy is contra-
● Tab. Oxcarbazepine 1200 mg/day indicated, because of age, debility or significant
● Valproic acid 600 mg/day systemic diseases with limited life expectancy.
● Mephenesin Carbamate (Tolceram) 5–15 mL ● Performed most commonly on infraorbital, inferior
five times a day for every 3 h alveolar, mental and rarely lingual nerves.
Other less toxic agents ● It has a disadvantage of producing full anaesthesia or
● Baclofen (Lioresal) 10 mg t.d.s. Side effects deep hypoesthesia related dysfunction.
include fatigue and vomiting ● To achieve better results, the peripheral nerve is al-
● Neurontin is the recently introduced drug ways avulsed both from the bone as well as from the
● Lamotrigine soft tissues.
● Gabapentin ● The duration of pain remission after neurectomy
● Felbamate may be lengthened, if the cut nerve end is cauter-
● Topiramate ized or redirected and sutured into viable muscle,
● Vigabatrin)} periosteum or bone tissue to prevent active neuroma
II. Surgical management (peripheral nerve surgical formation.
treatments) ● The bony foramen may be plugged with nonabsorb-
Peripheral injections able material or by the bone piece itself.
a. Long-acting anaesthetic agents without ● The procedure is carried out under general anaesthe-
adrenaline sia to ensure successful avulsion.
[SE Q.3] ● The antral mucoperiosteal flap in the vestibule is

repositioned and sutured back.
{Infraorbital neurectomy Complications
It can be performed through (i) conventional intraoral ap- ● Inadvertent section of the vessels in the pterygopala-
proach or (ii) Braun’s transantral approach. tine fossa.

i. Conventional intraoral approach ● Inadvertent sectioning of the branches of the spheno-
● A U-shaped Caldwell–Luc incision is made in the palatine ganglion or the vidian nerve entering the
upper buccal vestibule in the canine fossa region. posterior aspect of the ganglion.}
● Mucoperiosteal flap is reflected superiorly to lo- Inferior alveolar neurectomy
cate the infraorbital foramen. ● It can be performed via intraoral or extraoral ap-
● Once the nerve is exposed, all the peripheral proach.

branches are held with the haemostat and avulsed ● The intraoral approach is preferred, as it is simple
from the skin surface intraorally. and more cosmetic.

● Then the entire trunk separated from the skin sur- 1. Extraoral approach
face is held with the haemostat at the exit point ● It is through Risdon’s incision, where after re-
from the foramen and is removed by winding it flection of masseter, a bony window is drilled
around a haemostat and pulling it out from the in outer cortex and nerve is lifted with nerve
foramen. hook and avulsed from its superior attachment;
● The infraorbital foramen may be plugged with and mental nerve is avulsed anteriorly through
polyethylene plug and wound is closed with inter- the same approach.
rupted sutures. 2. Intraoral approach via Dr Ginwalla’s incision
ii. Braun’s transantral approach (1977) ● It is mainly used in dentulous cases.
● It has got the potential to have sound treatment for ● Incision is made along the anterior border of
intractable V2 neuralgia, because of the direct ac- ascending ramus, extending lingually and buc-
cess and visualization it provides. cally and ending in a fork, like an inverted Y.
● With sectioning of the maxillary nerve, anaesthe- ● Such incision provides better exposure of the
sia is created over its entire distribution. field.

● An intraoral incision is made from the maxillary ● The incision is then deepened on the medial
tuberosity to the midline in the maxillary vesti- aspect of the ascending ramus by means of
bule. blunt and sharp dissection.
● The mucoperiosteal flap is reflected to expose the ● The temporalis and medial pterygoid muscles
anterior and lateral maxillary antral wall, the zy- are split, rather than divided at their insertion
goma and the infraorbital nerve. and the inferior alveolar nerve is located.
● A 3 cm window is made in the anterolateral wall ● Two heavy black linen threads are then looped
of the maxillary sinus. around the nerve using nerve hook and then
● The operating microscope is usually required for divided between the two threads.
the remainder of the procedure. ● This is done as high as possible and the upper
● The lining in the posterosuperior portion of the end is cauterized while dividing and lower end
antrum is carefully excised and bone is removed is held with the haemostat.
to create a posterior window. ● Another linear incision is made in the buccal
● Careful dissection is now performed to expose the vestibule overlying the mental foramen.
descending palatine branches of V2, which are then ● A mucoperiosteal flap is reflected to expose the
traced superiorly to the sphenopalatine ganglion. mental nerve.

● In order to provide anatomical verification, the ● It is then tied with heavy black linen just little
infraorbital nerve is identified in the roof of the away from the foramen.
maxillary sinus and is carefully followed posteri- ● The nerve is then caught with the haemostat
orly to the trunk of V2 near the sphenopalatine distal to the knot and is divided between the two.
ganglion. ● The distal part held between the haemostat is
● Dissection is then completed by isolating and wound around it and the peripheral branches
identifying the trunk of V2 superiorly and posteri- entering the mucosa are avulsed out.
orly to the sphenopalatine ganglion. ● There is puckering of the skin surface seen
● The trunk of the maxillary nerve (V2) is then sec- during this procedure.
tioned posterior near the foramen rotundum to the ● Now after the mental nerve is freed, then at the
inferior orbital fissure. mandibular foramen, the distal part of the

nerve which is held with the haemostat is ● Infections: Acute otitis media and Herpes simplex
pulled, until the entire nerve length of the canal virus infection
is avulsed out. ● Exposure to common cold
● If any obstruction is encountered, a window Clinical features of Bell palsy

may be made in the buccal cortex posterior to ● Paralysis of facial nerve causes loss of all or many of
the mental foramen along the level of the infe- the functions as mentioned.
rior alveolar canal and the nerve is lifted out of ● Most commonly seen in middle-aged females, mostly
the canal through the window. unilaterally.

● The wound is closed with interrupted sutures. ● The patient cannot close his eyes on the affected side
Lingual neurectomy due to loss of muscle control, which results in con-

● A vertical incision is made at the inner border of the stant watering from eyes that can cause conjunctival
ascending ramus, extending from the coronoid pro- dryness or even ulceration.
cess down the level of the floor of the mouth. ● Drooping of the corner of the mouth on the affected
● Keeping the two sides of the incision retracted, the side.

dissection is continued downwards until the lingual ● The corner of the mouth on the affected side does not
nerve comes into view at the border of the medial rise during smile and this gives the patient a typical
pterygoid muscle. ‘mask-like’ expressionless appearance.
● In the region of the floor of the mouth, the nerve lies ● Patients have difficulties in speech, taking food and
even more superficially and it can be easily found there may be even loss of taste sensations.
between the anterior pillar of the fauces at the root of ● They cannot raise their eyebrows and there is no
the tongue. wrinkle formation in their forehead.

● After dissection, the nerve is grasped with a haemo- ● Patient fails to blow whistle.
stat and is then either avulsed or cauterized and cut.

Q.3. Infraorbital neurectomy.
● The wound is closed with interrupted sutures.
Ans.
Q.3. Classification of injuries of trigeminal nerve.
[Ref LE Q.2]
Ans.
Q.4. Atypical facial pain.
[Same as LE Q.1]
Ans.
Q.4. What is trigeminal neuralgia? Describe the various
Atypical facial pain
medical and surgical treatments.
Atypical facial pain refers to mixed group of conditions,
Ans. which are defined and diagnosed by exclusion of the
other typical patterns of facial pain.
[Same as LE Q.2]
It is also called as typical facial neuralgia, idiopathic
facial pain, atypical trigeminal neuralgia and trigeminal
SHORT ESSAYS: neuropathic pain.
There is occurrence of strong emotional overtones of
Q.1. Trigeminal neuralgia.
the condition.
Ans. It is usually psychogenic and occurs in patients who suf-
fer from depressive reaction, hysteria or schizophrenia.
[Ref LE Q.2]
Clinical features
Q.2. Aetiology and clinical features of Bell palsy. ● Common in sixth decade and women most com-
monly affected.
Ans.
● The condition is characterized by pain that is deep,
Aetiology of Bell palsy poorly localized and vaguely described by the patient.
● Change in the atmospheric pressure, e.g. while flying ● Pain is often boring, pressing, pulling, burning or
or dying aching. Distribution of pain is not anatomical, in

● Malignant tumours of parotid gland and brain general it is constant.
● Stroke ● Pain is referring to temple, neck and occipital area.
● Surgical procedures in the parotid region ● The mucosa of the affected person may contain zone
● Meningitits of increased temperature and bone marrow activity
● Head injuries showing hot spot on Technitium -99m diphosphonate
● Multiple sclerosis (MDP) bone scan.
Management Q.9. Any four clinical characteristics of trigeminal neu-

● Opioid analgesics can be given to patient, but they ralgia.
may be diminished over a period of time.
Ans.
● Tricyclic antidepressants like amitriptyline and nor-
triptyline are used for many cases. These should be [Same as SE Q.1]
given cautiously for the patient suffering from coro-
Q.10. Management of trigeminal neuralgia.
nary heart disease.
● Other therapies like psychotherapy, behaviour modi- Ans.
fication, transcutaneous electrical nerve stimulation
[Same as SE Q.1]
and sympathetic nerve block are helpful in atypical
facial pain. Q.11. Facial palsy.
Q.5. Trigger zones. Ans.

[Same as SE Q.2]
Ans.
Q.12. Cryosurgery – principles and indications in oral
[Ref LE Q.2]
lesions.
Q.6. Analgesics for orofacial pain. Ans.
Ans. [Same as SE Q.7]
[Ref LE Q.2]
Q.7. Cryosurgery.
SHORT NOTES:
Ans.
Q.1. Bell palsy.
Ans.
{SN Q.3}
Bell palsy
Cryosurgery Bell palsy refers to the paralysis of facial nerve resulting
Cryosurgery is the technique of using extreme rapid in inability to control the facial muscles on the affected side
cooling to freeze and thereby destroy tissue. of the face.
Rapid cooling to temperatures below freezing point Aetiology of Bell palsy
produces a localized destructive effect than slow ● Change in the atmospheric pressure, e.g. while flying
freezing, which causes generalized tissue necrosis. or dying
The apparatus consists of: ● Malignant tumours of parotid gland and brain
1. Bottles for storage of pressurized liquid gases. ● Surgical procedures in the parotid region
2. Liquid nitrogen gives a temperature of –196°C, ● Meningitits
while liquid carbon dioxide or nitrous dioxide ● Head injuries
gives a temperature between –20 and –90°C. ● Multiple sclerosis
3. A pressure and a temperature gauge. ● Infections: Acute otitis media and herpes simplex
4. A probe: The probe is connected to the bottles virus infection
via a tube through which the pressurized gas ● Exposure to common cold
can be directed at the tissue to be destroyed. Clinical features
It is applied in the treatment of malignancies, vas- ● Paralysis of facial nerve causes loss of all or many of
cular tumours and aggressive tumours like amelo- the functions as mentioned.
blastoma. ● Most commonly seen in middle-aged females, mostly
unilaterally.
● The patient cannot close his eyes on the affected side
Q.8. Clinical features and medical management of tri- due to loss of muscle control, which results in con-
geminal neuralgia. stant watering from eyes that can cause conjunctival
dryness or even ulceration.
Ans. ● Drooping of the corner of the mouth on the affected
[Same as SE Q.1] side.

The corner of the mouth on the affected side does not

● Q.5. Tinnel’s sign.
rise during smile and this gives the patient a typical
Ans.
‘mask-like’ expressionless appearance.
● Patients have difficulties in speech, taking food and Tinnel’s sign
there may be even loss of taste sensations. ● Tinnel’s sign was used earlier as an indication of the
● They cannot raise their eyebrows and there is no start of nerve regeneration.
wrinkle formation in their forehead. ● It is elicited by percussion over the divided nerve,
● Patient fails to blow whistle. which results in a tingling sensation in the part sup-
Management plied by the peripheral section.
● No specific treatment.
Q.6. Bell sign.
● Administration of histamines or nicotinic acid has
been beneficial in some cases. Ans.

● Physiotherapy is also helpful in some patients.
[Same as SN Q.1]
● The eye on the affected side has to be protected from
infections by using protective glasses, eye drops and Q.7. What is cryosurgery?
ointments.
Ans.
Q.2. What are trigger zones? Name their location on the
[Same as SE Q.7]
face with the relevant nerve.
Ans.
[Ref LE Q.2]
Q.3. Cryosurgery.
Ans.
[Ref SE Q.7]
Q.4. Pathways of pain.
Ans.
Receptors
g
Fibres carrying pain take origin
g
They merely pass through chief sensory nucleus
in PONS
g
Fibres descend down in CNS and synapse in spinal
nucleus of V nerve
g
Second-order fibre takes origin and crosses midline
g
They ascend up a trigeminal lemniscus to reach thalamus
and synapse in VPM nucleus
g
From here third-order fibres take origin and pass
through internal capsule
g
Ends up in cerebral cortex area no. 3, 1 and 2
(Centre for pain perception)
Topic 16
Preprosthetic Surgery
LONG ESSAYS:
1. Classify preprosthetic surgical procedure and the procedure to increase the depth of lingual sulcus. Add a note
on Kazanjian’s technique.
2. What is preprosthetic surgery? Describe how will you perform in upper anterior region?
3. Enumerate various alveoloplasty techniques and describe anyone technique for anterior maxillary object reduc-
tion in detail.
4. Define preprosthetic surgery. Discuss in detail the various preprosthetic procedures to improve the bony alveolar
ridge.
5. What do you mean by preprosthetic surgery? What are the aims of it? Describe various alveolar ridge altering
procedures. [Same as LE Q.4]
SHORT ESSAYS:
1. Alveoloplasty.
2. Alveolectomy. [Ref LE Q.2]
3. Vestibuloplasty.
4. Describe the steps of Obwegeser’s vestibuloplasty.
5. Preprosthetic surgery. [Ref LE Q.2 and LE Q.1]
6. Ridge augmentation procedure.
7. Frenectomy. [Ref LE Q.2]
8. Torus palatinus.
9. Give the indications for excision of tori and describe the procedure of removal of mandibular torus.
10. Describe one surgical procedure for deepening of mandibular buccal sulcus.
11. Dean’s alveoloplasty. [Same as SE Q.1]
12. Clark’s vestibuloplasty. [Same as SE Q.3]
SHORT NOTES:
1. Dean’s alveoloplasty. [Ref SE Q.1]
2. Mandibular ridge augmentation. [Ref LE Q.2]
3. Vestibuloplasty. [Ref LE Q.1]
4. Preprosthetic surgery of tuberosity.
5. What are possible intraoperative complications of lingual frenectomy?
6. High labial frenum. [Ref LE Q.2]
7. Genioplasty.
8. Torus palatinus. [Ref SE Q.8]
9. Torus mandibularis. [Ref SE Q.9]
10. Alveolectomy. [Ref LE Q.2]
11. Sulcus extension.
12. Give the names of any four instruments used in the ‘alveoloplasty’ procedure along with their functions.
[Same as SN Q.1]
13. Give the indication for Dean’s alveoloplasty. How does it differ from Obwegeser’s alveoloplasty? [Same as SN Q.1]
1 4. Ridge augmentation procedure. [Same as SN Q.2]
15. Kazanjian’s technique for vestibuloplasty. [Same as SN Q.3]
1 6. Frenectomy. [Same as SN Q.7]

17. Genioplasty – Indication diagnosis technique. [Same as SN Q.8]
18. Mandibular tori. [Same as SN Q.9]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Classify preprosthetic surgical procedure and the i i. Caldwell’s technique
procedure to increase the depth of lingual sulcus. Add a Combination vestibuloplasty (labial and lingual)
note on Kazanjian’s technique. i. Obwegeser’s technique
D. Mental nerve transpositioning
Ans.
E. Ridge augmentation procedures
F. Alveolar distraction osteogenesis}
[SE Q.5] Soft tissue attachments on the lingual aspect can interfere
{I. Initial preparations with prosthetic rehabilitation. Posteriorly, the mylohyoid
A. Correction of soft tissue deformities muscle and anteriorly, the genioglossus muscle on the lin-
a. Frenectomy gual surface of the mandible are the two problem areas.
i. Labial I. Technique provides an adequate denture-bearing
ii. Lingual area, hence improves retention and stability.
b. Correction of mobile soft tissue on the alveolar II. Eliminates the muscle attachments that dislodge the
ridge prosthesis.
c. Denture granuloma III. Used in the mandible, when the mylohyoid and ge-
B. Correction of hard tissue deformities – Alveoloplasty nioglossus attachments are close to the alveolar
● Torus removal ridge.
● Mandibular Following methods are adapted for lingual vestibuloplasty:
● Maxillary ● Trauner’s technique
● Sharp ridge removal ● Caldwell’s technique
● Shelf reduction ● Obwegeser’s technique (1963)
● Resection of genial tubercle Caldwell’s technique

C. Correction of soft and hard tissue deformities – ● An incision is made in the crest of the posterior man-
Tuberosity dibular ridge extending from one molar to the other

● Tuberosity reduction region.
● Tuberoplasty ● Subperiosteal dissection is carried out and thick-
II. Secondary preparations ness mucoperiosteal flap is elevated and reflected

A. Epulis fissuratum removal medially.
B. Correction of reactive inflammatory papillary hyper- ● The mylohyoid muscle is detached and mylohyoid
plasia ridge is removed or reduced.

C. Ridge extension procedures ● The subperiosteal stripping is carried out till the de-
a. Labiobuccal vestibuloplasty sired depth and so even to the inferior border of the
i. Mucosal advancement vestibuloplasty mandible.
● Closed submucous vestibuloplasty ● A rubber catheter is placed in the bottom of the lin-
● Open view vestibuloplasty gual sulcus and is secured with percutaneous suture.
ii. Secondary epithelialization It is left in place for 7–10 days.
● Labial approach
● Kazanjian’s method {SN Q.3}

● Godwin’s method
Kazanjian’s technique for vestibuloplasty
● Lipswitch method
● An incision is made in the mucosa of the lip and
● Clark’s method
a large flap of labial and vestibular mucosa is
iii. Grafting vestibuloplasty
retracted.
● Obwegeser’s method
● The mentalis muscle is detached from the perios-
iv. Maxillary pocket inlay vestibuloplasty
teum to required depth, and the vestibule is deep-
b. Lingual vestibuloplasty
ened via supraperiosteal dissection.
i. Trauner’s technique
Indications
● A flap of the mucosa is turned downwards from
● High attachments of labial frenum or bands at-
the attachment of the alveolar ridge and is placed
tached near the alveolar crest in the buccal regions
directly against the periosteum to which it is su-
often displace the dentures during function.
tured.
● Many times ulceration can be seen at the frenal
● A rubber catheter stent can be placed in the deep-
attachments due to impingement of the denture
ened sulcus and secured with percutaneous
peripheries. One option is to relieve the denture
sutures.
borders at these attachments. But for persistent
● This catheter helps to hold the flap in its new posi-
problem, frenectomy should be considered.)}
tion and maintain the depth of the vestibule. It is
ii. Alveoloplasty (dense hydroxyapatite alveolar ridge
removed after 7 days.
augmentation)
● The labial donor site is coated with tincture of
● Midline maxillary incision initially is carried
benzoin compound, and the surface heals by
down through periosteum unless simultaneous
granulation and secondary epithelialization. Con-
blind submucosal vestibuloplasty is indicated.
tracture of the wound margins takes place.
● Periosteum is incised after submucosal vestibulo-
plasty is performed.
● Incision is performed on facial side of alveolus for
patient with class I and class II deficiency and

Q.2. What is preprosthetic surgery? Describe how will
lateral to mandibular ridge for those with class III
you perform in upper anterior region?
and class IV deficiency.
Ans. ● The subperiosteal pockets are then filled with hy-
droxyapatite particles delivered from custom plas-

[SE Q.5] tic syringe.
{Preprosthetic surgery
‘Preprosthetic surgery is that part of oral and maxillofa- {SN Q.2}
cial surgery that restores oral function and facial form
rendered deficient through loss or absence of teeth and I I. Hard tissue procedures
associated structures as a result of disease, trauma or i. Ridge augmentation
elective surgery for tumour and other conditions. This is In this procedure, augmentation of the bone is
concerned with surgical modification of the alveolar achieved by building up the atrophied jawbone
process and its surrounding structures to enable the fab- using autogenous bone, homogeneous bone or
rication of a well-fitting comfortable and aesthetic den- alloplastic material.
tal prosthesis’.} Criteria for ridge augmentation
Preprosthetic surgeries for upper anterior region ● Gross atrophy of the jaws with the possibil-
I. Soft tissue procedures ity of mandibular fracture

i. Frenectomy ● Medically fit middle-aged or young indi-
They are of two types: viduals

i. Labial ● Atrophy of the jaws causing prosthetic dif-
ii. Lingual ficulties

Goals of ridge augmentation
(SE Q.7 and SN Q.6) ● Restoration of the optimum ridge height and
● {(A frenum is a fold of tissue or muscle connecting width, vestibular depth, ridge form and opti-
lips, cheek or tongue to the jawbone. mum denture-bearing area
● To increase retention and stability of the
● A frenectomy is removal of one of these folds of tis-
sues. denture
● To attain a proper interarch relationship to
● Patients receiving dentures may need a frenectomy if
the position of the frenum interferes with the proper protect the neurovascular bundle
fit of the denture, thereby frequently ulcerating and
reducing the stability of the denture. ii. Vestibuloplasty/sulcus extension
● Procedures performed on the labial frenum and lin- ● Deepening of the vestibule without any addition of
gual frenum are termed as labial frenecotmy and the bone is termed as vestibuloplasty or sulcoplasty
lingual frenectomy, respectively. or sulcus deepening procedure.
● Vestibuloplasty can be done in the maxilla or in 2. Intraseptal alveoloplasty – Dean’s alveoloplasty

the mandible or in both the jaws. with repositioning of labial cortical bone
● Whenever there is an inadequate vestibular depth 3. Obwegeser’s modification for intraseptal alveolo-
present. plasty
● To increase the retention and stability of the denture. 4. Alveoloplasty after postextraction healing
● For deepening of the vestibule, sufficient amount 5. Alveoloplasty performed on the edentulous ridge
of height of the alveolar bone should be available. Technique
● An impression of the ridge is made before the sur-
gery, cast is poured and the areas which require re-
iii. {(Alveolectomy duction are marked on the cast.
● Surgical removal or trimming of the alveolar pro- ● Mock surgery is carried out and once the irregulari-
cess is termed as alveolectomy. ties are removed from this cast and the shape is ideal,
● Clinically, after extraction, whenever there is a a template is constructed with clear acrylic.
presence of sharp margins at interdental, intersep- ● When surgery is done at the time of extraction of
tal or labiobuccal alveolar crest, they should be teeth, the incision is placed along the free gingival
trimmed with rongeur or round bur and smooth- margin and a full thickness mucoperiosteal flap is
ened with bone file. elevated, which extends up to one tooth distance on
● The trimming of the alveolar process should be either side of the bony surgery. The tooth is extracted
carried out judiciously. and a sharp cutting rongeur forceps is held with one
● Care is taken so that only minimum amount of beak beneath the bony rim of the socket and the other
areas is trimmed. on the crest of the ridge.
● Too much bone loss will result into poor denture ● Small pieces of required amount of bone are then
base.)} removed and then finally, bone file is used to

smoothen the bone. The mucous membrane is then
Q.3. Enumerate various alveoloplasty techniques and held with sutures over the interradicular bony
describe anyone technique for anterior maxillary object septa.
reduction in detail. ● If any excess flap is present, it is trimmed away and
the edges are approximated. Now, previously pre-

Ans.
pared template is fitted on and one should be noted
Alveoloplasty for the presence of any pressure points indicated by
Alveoloplasty is the term used to describe the trimming the blanching of the mucosa under the transparent
and removal of the labiobuccal alveolar bone along acrylic template. If such pressure points are present,
some interdental and interradicular bone, and is carried then they should be again trimmed.
out at the time of extraction of teeth.
Indications Q.4. Define preprosthetic surgery. Discuss in detail the
● Patients with prominent and dense alveolar bone various preprosthetic procedures to improve the bony
undergoing extraction. alveolar ridge.
● Done as a procedure prior to immediate denture.
Ans.
Goals
● To provide optimal ridge contour quickly. Preprosthetic surgery
● The alveolar ridges should be left as broad as for ‘Preprosthetic surgery is that part of oral and maxillofa-
maximum distribution of the masticatory load. cial surgery that restores oral function and facial form
● The ridge need not be perfectly smooth, but sharp rendered deficient through loss or absence of teeth and
irregularities should be removed and the edge should associated structures as a result of disease, trauma or
be rounded. elective surgery for tumour and other conditions. This is
● The mucosa covering the ridge should have uniform concerned with surgical modification of the alveolar
thickness, density and compressibility for even process and its surrounding structures to enable the fab-
transition of the masticatory forces to the underlying rication of a well-fitting comfortable and aesthetic den-
bone. tal prosthesis’.
Various alveoloplasty techniques are Alveolar ridge can be corrected by:
1. Simple conservative alveoloplasty with multiple A. Bony surgeries
extractions B. Soft tissue surgeries
Bony surgeries III. Very rarely it is removed, when the patient fears of
● Labial alveolectomy malignancy.
● Primary alveoloplasty 3. Sharp ridge removal
● Secondary alveoloplasty ● The irregular and sharp bony edges cause great
● Excision of tori denture irritation. They are usually found in the

● Reduction of genial tubercle anterior part of the mandible. Localized tender-
● Reduction of mylohyoid ridge ness over such ridge on palpation or on wearing
● Maxillary tuberosity reduction and exostosis removal denture is common. As a result, they are trimmed
Soft tissue surgeries to a depth of 1–2 mm with the help of rongeurs,
● Removal of redundant crestal soft tissue bone files or burs; and the wound closed with silk
● Frenectomy – Labial and lingual sutures. The ridge can further be supported with a
● Excision of epulis fissurata and palatal papillary relined existing denture with soft acrylic.
hyperplasia 4. Shelf reduction
1. Alveoloplasty ● Mandibular lingual shelf along with the mylohyoid
● Alveoloplasty is the term used to describe the muscle insertion becomes more prominent and su-
trimming and removal of the labiobuccal alveolar perficial in the due course of time due to atrophy of
bone along some interdental and interradicular the mandible. A sharp lingual shelf interferes with the
bone, and is carried out at the time of extraction denture construction and insertion, and the mylohy-
of teeth. oid muscle attachment here dislodges the denture.
● A well-contoured smooth ridge is essential for Therefore, this shelf needs to be reduced and the
proper construction of denture. While contouring mylohyoid muscle attachment should be released.
the ridge, it is highly essential to remember that 5. Resection of genial tubercles
greater the excision of bone greater will be the ● The two genial tubercles located superiorly are
resultant resorption. more prominent than the inferior due to the re-
● Therefore, procedure of contouring should be sorption of the mandibular ridge. This may ele-
limited to the excision of irregular sharp ridges vate the ridge lingually giving a shelf-like appear-
and unfavourable undercuts are unsuitable for the ance making the anterior lingual seal impossible.
denture construction. It is also a frequent site of ulceration when a lower
2. Torus removal denture is used, hence needs trimming.
● Tori are small developmental anomalies that oc- 6. Alveolectomy
cur in constant sites on the jawbones. ● Surgical removal or trimming of the alveolar pro-
● A torus palatinus is an exostosis found along the cess is termed as alveolectomy.

line of the hard palate. Not all the tori require re- ● Clinically, after extraction, whenever there is a
moval, as all of them do not cause prosthetic dif- presence of sharp margins at interdental, intersep-
ficulty. tal or labiobuccal alveolar crest, they should be
Indications trimmed with rongeur or round bur and smooth-
● Smooth maxillary torus can be ignored. But, when it ened with bone file.
is extensively irregular, large and extends beyond ● The trimming of the alveolar process should be
junction of the hard and soft palate and interferes carried out judiciously.
with the post-dam seal of the denture, it should be ● Care is taken so that only minimum amount of
removed. areas is trimmed.

● Torus that is subjected to constant masticatory ● Too much bone loss will result into poor denture
trauma. base.
● When it interferes with normal speech. Aims of preprosthetic surgery
● When the patient fears of malignancy. ● It should provide adequate residual tissue with proper
Mandibular tori configuration, which can support and retain the den-
● It is an exostosis located on the lingual aspect of ture and withstand masticatory stress.
mandible in the region of the premolar, above the ● It should help in proper speech and deglutition.
mylohyoid line. They may be unilateral or bilateral. ● It should satisfy the aesthetic concerns of the patient.
Indications ● It should remove all the hard and soft tissue protu-
I. It is removed, if lower denture is to be constructed. berances and undercuts.

II. It should be removed, if there is chronic irritation. ● It should provide adequate vestibular depth.
● It should provide appropriate frenal attachment.

Technique
● It should achieve proper jaw relationship in antero-
● Local anaesthesia is secured and incision is made
posterior, transverse and vertical dimension.
along the gingival margin with epithelial attach-
● To relocate the mental nerve and establish correct
ment and interdental papilla left attached to the
vestibular depth.
respective teeth. An envelope flap is raised as
● It should reduce the pain and discomfort produced by
much conservatively as possible.
the denture pressure on a narrow alveolar ridge and
● Now, the teeth are extracted starting from the ca-
unsupported (by soft tissue) alveolus due to the pres-
nine to the incisors. After extraction of the teeth,
ence of superficial mental nerve or an impacted or
the interradicular bony septa should be removed
buried tooth or root which was asymptomatic prior to
with a rongeur forceps introduced into the socket
denture placement.
to separate the labial and palatal cortical plate.
Q.5. What do you mean by preprosthetic surgery? What ● A V-shaped excision of the bone is done in the
are the aims of it? Describe various alveolar ridge alter- labial cortical plate distal and posterior to the
ing procedures. canine eminence as close to the alveolus as pos-
sible. Thus, three sides of the labial cortex be-
Ans.
come free and the labial cortex becomes a freely
[Same as LE Q.4] movable osteoperiosteal graft attached to only
the mucoperiosteum from which it receives its
blood supply.
SHORT ESSAYS: ● Now, finger pressure is applied to the labial corti-
Q.1. Alveoloplasty. cal plate which is collapsed towards the socket.

After the removal of any infected gingival tissue,
Ans.
sutures are placed to stabilize the tissues.
Alveoloplasty
This procedure helps in eliminating anterior maxillary Q.2. Alveolectomy.
undercuts and reducing the large anterior maxilla.
Ans.
● The procedure involves separation of six anterior teeth
and sometimes the premolars are included. The advan- [Ref LE Q.2]
tage of this technique is that since it retains much of the
Q.3. Vestibuloplasty.
compact labial cortical bone, it reduces resorption of the
bone postoperatively. This procedure is used at the time Ans.
of extraction only.
Clark’s vestibuloplasty
Dean’s intraseptal alveoloplasty is based on the following Clark’s technique is the reverse technique of Kazanjian’s
biological principles: technique. It is based on the following principles:
The prominence of the labial and buccal alveolar mar- ● Raw surface on connective tissue contracts; whereas,
gin is reduced to facilitate the reception of dentures. when covered with epithelium the contracture is mini-
● The muscle attachments are undisturbed. mum.
● The periosteum remains intact. ● Raw surface on bone does not undergo contracture.
● The cortical plate is preserved as a viable onlay bone ● For repositioning and fixation, epithelial flap must be
graft with an intact blood supply. undermined adequately.
● Because the cortical bone is spared, postoperative re- ● Soft tissues which are repositioned tend to return to
sorption is minimized. their normal position, therefore over correction is neces-
sary.
Technique
In this procedure, a flap is pedicled of the lip along the
{SN Q.1} alveolar process leaving a raw surface on the bone
According to Dean, the most posterior teeth should be instead of on the lip. An incision is made slightly at
removed first to preserve the integrity of labial cortical the crest of the alveolar ridge. The dissection is car-
plate and avoid any disturbance to its blood supply. For ried supraperiosteally till the desired depth of the
example, the cuspids should be removed before the inci- sulcus mucosa is undermined up to the vermilion bor-
sors, to avoid fracturing and removing the labial cortex der, so that free edge of the mucosal flap is secured to
attached to the cuspid teeth. the periosteum deep in the sulcus. The raw surface on
the bone heals by granulation tissue formation and
epithelialization without contracture. Initially, the Mandibular and maxillary augmentation procedure
depth of the sulcus is maintained for a long time. But Mandibular augmentation procedures
the drawback of the technique is that, as the days pass, 1. Superior border augmentation
the attachment of the lip musculature to the alveolar a. Bone graft
bone shifts towards the alveolar crest thus obliterating b. Cartilage graft
the sulcus. c. Alloplastic graft
2. Inferior border augmentation
Q.4. Describe the steps of Obwegeser’s vestibuloplasty.
a. Bone graft
Ans. b. Cartilage graft
3. Interpositional or sandwich bone grafting
Obwegeser’s vestibuloplasty
a. Bone graft
● This technique is very similar to Clark’s technique. The
b. Cartilage graft
difference is that here the raw surface of the ridge with
c. Hydroxyapatite blocks
its periosteal attachment is covered with a split thick-
4. Visor osteotomy
ness skin graft in order to maintain the depth of the
5. Onlay grafting
vestibule at the desired level.
Maxillary augmentation procedures
● Mucosal grafts can also be used for this purpose. In
1. Onlay bone grafting
all the above cases, new prosthesis is made after
2. Onlay grafting of alloplastic material
4–5 weeks.
3. Interpositional or sandwich graft
● The flange of the new denture should be of sufficient
4. Sinus lift procedures
length to maintain the new depth of the sulcus. The
Augmentation with orthognathic surgery
denture flange should not irritate the periosteal surface.
1. Mandibular osteotomy procedures
● Corticosteroids can sometimes be injected into the ves-
2. Maxillary osteotomy procedures
tibule to reduce the scar contracture. In spite of all the
3. Combination procedures
efforts to increase the vestibular depth, 50% relapse can
take place. Q.7. Frenectomy.
● Therefore, overcorrection is done to compensate this
Ans.
relapse. When the residual bony ridge is too small to
perform overcorrection, a free epithelial graft should be [Ref LE Q.2]
considered to cover the wound.
Q.8. Torus palatinus.
Q.5. Preprosthetic surgery. Ans.
Ans.
{SN Q.9}
[Ref LE Q.2 and LE Q.1]
Torus palatinus
Q.6. Ridge augmentation procedure. A torus palatinus is an exostosis found along the line
Ans. of the hard palate. Not all the tori require removal, as
all of them do not cause prosthetic difficulty.
Ridge augmentation Indications
In this procedure, augmentation of the bone is achieved ● Smooth maxillary torus can be ignored. But,
by building up the atrophied jawbone using autogenous when it is extensively irregular, large and extends
bone, homogeneous bone or alloplastic material. beyond junction of the hard and soft palate and
Criteria for ridge augmentation interferes with the post-dam seal of the denture, it
● Gross atrophy of the jaws with the possibility of should be removed.
mandibular fracture. ● Sometimes the torus may be subjected to constant
● Medically fit middle-aged or young individuals. trauma during mastication.
● Atrophy of the jaws causing prosthetic difficulties. ● When it interferes with normal speech.
Goals of ridge augmentation ● When the patient fears of malignancy.
● Restoration of the optimum ridge height and width,
vestibular depth, ridge form and optimum denture-

bearing area. Technique
● To increase retention and stability of the denture. ● Before surgical excision of the tori, an impression be
● To attain a proper interarch relationship to protect the made and the cast poured. The tori should be in this
neurovascular bundle. cast and an acrylic stent made. Removal of tori
involves a Y-incision for small tori and a double ● Excess soft tissue is trimmed and the wound irrigated
Y-incision for the large tori. and sutured back.
● A full thickness mucoperiosteal flap is elevated care- Precaution
fully to expose the tori entirely. The tori is divided by ● To prevent formation of sublingual haematoma.
vertical and anteroposterior bur cuts to a depth just While removing bilateral mandibular tori, the flap
above the level of horizontal palatal shelf in order to should be kept intact in the midline.
prevent any fracture of the palate and perforation into ● Gauze piece is placed below the torus to prevent the
oral cavity. These cut sections are removed with the excised bone into the soft tissues to prevent space
chisel and mallet. The surface should be finely infection.
smoothened using large bone files or vulcanite bur.
Q.10. Describe one surgical procedure for deepening of
The tori can removed with the help of acrylic bur
mandibular buccal sulcus.
alone without the chisels, but this may cause acci-
dental perforation of nasal cavity or trauma to the Ans.
soft tissues. This area be copiously irrigated and the
Visor osteotomy
mucoperiosteal is trimmed accordingly and sutured
● The goal of Visor osteotomy is to increase the height
back. The acrylic which was initially constructed
of the mandibular ridge for denture support.
must be inserted now. Stent supports the flap and
● The Visor osteotomy consists of central splitting of
prevents any haematoma formation and covers the
the mandible in buccolingual dimension and the su-
wound. The stent can be used, as the wound healing
perior positioning of the lingual section of the man-
is completed.
dible, which is wired in position.
Complications
● Cancellous bone graft material is placed at the outer
● The risk of creation of oronasal fistula is more, ow-
cortex over the superior labial junction for improving
ing to the thin palatal shelf.
the contour.
Q.9. Give the indications for excision of tori and de- Modified visor osteotomy
scribe the procedure of removal of mandibular torus. ● Consists of splitting of mandible buccolingually by
vertical osteotomy only in the posterior regions and

Ans.
a horizontal osteotomy in the anterior region.
● The posterior lingual segments are then pushed supe-
{SN Q.10} riorly on both the sides and anterior fragment is also
Mandibular tori pushed superiorly and fixed with wires to the poste-
Mandibular torus is an exostosis located on the rior newly mobilized lingual segments.
● Corticocancellous bone graft particles with hydroxy-
lingual aspect of the mandible in the region of
the premolar, above the mylohyoid line. They may be apatite granules are placed in the gap between the
unilateral or bilateral. superior and inferior anterior segments. Rest of the
Indications for removal graft material can be moulded on the buccal aspect of
● Removed if lower denture is to be constructed.
the posterior segments.
● It should be removed, if there is chronic irritation.
Advantage
● If the patient fears of malignancy.
Eighty per cent of the height is maintained at the end of
3–5 years.
Disadvantages
● Nerve paraesthesia and dysaesthesia
Technique
● Need for hospitalization
● Inferior alveolar nerve and lingual nerve block are
● Donor site morbidity
given along with local infiltration on the tori.
● Inability to wear the dentures for 3–5 months follow-
● Once anaesthesia is secured, incision is made on the
ing surgery
crest of the alveolar ridge for sufficient length to
expose the entire tori. Q.11. Dean’s alveoloplasty.
● In case of edentulous patients, incision can be placed Ans.
on the lingual gingival sulcus.
● Soft tissues are elevated using periosteal elevator to
[Same as SE Q.1]
expose the tori. Q.12. Clark’s vestibuloplasty.
● Using a chisel, bur or rongeurs, tori is removed and
Ans.
the rough bony surface is smoothened using a bone
file. [Same as SE Q.3]
SHORT NOTES: ● Genioplasties can be used to straighten or lengthen the

chin.
Q.1. Dean’s alveoloplasty.
Ans.
Ans.
[Ref SE Q.1]
[Ref SE Q.8]
Q.2. Mandibular ridge augmentation. Q.9. Torus mandibularis.
Ans. Ans.
Q.3. Vestibuloplasty. Q.10. Alveolectomy.
Ans. Ans.
Q.4. Preprosthetic surgery of tuberosity. Q.11. Sulcus extension.
Ans. Ans.
● In the tuberosity, hamular notch region helps in reten- Sulcus extension

tion of denture and also aids in peripheral seal of the Deepening of the vestibule without any addition of the
maxillary denture. bone is termed as vestibuloplasty or sulcoplasty or sulcus
● This procedure is undertaken to increase the depth be-
deepening procedure. Vestibuloplasty can be done in the
tween the hamular notch and the distal aspect of the maxilla or in the mandible or in both the jaws.
● Whenever there is an inadequate vestibular depth
maxilla.
● Tuberoplasty is carried out under general anaesthesia. In
present.
● To increase the retention and stability of the denture.
this technique, tuberoplasty is done to deepen the hamu-
● For deepening of the vestibule.
lar notch, by repositioning the pterygoid plate and the
hamulus in the posterior direction. Sufficient amount of height of the alveolar bone should
Q.5. What are possible intraoperative complications of be available.
lingual frenectomy? Q.12. Give the names of any four instruments used in
the ‘alveoloplasty’ procedure along with their functions.
Ans.
Ans.
Intraoperative complications of lingual frenectomy
● Injury to superior lingual vessels [Same as SN Q.1]
● Injury to Wharton’s duct/papilla Q.13. Give the indication for Dean’s alveoloplasty. How
Q.6. High labial frenum. does it differ from Obwegeser’s alveoloplasty?
Ans.
Ans.
[Same as SN Q.1]
[Ref LE Q.2]
Q.14. Ridge augmentation procedure.
Q.7. Genioplasty.
Ans.
Ans.
[Same as SN Q.2]
Genioplasty
Q.15. Kazanjian’s technique for vestibuloplasty.
● Genioplasty can be used as a single procedure. It can be
used as an adjunctive procedure along with major oste- Ans.

otomies of the jawbone. [Same as SN Q.3]
● The deformities of the chin should be considered in all
three planes, i.e. anteroposterior, vertical and transverse. Q.16. Frenectomy.

Morphology of the symphysis region is highly variable Ans.
in different individuals even with the same basic types
of dentofacial deformities. [Same as SN Q.7]
Q.17. Genioplasty – Indication diagnosis technique. Q.18. Mandibular tori.

Ans. Ans.
Topic 17
Premalignant and Malignant Lesions
LONG ESSAYS:
1 . Describe the surgical management of squamous cell carcinoma involving the lateral border of tongue.
2. Define and classify tumours. TNM classification and staging in oral malignancy. Add a note on radiotherapy and
chemotherapy in the management of oral cancers.
3. Discuss the management of oral submucous fibrosis.
4. What is the role of chemotherapeutic agents used in the management of oral malignancies?
5. Enumerate premalignant conditions and premalignant lesions of oral mucosa. Describe in detail any two of
them.
6. Classify the white lesions of the mouth. Describe in detail the clinical features, differential diagnosis and man-
agements of oral lichen planus.
SHORT ESSAYS:
1 . Leukoplakia. [Ref LE Q.5]
2. Submucous fibrosis. [Ref LE Q.5]
3. T.N.M. classification. [Ref LE Q.2]
4. Squamous cell carcinoma of lip.
5. Erythroplakia.
6. Lichenoid reaction.
7. Cellular change in radiation and its manifestation.
8. Leukoplakia treatment. [Same as SE Q.1]
9. Treatment plan of leukoplakia. [Same as SE Q.1]
SHORT NOTES:
1. Radiotherapy. [Ref LE Q.2]
3. Oral submucous fibrosis. [Ref LE Q.5]
4. Carcinoma in situ.
5. Premalignant conditions.
6. Premalignant lesions.
7. Neck metastasis.
8. Aetiology of leukoplakia. [Ref LE Q.5]
9. Mention any four premalignant white patches.
10. En bloc resection.
11. Chemotherapy.
1 2. Erosive lichen planus. [Ref LE Q.6]

13. Radiotherapy for oral carcinoma. [Same as SE Q.1]
14. Submucous fibrosis. [Same as SN Q.3]
15. Chemotherapy in oral surgery. [Same as SN Q.11]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Describe the surgical management of squamous TNM staging.
●
cell carcinoma involving the lateral border of tongue. Incisional biopsy.
●
Treatment
Ans. ● The tumour can be treated through surgery and
Squamous cell carcinoma radiation.

● Generally, the primary tumour is excised with
● Squamous cell carcinoma is defined as ‘a malignant
epithelial neoplasm exhibiting squamous differentia- 1.5 cm margins for T1N0M0 lesions.
● Treating the neck prophylactically with either an
tion as characterized by the formation of keratin and/
or the presence of intercellular bridges’. incontinuity functional neck dissection or radio-
● The most common malignant neoplasm of the oral
therapy in a dose of 5000 cGy to 6500 cGy is rec-
cavity is epidermoid carcinoma. Although it may oc- ommended for T2N0M0 and more advanced stages.
● If the incisional biopsy shows that the lesion is
cur at any intraoral site, certain sites are more fre-
quently involved than others. greater than 3 mm depth of invasion for nodal in-
Aetiology vasion disease of N1, then functional neck dissec-
● Tobacco: Its effect is synergistic with alcohol
tion is recommended. For nodal disease of N2 or
● HIV infected
N3, modified radical neck dissection is preferred
● Immunosuppressed individuals
followed by postoperative radiotherapy.
● Low consumption of vitamins A and C Q.2. Define and classify tumours. TNM classification
● UV light and staging in oral malignancy. Add a note on radio-
● Syphilitic history therapy and chemotherapy in the management of oral
● Leukoplakia cancers.
● Chronic irritation/trauma
Ans.
● Poor oral hygiene
Clinical features ● A ceaseless, purposeless, uncoordinated and uncon-

● Painless mass or ulcer. trolled growth of the tissue resulting from multiplication
● The tumour begins as a superficially indurated of its cell; and if the condition persists even after the
ulcer with slightly raised borders and may pro- stimulus or the initiating factors is removed, then it is
ceed to develop a fungating, exophytic mass or known as a tumour.
may proceed to infiltrate the deep layers of the Classification of tumours
tongue, producing fixation and induration without I. Tumours of ectodermal origin
much surface change. A. Benign
● Typical lesion develops on the lateral border or i. Ameloblastoma
ventral surface of the tongue. ii. Adenoameloblastoma
● The colour of the lesion is red and white. iii. Calcifying epithelial odontogenic tumour
● It can appear as exophytic or ulcerated leuko- iv. Ameloblastic fibroma
plakia. v. Odontogenic fibroma
● In some lesions, tumour cells infiltrate muscle fi- vi. Odontogenic myxoma
bres of the tongue. vii. Cementoma
Differential diagnosis viii. Odontomes
● Ulcerations due to trauma B. Malignant
● Primary syphilis i. Intra-alveolar carcinoma
Diagnosis ii. Squamous cell carcinoma from the cyst lining
● Clinical examination includes head and neck ex- II. Tumours of mesodermal origin
amination followed by a fiberoptic examination of A. Benign
the laryngopharynx. i. Odontogenic myxoma
ii. Odontogenic fibroma

● Radiation prevents the cells from multiplying, by
iii. Cementifying fibroma
interfering with their nuclear material. Normal
B. Malignant
host cells are also affected by radiation and must
i. Odontogenic sarcoma
be protected as much as possible during treatment.
III. Tumours of ectodermal and mesodermal origin
The principal methods employed are
(mixed)
i. X-ray therapy
A. Benign
a. Superficial X-ray therapy 45–100 kV
i. Ameloblastic fibroma
b. Kilo voltage X-ray therapy 300 kV
ii. Ameloblastic fibro-odontoma
ii. Electron therapy
B. Malignant
iii. Surface applicator (radium mould)
i. Ameloblastic fibrosarcoma
iv. Interstitial implantation (radium source)
[SE Q.3]
{TNM staging system l Most commonly, radiation is delivered exter-
TNM staging system is developed by The American nally by the use of large X-ray generators.
Joint Committee on Cancer. l The normal amount of tolerable radiation for a
Clinical and histopathological T classification of can- person should not be exceeded and adjacent
cer of the oral cavity uninvolved areas are spared by the protective
TX: Primary tumour cannot be assessed. shielding.
T0: No evidence of primary tumour. l The patient’s host tissues are protected from
T: Carcinoma in situ. radiation by two mechanisms of delivery:

T1: Tumour 2 cm or less in greatest dimension. i. Fractionation
T2: Tumour more than 2 cm, but not more than 4 cm ii. Multiple ports
in greatest dimension. Chemotherapy in the management of oral cancers
T3: Tumour more than 4 cm in greatest dimension. ● Chemicals that act on various types of tumour cells
T4: Tumour invades adjacent structures. are used to treat malignancies. They are not very se-
Clinical and histopathological N classification of lective in their action and may harm normal cells as
cancer of the oral cavity well.
NX: Regional lymph nodes cannot be assessed. ● Chemotherapy is basically palliative in cases having
N0: No regional lymph node metastasis. relapse after extensive surgery and radiation.
N1: Metastasis in ipsilateral single lymph node 3 cm ● Methotrexate, vincristine, bleomycin and cisplatin
or less in greatest dimension. are used in combination.

N2a: Single ipsilateral lymph node greater than ● Most recently used drugs are platinum compounds
3 cm, but less than 6 cm in greatest dimension. mostly in combination with 5-fluorouracil.
N2b: Multiple ipsilateral nodes up to 6 cm in greatest ● Taxanes are the newer agents known to stabilize
dimension. microtubular formation and disrupt cells during

N2c: Bilateral or contralateral lymph nodes up to M-phase of cell cycle.
6 cm in greatest dimension. ● They are given intravenously. They affect body sys-
N3: Metastasis in lymph nodes greater than 6 cm in tems like the haemopoietic system.
greatest dimension. ● Multiple agent therapy is preferred to reduce the
Clinical and histopathological M classification of toxicity of a single agent.

cancer of the oral cavity ● Intra-arterial therapy is reserved for T3 and T4 le-
MX: Distant metastasis cannot be assessed. sions, because of the difficulty in performing and
M1: No distant metastasis. maintaining catheterization. The drugs are intro-
M2: Distant metastasis.} duced through the external carotid artery.
● Chemotherapy is of two types: (i) primary chemo-
{SN Q.1} therapy and (ii) adjuvant chemotherapy.
I. Primary chemotherapy
Radiotherapy in the management of oral cancers
● It refers to use of chemotherapy before starting
● Tumour cells in stages of active growth are more
local therapy of radiation or surgery or after local
susceptible to ionizing radiation than adult tis-
treatment.
sues. The faster the cells are multiplying or the
● It consists of induction of cisplatin and bleomycin
more undifferented tumour cells, the more likely
combination given for two cycles prior to local
that radiation will be effective.
treatment.
II. Adjuvant chemotherapy ● For surgical excision of fibrous bands and sub-
● Given after surgery or radiation to eradicate mi- mucosal placement of fresh human placenta
crometastasis. grafts, dexamethasone is injected.
VI. Physiotherapy
Q.3. Discuss the management of oral submucous l Forceful mouth opening after surgical proce-
fibrosis. dure is absolutely essential to prevent high re-

currence rate.
Ans.
l Heat therapy in the form of warm saline gar-
Management of oral submucous fibrosis gles, short wave diathermy or microwave dia-
I. Restriction of the habits: It is safe to restrict betel thermy is given.
nut chewing and to avoid spicy food.
II. Nutritional support: Vitamin B complex and iron Q.4. What is the role of chemotherapeutic agents used in
therapy and long-term therapy of antioxidants. the management of oral malignancies?
III. Intralesional injection: Steroids are injected with
Ans.
the aim of antifibrinolytic and antiinflammatory
therapy. Intralesional injection of 1 mL suspension Chemotherapy
containing hydrocortisone along with 1 mL of lig- ● Chemicals that act on various types of tumour cells
nocaine hydrochloride once a week. It may be in- are used to treat malignancies. They are not very se-
creased to twice a week depending on the severity lective in their action and may harm normal cells as
of the disease. well.
IV. Medications: Antioxidants like retinoid, beta caro- Chemotherapeutic approaches
tene and vitamin E prevent the formation of toxic ● Combination therapy
substances and enhance the indigenous concentra- ● Induction chemotherapy
tion of vitamin A. The functional and structural in- ● Concomitant chemotherapy
gredients of epithelial cells are dependent on ade- ● Adjuvant chemotherapy
quate concentration of vitamin A. ● Palliative chemotherapy
V. Surgical treatment ● Chemoprevention
● Surgical treatment is indicated in two types of Commonly used chemotherapeutic agents

cases: ● Methotrexate, vincristine, bleomycin and cisplatin
a. Patients with marked limitation of mouth are used in combination.

opening ● Most recently used drugs are platinum compounds
b. Case, where biopsy has revealed dysplastic or mostly in combination with 5-fluorouracil.
neoplastic changes ● Taxanes are the newer agents known to stabilize
● Skin grafts give better results in small lesions. microtubular formation and disrupt cells during
Coverage of the small area with full thickness M-phase of cell cycle.
flaps like nasolabial, tongue and palatal flaps ● They are given intravenously. They affect body sys-
have provided better long-term relief. Soft laser tems like the haemopoietic system.
is used to reduce scar formation further. ● Multiple agent therapy is preferred to reduce the
● Severe OSMF involving the lamina propria and toxicity of a single agent.
upper submucosa are excised with a wide field ● Intra-arterial therapy is reserved for T3 and T4 le-
excision in the area of clinical involvement, until sions, because of the difficulty in performing and
the soft tissue release is sufficient to gain an maintaining catheterization. The drugs are intro-
opening in excess of 35 mm between the erupted duced through the external carotid artery.
incisors. Sometimes, excision of a small portion ● Vincristine, bleomycin and methotrexate are used in
of muscles is also required. combination. Most recently used drugs are platinum
● Excision of fibrous bands and covering defect compounds mostly in combination with 5-fluorouracil.
with split skin graft. ● Sarcoma is treated with combinations of vincristine,
● This procedure can be combined with bilateral actinomycin D, cyclophosphamide and doxorubicin.
temporalis myotomy or coronoidectomy. Intralesional chemotherapy
● In several patients to give long-term relief of se- ● Intralesional injection of vinblastine, vincristine or
vere trismus caused by OSMF excision of fi- interferon – Alpha has been shown to be effective in
brotic bands and reconstruction with bilateral the local control of epidemic Kaposi sarcoma and
full thickness, nasolabial flaps has been used suc- can be used in combination with systemic chemo-
cessfully. therapy or radiotherapy.
● If necessary, lesions are reinjected at 3–6 week inter- ● Hot, cold, spicy and acidic foods and beverages
vals. No lesions require more than three injections ● Alcoholic mouth rinse
for initial control; some lesions recur later and re- ● Occlusal trauma
quire additional injections. ● Sharp edges of prosthesis and teeth
Topical chemotherapy ● Actinic radiation
● Actinic keratotic lesions have been effectively treated ● Syphilic
with the application of 5% fluorouracil cream. ● Presence of Candida albicans
● Fluorouracil cream is applied twice daily until the ● Presence of viruses)}
area exhibits a significant inflammatory reaction and
ulceration (usually 3–4 weeks). [SE Q.1]
● Similar topical application of fluorouracil in selected
cases of multiple superficial basal cell carcinomas as

{Types of leukoplakia
● Homogenous type
may be seen in basal cell nevus syndrome has been
● Speckled type
effective.
● White and red patches
● It is not effective for invasive lesions and results in
● Verrucous type
needless delay in definitive therapy. Surgical exci-
Clinical features
sion is still the treatment.
● Asymptomatic – Discovered during routine oral ex-
Chemoprevention
amination.
● Chemoprevention includes strategies to prevent or
● More common in older age group .35 years, espe-
reverse carcinogenesis before an invasive cancer de-
cially in men.
velops or to prevent a second primary cancer in pa-
● Lips, vermillion, buccal mucosa, mandibular gin-
tients who have had a previous strategy for upper
giva, tongue oral floor and hard palate are the most
aerodigestive tract cancer in cessation of smoking.
frequent sites.
● Retinoids: Molecular biology has provided new in-
● The floor of the mouth, lateral borders of tongue and
formation on how retinoids regulate gene expression.
soft palate are high-risk sites for malignant transfor-
This has led to the development of synthetic reti-
mation.
noids, which may be less toxic and more effective in
● Lesions may vary greatly in size, shape and distribu-
the prevention of cancer.
tion. The borders may be distinct or indistinct, and
● The use of chemopreventives should be limited to
smoothly contoured or ragged.
controlled clinical trials.
● The surface texture can vary from smooth thin sur-
Q.5. Enumerate premalignant conditions and premalig- face to leathery appearance with surface fissures re-
nant lesions of oral mucosa. Describe in detail any two ferred to as ‘cracked mud’.
of them. ● The non-homogenous type of oral leukoplakia also
known as erythroplakia or speckled leukoplakia may

Ans.
have white patches or plaque intermixed with red
Premalignant lesions tissue elements.
● Leukoplakia ● Verrucous leukoplakia has papillary projections sim-
● Leukoedema ilar to oral papillomas.}

● Erythroplakia Differential diagnosis
● Smoker’s palate i. Lichen planus
Premalignant conditions ii. Leukoedema (cheek biting lesions)
● Oral submucous fibrosis iii. Smoker’s tobacco lesions
● Lichen planus iv. Lupus erythematosus
● Intraepithelial carcinoma
[SE Q.1]
(SE Q.1 and SN Q.8)
{Management
{(I. Leukoplakia i. Elimination of aetiological factors
● It is defined as a predominantly white lesion of the Discontinuation of habits like alcohol and smoking by
oral mucosa that cannot be characterized as any the patients are well established risk factors.
other definable lesion. ii. Conservative therapy
Aetiology Vitamin therapy, especially vitamins A and E,
● Tobacco products B complex, 13-cis-retinoic, antioxidant therapy and
● Ethanol nystatin therapy.
iii. Surgical therapy Management

l Cold knife surgical excision i. Restriction of the habits: It is safe to restrict betel
l Laser surgery nut chewing and to avoid spicy food.
l Cryosurgery ii. Nutritional support: Vitamin B complex and iron
l Fulguration therapy and long-term therapy of antioxidants
l Re-examining the site every 3 months for the first iii. Intralesional injection: Steroids are injected with
year the aim of antifibrinolytic and anti-inflammatory
l Follow-up for every 6 months, if the lesion does therapy. Intralesional injection of 1 mL suspen-
not relapse or change in reaction pattern sion containing hydrocortisone along with 1 mL
l If new clinical features emerge, then new biopsies of lignocaine hydrochloride once a week is rec-
should be taken.} ommended. It may be increased to twice a week
depending on the severity of the disease.
(SE Q.2 and SN Q.3) iv. Medications: Antioxidants like retinoid, beta car-
otene and vitamin E prevent the formation of
{(II. Oral submucous fibrosis
toxic substances and enhance the indigenous con-
● It is a chronic scarring disease that affects the oral
centration of vitamin A. The functional and struc-
mucosa as well as the pharynx and upper two-third
tural ingredients of epithelial cells are dependent
of the oesophagus. It is a high-risk precancerous
on adequate concentration of vitamin A.
condition.
v. Surgery: Skin grafts give better results in small
lesions. Coverage of the small area with full
i. Chronic irritation from betel nut, i.e. areca nuts,
thickness flaps like nasolabial, tongue and palatal
chillies, tobacco and lime
flaps have provided better long-term relief. Laser
ii. Genetic predisposition
is used to reduce scar formation further.}
iii. Nutritional deficiency
iv. Bacterial infections
Q.6. Classify the white lesions of the mouth. Describe in
v. Collagen disorders
detail the clinical features, differential diagnosis and
vi. Immunological disorders)}
managements of oral lichen planus.
[SE Q.2] Ans.
{Clinical features White lesions of the mouth
● It equally affects both the sexes. i. Variations in structure and appearance of the normal
● It affects the patients of age group between second oral mucosa
and fourth decades. ● Leukoedema
● Most frequent locations are buccal mucosa and retro- ● Fordyce granules
molar areas. ● Linea alba and other areas of frictional corni-
● Most common initial symptoms are burning sensa- fication
tion of oral mucosa, which is aggravated by spicy ii. Nonkeratotic white lesions
food followed by either hypersalivation or dryness of ● Habitual cheek biting
mouth. ● Burns (thermal, aspirin and dental medicaments)
● The first sign is erythematous lesion sometimes ● Caused by specific infectious agents
associated with petechiae, pigmentations and ves- iii. Candidiasis
icles. ● Acute pseudomembranous candidiasis
● Initial lesions are followed by paler mucosa, which ● Acute atrophic candidiasis
comprises marbling. ● Chronic atrophic candidiasis
● Fibrotic bands located beneath an atrophic epithe- ● Median rhomboid glossitis
lium are the most prominent clinical feature. ● Chronic hyperplastic candidiasis
● Increased fibrosis leads to loss of resilience, which iv. Keratotic white lesions with no increased potential
causes interference with speech, tongue mobility and for the development of oral cancer
a decreased ability to open the mouth. ● Stomatitis nicotina
● The atrophic epithelium may cause a smarting sensa- ● Traumatic keratosis
tion and inability to eat hot and spicy food. ● Intraoral skin grafts
● Diagnosis of OSMF is based on clinical feature and ● Focal epithelial hyperplasia
patient’s report of habit of betel quid chewing. ● Psoriasiform lesions
● Intralesional triamcinolone injected in 1 mL in-

{SN Q.12}
crements may also be used for focal symptomatic.
Lichen planus ● Most erosive lichen planus requires systemic
● It is a T-cell mediated autoimmune interface, in corticosteroid regimen I or II and only rarely III A
which the basal cell layer of mucosa and/or skin or III B.
is attacked. ● Griseofulvin or topical fluocinonide or topical
Clinical features fluocinonide can be added to either regimen to

● It presents in one of the three clinical forms, reduce the prednisone requirements or help main-
i.e. reticular form, plaque form and erosive tain a remission.
form. ● Topical retinoids and vitamin A analogue for re-
● All forms are seen in patients older than ticulous lichen planus.
40 years and equally in men and women.
● Predilection for buccal mucosa, the tongue and SHORT ESSAYS:
the attached gingiva is more. Q.1. Leukoplakia.
Ans.
Reticular form is characterized by Wickham’s striae
of lacy white interlacing lines found mostly on buc- [Ref LE Q.5]
cal mucosa, attached gingiva and tongue. These
Q.2. Submucous fibrosis.
striae are asymptomatic.
Plaque form is characterized by white patch or leu- Ans.
koplakia appearance. These plaques are slightly ele-
[Ref LE Q.5]
vated and irregular hyperkeratotic in form. They are
usually asymptomatic, but may sometimes cause Q.3. TNM classification.
discomfort. Biopsy is required to differentiate this
Ans.
lesion from premalignant or malignant mucosal
changes. [Ref LE Q.2]
Q.4. Squamous cell carcinoma of lip.
{SN Q.12} Ans.
Erosive form is characterized by intense pain and ery- Squamous cell carcinoma of lip
thematous mucosal inflammation. When it involves buc- ● Squamous cell carcinoma is defined as ‘a malignant
cal mucosa or tongue, it will produce fibrinous-based epithelial neoplasm exhibiting squamous differentia-
ulcers against a background of erythema and sometimes tion as characterized by the formation of keratin and/
hyperkeratotic foci. Some lesions present as vesicle for- or the presence of intercellular bridges’.
mation and Nikolsky’s sign. ● The most common malignant neoplasm of the oral
cavity is epidermoid carcinoma.
Differential diagnosis ● Squamous cell carcinoma occurs mostly in elderly
● Clinical leukoplakia men. The lower lip is more commonly involved as
● Benign hyperkeratosis compared to the upper lip.
● Epithelial dysplasias Aetiology
● Verrucous hyperplasia ● Tobacco through pipe smoking. The heat, the
● Verrucous carcinoma trauma of the pipe stem and possibly the combus-
● Invasive squamous cell carcinoma tion end products of tobacco may be of some
● Hypertrophic candidiasis significance.
● Chronic ulcerative stomatitis ● Syphilis.
Management ● Sunlight.
● The milder cases of erosive lichen planus and ● Poor oral hygiene.
some symptomatic cases of the other forms of- ● Leukoplakia.
ten can be managed with topical corticoste- Clinical features
roids, usually 0.05% fluocinonide gel four ● The clinical appearance depends on duration of
times daily or combined with antifungal agent the lesion and nature of the growth. The tumour
griseofulvin 250 mg of the micronized form usually begins on the vermillion border of the lip
twice daily. to one side of the midline.
It starts as a small area of thickening, induration

● ● The surface texture can vary from smooth thin
and ulceration or irregularity of the surface. surface to leathery appearance with surface fis-
● As the lesion becomes larger, it may create a sures referred to as ‘cracked mud’.
small crater-like defect or produce an exophytic ● The nonhomogenous type of oral leukoplakia also
and proliferative growth of tumour tissue. known as erythroplakia or speckled leukoplakia

● Some patients may have small fungating masses may have white patches or plaque intermixed with
in relatively short time, while in other patients the red tissue elements.
lesion may be only slowly progressive. ● Verrucous leukoplakia has papillary projections
● As it is slow to metastasize, a massive lesion may similar to oral papillomas.

develop before any regional lymph nodes are in- Management
volved except for anaplastic ones. i. Elimination of aetiological factors: Discontinua-
● When metastasis does occur, it is usually ipsilateral tion of habits like alcohol and smoking by the
and involves the submental and submaxillary nodes patients which are well established risk factors.
and sometimes contralateral metastasis may occur. ii. Conservative: Vitamin therapy especially vita-
Treatment min A and E, B complex, 13-cis-retinoic, anti-
● Surgery or X-ray can be used depending on the oxidant therapy and nystatin therapy.
size of the lesion, its duration, the presence or iii. Surgical therapy: Cold knife surgical excision
absence of metastatic lymph nodes and the histo- l Laser surgery
logic grade of the lesion. l Cryosurgery
l Fulguration
Q.5. Erythroplakia. iv. Re-examining the site every 3 months for the
first year. Follow-up for every 6 months, if the
Ans.
lesion does not relapse or change in reaction
Erythroplakia pattern.
● Erythroplakia is used analogously to leukoplakia to v. If new clinical features emerge, then new biop-
designate lesions of the oral mucosa that present as sies should be taken.
bright red velvety plaques, which cannot be charac-
terized clinically or pathologically as due to any Q.6. Lichenoid reaction.
other condition.
Ans.
Aetiology
● Tobacco products Lichenoid reaction
● Ethanol ● A characteristic lesion consisting of white, wavy,
● Hot, cold, spicy and acidic foods and beverages parallel and nonelevated striae that do not criss-cross
● Alcoholic mouth rinse is observed in habitual betel quid chewers. Some-
● Occlusal trauma times, these striae radiate from a central erythema-
● Sharp edges of prosthesis and teeth tous area at the site of placement of betel quid.
● Actinic radiation Clinical features
● Syphilic ● The lesions always occur on the buccal mucosa
● Presence of Candida albicans and mandibular groove areas, which are in inti-
● Presence of viruses mate contact with the betel quid.
Clinical features ● The factors involved are the immune mechanism,
● Asymptomatic – Derived during routine oral ex- the susceptibility of the individual and the trigger-
amination. ing drug.
● More common in older age group .35 years, es- There are four general drug reaction mechanisms:
pecially in men. i. Histamine release: Certain drugs directly
● Frequent sites are lips, vermillion, buccal mucosa, stimulate degranulation of fixed tissue mast
mandibular gingiva, tongue oral floor and hard cells. Common offending drugs are narcotics,
palate. morphine, meperidine hydrochloride and co-
● The high-risk sites for malignant transformation deine; and many antimicrobials such as van-
are floor of the mouth, lateral borders of tongue comycin and amphotericin B.
and soft palate. ii. IgE-mediated reactions: Other drugs indi-
● Lesions may vary greatly in size, shape and distri- rectly cause histamine release, as they contain
bution. The borders may be distinct or indistinct an antigenic site that causes it to be bound to
and smoothly contoured or ragged. IgE fixed to the cell membranes of mast cells.
iii. Antigen–antibody complexes: If a drug is Although they live out their normal life spans or short-
taken over a long period, then circulating an- ened life spans, these impaired cells often are not re-
tibodies to it may slowly develop. Over time, placed by daughter cells when they die.
new antigen–antibody complexes may get ● Consequently, the tissue becomes less cellular, less vas-
lodged in the skin or any organ to initiate in- cular and less oxygenated over time. The well-known
flammation. ‘three H tissue’ develops which progresses and there-
iv. Cytotoxic drug reactions: Some drugs before worsens over time. This explains why irradiated
come bound to cell membranes in one or tissue heals slowly or not at all.
many organs as part of their mechanism of
Q.8. Leukoplakia treatment.
action or their elimination. If through sensiti-
zation the drug has stimulated antibody pro- Ans.
duction by the coupling of antibody to the
[Same as SE Q.1]
antigen fixed to the cell membrane, then the
drug may cause cell lysis. Q.9. Treatment plan of leukoplakia.
Treatment
Ans.
● Identify the drug and discontinue its use.
● If the reaction is anaphylaxis, then full cardiopulmo- [Same as SE Q.1]

nary resuscitation and cardiac life support may be
needed. If the reaction is known to be drug precipi-
tated, then 0.3 mL of 1:1000 epinephrine solution SHORT NOTES:
subcutaneously should be part of the resuscitation.
Q.1. Radiotherapy.
● If the reaction is clinically angioedema, then air-
way is observed. For histamine releasing reac- Ans.

tions, diphenhydramine hydrochloride 50 mg IV
[Ref LE Q.2]
remains the best option for reversal of symptoms.
● If the offending drug cannot be discontinued, then Q.2. Osteoradionecrosis.
prednisone is a reasonable therapeutic choice. It
Ans.
should be in the lowest dose possible, to maintain
control of the reaction. Osteoradionecrosis
● Osteoradionecrosis is bone death caused by radia-
Q.7. Cellular change in radiation and its manifestation. tion injury.

● It is not an infection of compromised bone, as had pre-
Ans.
viously been thought, but an avascular necrosis of bone
● Radiation is high linear energy transferred to tissue with caused by the three H tissue effects of radiotherapy.
the intention to kill cancer cells, but normal cells are ● Infections associated with oteoradionecrosis are sec-
also damaged. ondary infections due to the exposure of bone and

● Cancer cells replicate more frequently than normal deep tissue plans.
cells, as they are more likely to be irradiated at a vulner- ● There are three types of osteoradionecrosis: Early
able time in their cell cycle. trauma-induced osteoradionecrosis, spontaneous os-

● However, many normal cells are also caught at vulner- teoradionecrosis and late trauma-induced osteoradio-
able times in their cell cycle, thereby creating the radia- necrosis.
tion sensitivity spectrum. Germinal and lymphoreticular
Q.3. Oral submucous fibrosis.
cells are the most sensitive, endothelial cells and fibro-
blasts are of intermediate sensitivity and the muscle and Ans.
the nerve have little sensitivity to radiation.
[Ref LE Q.5]
● It is the intermediate group of endothelial cells and fi-
broblasts that is important to the clinician, because they Q.4. Carcinoma in situ.
are the primary cells involved with healing.
Ans.
● When radiation energy passes through normal tissue, it
kills a small number of cells immediately. Most cells ● Carcinoma in situ is also known as intraepithelial carci-
survive, but incur internal damage to their DNA, RNA, noma.
enzyme systems and cell membranes. ● It is a condition which arises frequently on the skin, but
● These cells, mainly the vascular endothelial cells and occurs also on mucous membranes including those of
healing related fibroblasts, can be considered impaired. the oral cavity.
● Carcinoma in situ is used for lesions in which epithelial ● The groups of nodes are localized between the ster-
changes occur throughout their entire thickness, but nocleidomastoid and trapezius muscle. Parotid nodes
without violation of the basement membrane. drain the buccal mucosa.
● The submandibular nodes drain the ipsilateral, upper and
Q.5. Premalignant conditions. lower lip, cheek, nose, nasal mucosa, medical canthus,
Ans. anterior gingiva, anterior tonsillar pillar, soft palate, ante-
rior two-thirds of the tongue and submandibular gland.
Premalignant conditions ● The submental nodes drain the mentum, the middle
● It is a generalized state associated with a signifi-
portion of the lower lip, the anterior gingiva and the
cantly increased risk of cancer. anterior portion of the tongue.
These alterations include genetic changes, epigenetic ● The sublingual nodes drain the anterior floor of the
changes and surface alterations in intercellular inter- mouth and ventral surface of the tongue.
actions. ● The other nodes are retropharyngeal nodes, anterior
● The diagnosis of precancers is primarily based on
cervical nodes, juxta visceral nodes, pretracheal
morphology and its grading on histology (dysplasia). group, paratracheal nodes, latetral cervical nodes, the
● Despite the fact that this estimation is subjective and
deep group of nodes, internal jugular chain, deep
therefore carries a low prognostic value of an im- posterior cervical group and postauricular nodes.
pending malignancy, it is still widely practiced to ● Radiological investigations of cervical metastasis
assess the risk of malignant potential of such lesions. can be done by ultrasound, CT scan, MRI and posi-
● Because of this inherent discrepancy, such lesions
tron emission tomography imaging.
may well be designated as potentially malignant.
Example of premalignant condition is oral submu- Q.8. Aetiology of leukoplakia.
cous fibrosis. Ans.
Q.6. Premalignant lesions. [Ref LE Q.5]
Ans. Q.9. Mention any four premalignant white patches.
Premalignant lesions Ans.
● It is defined as morphologically altered tissue in
which cancer is more likely to occur than in its ap- Premalignant white patches
● Leukoplakia
parently normal counterpart.
● Lichen planus
● These alterations include genetic changes, epigenetic
● Leukoedema
changes and surface alterations in intercellular inter-
● Lichenoid reaction
actions.
● The sum total of these physical and morphological Q.10. En bloc resection.
alterations are of diagnostic and prognostic relevance
and are designated as ‘precancerous’ changes. Ans.
● The diagnosis of precancers is primarily based on En bloc resection
morphology and its grading on histology (dysplasia). ● In en bloc resection, the tumour is removed along
● Despite the fact that this estimation is subjective with a rim of uninvolved bone, while maintaining the
and therefore carries a low prognostic value of an continuity of the jaw.
impending malignancy, it is still widely practiced ● This is the treatment of choice for aggressive lesions
to assess the risk of malignant potential of such with high recurrence rate.
lesions. ● Intraoral approach is used for lesions anterior to the
● Because of this inherent discrepancy, such lesions ramus of the mandible; whereas those lesions involving
may well be designated as potentially malignant. the ramus of the mandible are approached extraorally.
Example of premalignant lesion is leukoplakia.
Q.11. Chemotherapy.
Q.7. Neck metastasis.
Ans.
Ans.
● Chemicals that act by interfering with rapidly growing
Neck metastasis tumour cells are used for treating many types of malig-
● Careful clinical evaluation is done with careful pal- nancies.
pation of the neck with specific attention to location, ● Infections and bleeding are therefore common compli-
size, firmness and mobility of each node. cations in these patients.

● They are introduced through branches of the external Q.14. Submucous fibrosis.
carotid artery including even the superficial temporal
Ans.
branch in a retrograde fashion.
[Same as SN Q.3]
Q.12. Erosive lichen planus.
Q.15. Chemotherapy in oral surgery.
Ans.
Ans.
[Ref LE Q.6]
[Same as SN Q.11]
Q.13. Radiotherapy for oral carcinoma.
Ans.
[Same as SN Q.1]
Topic 18
Management of Medically Compromised
Patients and Medical Emergencies
LONG ESSAYS:
1. How do you manage a patient for tooth extraction with (a) diabetes mellitus, (b) bacterial endocarditis and
(c) bronchial asthma?
2. What are the common medical emergencies in dental practice? How would you manage syncope?
3. Describe the treatment plan of extraction in patients with history of (a) hepatitis B and (b) anticoagulant
therapy.
4. Haemophilia.
5. Cardiopulmonary resuscitation.
6. Define shock. Discuss the pathogenesis, clinical features and management of hypovolaemic shock.
7. Various types of haemorrhage encountered in oral surgery and its treatment.
8. What are all the various complications that can occur in oral surgery? Discuss dry socket in detail.
9. What precautions can you take while carrying out dental treatment for a patient suffering from haemophilia?
[Same as LE Q.4]
10. Discuss ‘shock’ in oral surgery. [Same as LE Q.6]
11. Classify the shock. Discuss in detail the pathogenesis, clinical features and management of haemorrhagic
shock. [Same as LE Q.6]
12. Discuss the management of haemorrhage in oral surgery. [Same as LE Q.7]
SHORT ESSAYS:
1 . Tracheostomy.
2. Minor oral surgeries in diabetic patients.
3. Haemophilia. [Ref LE Q.4]
4. Shock in oral surgery.
5. Hyperparathyroidism.
6. Blood groups.
7. Indications for blood transfusion.

8. Hepatitis B infection. [Ref LE Q.3]
9. Bacterial endocarditis.
10. Cricothyrotomy.
11. Types of haemorrhage. [Ref LE Q.7]
12. Contents of medical emergency drug tray in dental office.
13. Describe briefly the management of a hypertensive patient for teeth extraction in dental chair.
14. Oral manifestations of HIV infection.
15. Haemophilia A. [Same as SE Q.3]
16. Haemophilia patient for dental extraction. [Same as SE Q.3]
17. Management of anaphylactic shock. [Same as SE Q.4]
18. Hyperparathyroidism investigations. [Same as SE Q.5]
19. Blood grouping and transfusion. [Same as SE Q.6]
20. Autologous blood transfusion. [Same as SE Q.7]
21. Blood transfusion reactions. [Same as SE Q.7]
22. Prophylaxis for subacute bacterial endocarditis. [Same as SE Q.9]
23. Postextraction haemorrhage management. [Same as SE Q.11]
SHORT NOTES:
1. Define tracheostomy and mention five of its indications. [Ref SE Q.1]
2. Cricothyroidotomy. [Ref SE Q.10]
3. Define shock. [Ref LE Q.6]
4. Neurogenic shock.
5. Name four blood products that can be transfused parenterally with one indication for each.
6. HIV. [Ref SE Q.14]
7. Post-HIV exposure prophylaxis.
8. Bacterial endocarditis. [Ref SE Q.9]
9. Hyperthyroidism.
10. Hyperventilation.
11. Anaphylaxis.
12. Haemophilia.
13. Secondary haemorrhage.
14. Reactionary haemorrhage.
15. Tracheostomy. [Same as SN Q.1]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. How do you manage a patient for tooth extraction ● When the fasting glucose levels are constantly above
with (a) diabetes mellitus, (b) bacterial endocarditis and 140 mg/dL, a patient can be classified as a diabetic.
(c) bronchial asthma? Preoperative investigations
i. Routine chest radiograph: PA view of the chest
Ans.
ii. Electrocardiogram
A. Diabetes mellitus iii. Routine blood investigations
● An absolute or relative deficiency of insulin in the a. Blood sugar fasting and postprandial
body causes diabetes mellitus. b. Glucose tolerance test
● It can be classified as follows: c. Renal profile (BUN, SC and SE)
a. Type 1 (insulin-dependent diabetes mellitus) iv. Estimation of urine sugar
b. Type 2 (noninsulin-dependent diabetes mellitus) Preoperative preparation of patient
● Type 1 is more commonly seen in young patients, ● If the patient is on oral hypoglycaemics, then on
while type 2 occurs more commonly in adults. the day of surgery he/she must be shifted to insulin.
● The general principle followed in the manage- Preoperative investigations

ment of the patient under general anaesthesia is to i. Chest radiograph: PA view
provide at least 200 g of carbohydrate with ade- ii. Blood investigations like arterial blood gases
quate insulin to cover his/her need. iii. AFB culture of sputum
Intra- and postoperative management of diabetics iv. Bronchoscopy, if required
● The patient’s blood and urine sugar levels are v. Pulmonary function tests
checked in the morning on the day of surgery with ● Prior to the procedure, the patient should be
the help of blood glucose strips and urostrips or counselled and advised to discontinue beedi/
glucometer. cigarette smoking.
● Based on the patient’s sugar levels, a sliding insulin ● Any acute infection should be treated by anti-
scale to be followed intraoperatively is prepared. biotics.

● Pre- and postoperative broad-spectrum antibiotic ● Preoperatively and as well intra- and postop-
coverage. eratively, the patient should be on broncho-

● Close monitoring of the blood and urine sugar dilators.
levels is required intra- and postoperatively. ● All the time, patient must carry his/her inhaler
● The patient is prevented from going into ketoaci- with him/her for use in case of an emergency.
dosis or hypoglycaemia. Intra and postoperative management
● At the earliest possible, the patient should be i. Intra- and postoperatively, arterial blood gas
shifted to his regular oral feeds and antidiabetic monitoring should also be carried out.
medications. ii. Fluid overload should be avoided.
B. Bacterial endocarditis iii. To avoid decrease in the oxygen carrying capacity
● The cardiac disease is not an absolute contraindication of blood, blood loss should be replaced by whole
even then the surgeon should weigh the benefits against blood or packed cells.
the risks before deciding the choice of anaesthesia. iv. Long-term corticosteroid therapy.
Preoperative investigations v. Constant monitoring of the vital parameters.
i. Routine chest radiograph: PA view of chest vi. Broad-spectrum antibiotic coverage:
ii. Electrocardiogram As these patients are highly susceptible to infec-
iii. Echocardiogram tions, they must be given broad-spectrum antibi-
iv. Stress test otic coverage.
v. Routine blood tests
● Bleeding and clotting time
Q.2. What are the common medical emergencies in den-
● Prothrombin time and index, in case the patient
tal practice? How would you manage syncope?
is on long-term anticoagulants Ans.
● Lipid profile
Preoperative medication Medical emergencies in dental practice

● In case if the patient is on injection penidure every ● Emergency is defined as an unforeseen or unex-
3 weeks, then the surgery should be scheduled pected situation requiring immediate attention.
immediately after the scheduled dose to reduce ● In oral surgery practice, there are two possibilities:
the risk of infective endocarditis. a. A dental surgeon may be required to manage den-
Intra- and postoperative management tal emergencies, which may not arise as a result of
i. All these patients should be monitored intra- and treatment.
postoperatively, by means of an ECG, pulse b. Sometimes the patient may call upon the dental sur-
oximeter and arterial line. geon, seeking emergency treatment for the suffering.
ii. A central venous pressure (CVP) cut-down may Problems normally encountered
be performed, if necessary. a. Altered consciousness
iii. Until oral feeds are given, the patient should be b. Chest pain and discomfort
maintained on intravenous cardiac drugs. c. Respiratory disturbances
C. Bronchial asthma d. Allergic manifestations/anaphylaxis
● In case of asthma, the most important aspect is the Systemic complications
patient’s respiratory reserve and the patient’s ability a. Vasovagal attack
to tolerate general anaesthesia. b. Postural hypotension
● A bronchodilator inhaler should be kept ready for c. Diabetes mellitus
use in case of an emergency, if the patient is treated d. Primary insufficiency due to pathology of adrenal
under local anaesthesia. cortex
e . Epilepsy iii. Postsyncope

f. Chest pain and discomfort ● Pallor
g. Respiratory emergencies like: ● Nausea
● Foreign body aspiration ● Weakness
● Bronchial asthma ● Sweating
● Hyperventilation ● Short period of confusion or disorientation
● Cardiopulmonary arrest ● Arterial blood pressure begins to rise
h. Allergy and anaphylaxis ● Heart rate returns to normal
Syncope Pathophysiology
● Syncope is the transient loss of consciousness due
to cerebral ischaemia. Stress

● Other names of syncope are atrial bradycardia, g
neurogenic syncope, psychogenic syncope and
Release of catecholamines, epinephrines and
vasovagal syncope.
norepinephrines into circulatory system
g
Psychogenic factors
● Anxiety and emotional stress
Changes in tissue blood perfusion
● Receipt of unwelcome news
g
● Fright Decrease in peripheral vascular resistance
● Sudden and unexpected pain g
● Sight of blood and surgical instruments
Pooling of blood in the muscles
Nonpsychogenic factors g
● Erect sitting or standing posture
● Hunger due to missed meal Relative decrease in circulating blood volume, drop in
● Exhaustion arterial blood pressure and decrease in
● Poor physical condition cerebral blood flow
● Hot, humid and crowded environment
g
● Male persons Compensatory mechanisms are activated
● Age range between 16 and 35 years g
Clinical features
Cerebral ischaemia
i. Presyncope
g
● Feeling of warmth in the neck and the face
● Pale or ashen grey skin colour Loss of consciousness

● Bathes in cold sweat
● Bad/faint feeling/nauseous feeling
● BP is normal and heart rate increases

● Pupillary dilation Management
● Hyperpnoea ● Stopping the procedure.
● Coldness in hands and feet ● Loosening the patient’s clothing.
● Disturbed vision ● Placing the patient in supine position.
● Dizziness ● Raising the legs above the head will help the
ii. Syncope blood to return from periphery.
● Loss of consciousness ● Airway breathing and circulation maintained.
● Breathing becomes shallow ● Oxygen administered through face mask.
● Convulsive movements ● Ammonia ampoule crushed under patient’s nose.
● Muscular twitching of hands and legs or facial ● Monitoring of vital signs.
muscles ● Avoiding the cause of syncope.
● Brains become hypoxic ● An anticholinergic, e.g. atropine may be adminis-
● Bradycardia tered intravenously or intramuscularly, if brady-
● Heart rate of less than 50 beats/min cardia persists.
● Blood pressure falls to an extremely low level ● Emergency medical service should be consid-
● Pulse become weak and thready ered, if patient does not gain consciousness for
● Partial/complete airway obstruction 15–20 min.
Q.3. Describe the treatment plan of extraction in pa- e. Use the measures to promote clot formation and
tients with history of (a) hepatitis B and (b) anticoagu- its retention.
lant therapy. f. Medications to be started once stable clots form.
g. Patient to be instructed not to dislodge the clot.
Ans. h. Avoid nonsteroidal anti-inflammatory drugs.
[SE Q.8] Q.4. Haemophilia.
{a. Hepatitis B Ans.
● A patient with viral hepatitis should be handled with
[SE Q.3]
care to avoid inadvertent transmission of the disease
to the OT personnel or another patient. {Haemophilia
● The risk of transmission depends on the type of ● Haemophilia A is a congenital coagulopathy caused
hepatitis carrier, the patient is. due to lack of factor VIII.
Preoperative investigations ● It is a sex-linked disorder whose gene is localized on
i. Bleeding time and clotting time the X chromosome. It affects males and females.
ii. Prothrombin time and index ● The disease is characterized by prolonged bleeding
iii. Assessment of liver enzymes time, as a result of failure of normal clotting proce-
a. Serum glutamic oxaloacetic transaminase dure. These usually begin spontaneously without
(SGOT) apparent trauma and the most commonly affected
b. Serum glutamic pyruvic transaminase (SGPT) areas are knees, elbows, ankles and legs. Muscle
iv. Total bilirubin (direct and indirect bilirubin) haematomas are also characteristics of haemophilia.
v. Serum albumin ● Although joints and muscles are the most common
vi. Serum alkaline phosphatase sites for the haemorrhage, bleeding can occur at al-
vii. Ultra sonography (USG) liver most any site.
Management ● Bleeding should be treated early by raising factor
a. Consult the physician VIII level. It is accomplished by intravenous infusion

b. Avoid any elective procedures of factor VIII concentrate.
c. Minimize or avoid medications and treatment Tests
d. During the treatment: ● Bleeding time
Strictly adhere to aseptic techniques like gloves, ● Platelet count
masks, disposables and adequate sterilization ● Partial thromboplastin time (PTT)
e. Use rubber dam to minimize the contact with ● Prothrombin time (PT)
saliva and blood.} ● Evaluation of clotting factors and time
b. Anticoagulant therapy Management

● At least 4–5 days prior to surgery, with the physi- ● If the bleeding disorder is due to specific coagu-
cian’s consent, patients on long-term anticoagulant lation factor deficiency, the respective factor
therapy should discontinue the anticoagulants. should be replaced before carrying out the surgi-
● The patient should be shifted to intravenous antico- cal procedures. If the patient is under anticoagu-
agulants like heparin, if discontinuation of oral anti- lants, ask him to stop the medication 1 week prior
coagulant therapy is not advisable. to surgery.
● On the day of surgery, after omission of the antico- ● Use coagulation promoting factors like fibrin,
agulant therapy, the patient’s bleeding time and clot- thrombin, adrenaline, sutures and pressure packs.
ting time is checked. ● Once the clot has been formed, the patient is in-
Management structed not to do any activity like blowing, gar-

a. Consult the physician regarding therapy. gling, etc., which would result in dislodgement of
b. Hospitalization is mandatory. the clot.
c. Rescheduling the medication (only in consulta- ● Avoid prescription of NSAIDs, which can pro-
tion with the physician for stopping of platelet- long bleeding.

inhibiting drugs). ● Avoid drugs that may cause drug interactions and
Aspirin: Five days prior to treatment. inhibit warfarin metabolism.}

Coumarin: Two days prior to treatment.
Q.5. Cardiopulmonary resuscitation.
Heparin: 6 h prior to treatment.
d. During elective surgery: Ans.
Cardiopulmonary resuscitation ● The breath is looked for, listened and felt. If

● When circulation ceases or stops and vital organs are there is no breathing, then two breaths are
deprived of oxygen, the cardiac arrest occurs. given and the chest is made to rise.
● In case of cardiac arrest, CPR is most effective when ● After checking for 5–10 s, if there is no pulse
started immediately and should be initiated by any and the heart rate is less than 60 beats per min,
person present at the time of cardiac arrest/when the then cycles of 30 compressions and two breaths
patient collapses. are started. AED arrives after two cycles of
Aetiology of cardiac arrest CPR. Interruptions are minimized in chest
● Cardiac disease compressions. Interruptions are tried to be kept
● Hypoxia to 10 s or less.
● Hypotension ● After five cycles, the emergency response sys-
● Hypoglycaemia tem is activated and the AED is got.
● Effect of drugs ● The remaining steps are followed for adults
● Electrolytic changes with child pads and adult pads are used, if
● Vagal reflex mechanism child pads do not help.
● Terminal changes of any disease
Q.6. Define shock. Discuss the pathogenesis, clinical
Checking for response
features and management of hypovolaemic shock.
● In case if there is failure in response, someone is
sent to activate the emergency response system Ans.

and to get the AED.
Opening the airway
{SN Q.3}
● Check for adequate breathing (take at least 5 s and
not more than 10 s) by tilting the head and lifting Shock

the chin. ● Shock is a pathophysiologic condition, clinically
● The breath is look for, listened and tried to feel. If recognized as a state of inadequate perfusion. Due to
there is no adequate breathing, then make the inadequate blood flow, there is inadequate delivery
chest rise by giving two breaths. of nutrients to the tissues and inadequate removal of
Checking the pulse cellular waste products from the tissue cells, which
● To check the pulse, at least 5 s and not more than results in disruption of vital organ functions.
10 s are taken.
● If no pulse, then cycles of 30 compressions and
two breaths are started. Hypovolaemic shock

● AED arrives after two cycles of CPR. Interrup- ● Hypovolaemic shock results from a decrease in the
tions in chest compressions are minimized. Inter- circulating or effective intravascular volume.
ruptions are tried to be kept to 10 s or less. ● It is the most common type of shock in the victim of
The AED is put next to the victim and below com- maxillofacial trauma.
mands are followed: ● Hypovolaemic shock can be further classified into
● The AED is turned on and adult pads are haemorrhagic and nonhaemorrhagic.
attached. i. Haemorrhagic shock
● It is made sure that no one is touching the vic- ● Haemorrhagic shock occurs due to loss of blood
tim and the AED is allowed to check the heart from the body as a result of injury.
rhythm. ● Haemorrhage decreases the mean systemic filling
● The AED prompts are followed and a shock is pressure and there is a resultant decrease of venous
delivered. return, which results in the fall of cardiac output.
● Shock delivery is followed. CPR is started im- ● Approximately 10%–15% of the total blood vol-
mediately beginning with chest compressions. ume loss will not significantly affect the arterial
For children pressure or cardiac output.
● After checking, if there is no response, then ● 15%–25% loss of blood volume may not cause
one should shout for help. haemodynamic change. If the blood loss is not
● Someone is sent to activate the emergency re- rapid, then the metabolic changes associated with
sponse system and to get the AED. shock may be initiated.
● By tilting the head and lifting the chin, the ● Shock results due to rapid loss of 30%–40% of
airway is opened and checked for 5–10 s for the blood volume, and if not treated becomes pro-
breathing response. gressive and may lead to death.
ii. Nonhaemorrhagic shock Severe . 40%: Agitation confusion; supine hypo-

● There is massive fluid shift from intravascular tension and tachycardia are invariably present;
compartment to extravascular compartment. and there is rapid deep respiration.
● This can result from burns, crush injuries, pancre- Treatment
atitis, peritonitis, pleural effusion and ascites. ● Replacement of fluids and tissue perfusion are the
● Water loss due to severe diarrhoea, vomiting, dia- mainstay of the treatment of shock. Volume resus-
betes insipidus, hyperglycaemia, nephritis and citation must be undertaken promptly.
excessive diuretic use can also lead to nonhaem- ● The legs raised and body supine is the preferred
orrhagic hypovolaemic shock. posture, as this increases venous return and car-
Pathophysiology diac index.
● Decrease in arterial pressure caused by blood loss ● Patient should be kept warm.
stimulates powerful sympathetic reflexes that re- ● When haemorrhage is massive, type specified
sult in constriction of arterioles, veins and venous matched transfused blood is the preferred method to
reservoirs; and there is increase in heart activity. correct hypovolaemia. Typing and cross-matching
● The body tries to maintain cardiac output and ar- of blood takes time sometimes.
terial pressure to normal levels. There is forma- ● Uncrossed type O 2ve blood should be reserved
tion of angiotensin and vasopressin, which con- for life-threatening blood loss that cannot be ad-
stricts the peripheral arteries and cause increased equately replaced by other fluids.
conservation of water and salt by the kidneys. ● Initial resuscitation is done with crystalloids, such
● If body reflex mechanisms are not able to raise the as normal saline or Ringer lactate. It requires up
arterial pressure sufficiently and no urgent interven- to several litres of fluids, but replacement of inter-
tion is done by replacement of fluids, then there is stitial fluid with crystalloids is preferred.
depression of myocardium and vasomotor centre. ● After initial resuscitation, colloids such as albu-
● Blood flow through the tissues becomes sluggish. min or starch solution can be used, as these re-
There is accumulation of acids due to continued store intravascular volume more effectively.
tissue metabolism. ● All these fluids should be warmed before transfu-
● These acids and other deterioration products from sion, because hypothermia worsens acid–base
the ischaemic tissues cause blood agglutination in disorders and myocardial function.
the capillaries. ● The amount of fluid administration is based upon
● Due to prolonged hypoxia, the permeability of improvement of clinical signs, particularly blood
capillaries gradually increases and large quanti- pressure and pulse pressure and heart rate.
ties of fluid transude into the tissues. ● Central venous pressure and urinary output also pro-
● This further decreases blood volume and there is vide indication of restoration of vital organ perfusion.
generalized cellular deterioration, generalized and ● Hypotension in patients with hypovolaemic shock
local tissue acidosis and tissue necrosis in vital should be aggressively treated with intravenous
organs. fluids.
● This leads to a vicious cycle, i.e. each increase in
degree of shock causes a further increase in the Q.7. Various types of haemorrhage encountered in oral
shock. surgery and its treatment.
● After the shock has progressed to a certain stage,
Ans.
transfusion or any other therapy becomes incapa-
ble of saving the life of the person. Therefore, the Haemorrhage
person is said to be in irreversible stage of shock.
[SE Q.11]
Clinical features
● Tachycardia {Types of haemorrhage
● Poor capillary perfusion I. Depending on the type of blood vessel involved
● Decrease in pulse pressure to hypotension 1. Arterial haemorrhage
● Tachypnoea 2. Venous haemorrhage
● Delirium 3. Capillary haemorrhage
Mild ,20%: Postural hypotension; patient feels II. Depending on the time of bleeding
cold; tachycardia; cool, pale and moist skin; col- 1. Primary bleeding – Immediate bleeding
lapsed neck veins; and concentrated urine. 2. Secondary bleeding – After 24 h to several days
Moderate .20%–40%: Thirst; supine hypoten- 3. Intermediate bleeding – 8 h after primary bleed-
sion and tachycardia; and oliguria or anuria ing stops
III. Depending on the confinement of bleeding iii. Lasers

1. Internal or concealed bleeding ● Lasers usually result in bloodless surgical
2. External bleeding field, as they effectively coagulate the small

Management of haemorrhage blood vessels during cutting of tissues.
The techniques for local haemostasis may be classified as:
[SE Q.11]
i. Mechanical
ii. Thermal { III. Chemical methods
iii. Chemical i. Local agents
I. Mechanical techniques for local haemostasis Astringent agents and styptics
● Monsel’s solution contains ferric subsulphate
i. Pressure
● For at least 5 min, pressure should be applied
and it acts by precipitating proteins.
● Tannic acid also helps in precipitating pro-
directly over the bleeding site firmly with a
gauze pack. One should not be in a hurry and teins and causes clot formation.
● Silver nitrate and ferric chloride are other
should not lift pack every minute to see
whether bleeding has stopped or not. agents, which can be used in case of minimal
● Post-traumatic nasopharyngeal bleeding or
capillary bleeding.}
pharyngeal bleeding due to maxillofacial Bone wax
● It acts mechanically by occluding the bony
trauma can be controlled by nasal packing.
ii. Use of haemostats canals.
● It should be used judiciously, as large quanti-
● Haemostat or mosquito, artery forceps are
specially designed to catch bleeding points in ties of bone wax may lead to foreign body
the surgical area. granuloma and infection.
● Electrosurgical thermocoagulation is done
Thrombin
● Topical use of thrombin acts by converting
after catching the bleeding point with artery
forceps, if the vessel is small. The large ves- fibrinogen into fibrin clot. It is very kind to
sels are ligated with suture. tissues and quite effective.
● It is applied to the bleeding surface via a
iii. Sutures and ligation
● Transected blood vessel may need to be tied
pack, gelatin sponge or surgicel.
with the help of ligature. Gelfoam
● It exerts pressure along with acting as scaf-
● When large pulsatile artery needs to be tied,
nonabsorbable material is preferred. fold for fibrin network. It is absorbed by

iv. Embolization of the vessels phagocytosis.
● Gelfoam should be moistened in saline or
● The exact bleeding point can be localized
with the help of angiography. thrombin solution prior to application and

● Agents such as steel coils, polyvinyl alcohol
all the air should be removed from inter-
foam, gel foam, silicon spheres and methyl stices.
methacrylate can be used for embolization.} Fibrin glue
● It is a type of biological adhesive.
II. Thermal techniques for local haemostasis
● Fibrin glue consists of thrombin, fibrinogen,
i. Cautery
● Heat achieves haemostasis by denaturation
factor XIII and aprotinin.
● Its mechanism of action is that the thrombin
of proteins, which results in coagulation of
large areas of tissue. converts fibrinogen to fibrin clot, which is
● In cauterization, heat is transmitted from the
unstable. Factor XIII stabilizes the clot and
instrument by conduction directly to the tis- aprotinin prevents its degradation.
sues. [SE Q.11]
ii. Cryosurgery
● Temperature ranging from 220°C to 215°C {Adrenaline
is used. At these temperatures, the tissues, ● The adrenaline is used in a concentration of 1:1000
capillaries, small arterioles and venules un- applied with the help of gauze pack over oozing
dergo cryogenic necrosis. sites. It can also be injected along with local anaes-
● This is caused by dehydration and denatur- thetic in concentration of 1:80,000 to 1:200,000.
ation of lipid molecules. Cryosurgery is spe- ● This drug should not be used in patients, who have
cially used to treat superficial haemangiomas. hypertension or previously existing cardiac disease.
ii. Systemic agents Local factors

Whole blood 1. Distribution within the dental arches
● Whole blood transfusion may be indicated, It is more common in the mandibular molar re-
when there is excessive blood loss due to gion, but very rare in the anterior region. It is
haemorrhage and there are symptoms of hy- much more frequent after the removal of retained
povolaemic shock. or unerupted teeth, probably due to the increased
● All the factors for coagulation are present in trauma during removal.
fresh whole blood. 2. Insufficient blood supply to the alveolar socket
● When specific blood components are not Dry socket develops more often if the surgery is
available to treat the patient’s haemostatic performed under local anaesthesia with excess of
defect, whole blood may be used.} vasoconstrictor-like adrenaline injected around
dense, sclerosed bone in the mandibular molar
Q.8. What are all the various complications that can oc-
region. Sclerotic bone changes caused by periapi-
cur in oral surgery? Discuss dry socket in detail.
cal infection can also result in decreased blood
Ans. supply to the alveolus.
3. Pre-existing infections
Complications in oral surgery Pericoronitis and periapical infections are consid-
Intraoperative complications that are preventable ered to be the predisposing factors of dry socket.
1. Primary haemorrhage 4. Trauma to the alveolar bone
2. Dislocation of the temporomandibular joint It is considered to be one of the main causes. Ex-
3. Fracture of the tooth or jawbone cessive trauma is known to result in delayed
4. Oroantral fistula wound healing and osteitis of the alveolar socket.
5. Displacement of the tooth Smoking and oral contraceptives may also predis-
6. Damage to the soft tissues pose to intravascular thrombosis.
7. Damage to the neighbouring dental structures 5. Disturbance of the clot
8. Failure to complete the operation Once the clot formation is complete, energetic
Postoperative complications and repeated irrigation of the socket disturbs the
1. Osteomyelitis clot and leaves the socket empty. Similarly, vio-
2. Impairment of sensation lent curettage might injure the alveolar bone.
3. Dry socket 6. Increased fibrinolytic activity
4. Reactionary or secondary haemorrhage Fibrinolysis is known to be a regulator of the co-
5. Pain and swelling agulation process where and when clot formation
6. Trismus is undesirable. Fibrinolysis can be traced in saliva
Dry socket and bacteria. Fibrinolysis is known to influence
Other terms used are necrotic alveolar socket, alveolal- the integrity of the clot and its organization is
gia, delayed extraction, wound healing, fibrinolytic al- important for the normal healing of the extracted
veolitis, alveolar osteitis and localized osteomyelitis. socket. Fibrinolysis of the clot seems to be the
Aetiology most outstanding clinical feature of dry socket.
Aetiology can be broadly considered as systemic and 7. Microorganisms
local factors. Fibrinolysis occurs due to the toxin fibrinolysin
Systemic factors released by Streptococcus viridans. It has been
1. Age distribution pointed out that the dry socket is not associated
It is most commonly seen in the age group of 20–40 with clinical features of inflammation like red-
years. Extraction of deeper and the more difficult ness, suppuration, swelling and pain. Metronida-
impacted teeth in later years of life become more zole is found to reduce the incidence of dry
traumatic, thereby predisposing to dry socket. socket.
2. Sex distribution Clinical features
Female patients have lower threshold and toler- 1. The patient usually complains of continuous,
ance of pain. Postextraction pain is more in throbbing and excruciating pain, usually radiating
females. to the ear.
General factors 2. The site of pain can be clearly identified as the site
The duration of this lesion is 2–10 days. General re- of removal of the tooth 48–72 h earlier.
sistance of the patient may be responsible for the 3. The pain is such that it becomes worse during
occurrence of this condition. meals. It also disturbs the patient during sleep.
4. The patient however has relief of pain with anal- Q.10. Discuss ‘shock’ in oral surgery.
gesics and local application of heat.
Ans.
5. The tooth socket appears dry and empty. It may
also contain brownish foul smelling necrotic tis- [Same as LE Q.7]
sue. The bone is markedly tender.
Q.11. Classify the shock. Discuss in detail the pathogen-
6. Halitosis is striking and marked.
esis, clinical features and management of haemorrhagic
7. It resolves in a week or two. The healing may be
shock.
hastened with the trusted local dressing like zinc
oxide eugenol impregnated cotton or polyantibi- Ans.
otic paste.
[Same as LE Q.7]
Diagnosis
The clinical diagnosis is made on the basis of the Q.12. Discuss the management of haemorrhage in oral
following features: surgery.
1. History of extraction a few days back.
Ans.
2. Empty alveolar socket, covered by greyish
necrotic tissue. [Same as LE Q.8]
3. The surrounding gingiva exhibits mild inflam-
matory reactions.
4. The patient complains of characteristic excru-
SHORT ESSAYS:
ciating pain and halitosis. Q.1. Tracheostomy.
5. The patient complains of feeling of ‘unwell’
Ans.
due to lack of appetite and sleep.
Management
● Scaling of teeth and treatment of inflammation of {SN Q.1}
the gingiva prior to dental extraction. Tracheostomy
● The technique must include the use of local an- ● Tracheostomy is a preferred opinion for relief of
aesthetic solution with minimum of vasoconstric- airway obstruction performed under local anaes-
tion. thesia, by making an opening in anterior wall of
● Extraction technique must be as least traumatic as the trachea and converting it into stoma on skin
possible. surface. If emphysema is present, there is some
● Insertions of antibiotics or steroids after extrac- difficulty in identifying surgical landmarks; but,
tion or prophylactic parenteral antibiotic therapy the operation is safer than intubation through a
into the socket are not found to be useful in reduc- swollen larynx.
ing its incidence. Indications
● In view of the Gram-negative organisms, metroni- I. Respiratory obstruction
dazole 600–800 mg per day appears to be effec- ● Infections: Ludwig angina, acute epiglotti-
tive. Incidence is high, if the impacted tooth with tis and peritonsillar and retropharyngeal ab-
pre-existing pericoronitis is removed. scess
● The ‘dry socket’ should be irrigated with warm ● Trauma to larynx and trachea, mandible
saline to eliminate the necrotic material from the fracture and maxillofacial injuries
socket. ● Tumour
● It is better to avoid surgical curettage. The time- ● Foreign body
honoured popular remedy of loosely packed cot- ● Laryngeal oedema due to allergy/irritants/
ton impregnated with zinc oxide eugenol is yet to radiation
be replaced by any other effective remedy. ● Bilateral abductor vocal cord palsy
● Usually, two or three dressings may be necessary ● Congenital anomalies like laryngeal web,
depending on the relief of symptoms. White- cyst and tracheoesophageal fistula
head’s varnish has also been tried, but it is not as II. Retained secretions.
effective as zinc oxide eugenol dressing.
Q.9. What precautions can you take while carrying out (Inability to cough)
dental treatment for a patient suffering from haemo- Technique
philia? ● To bring trachea as near the surface as pos-
sible, the head is held firmly with neck fully

Ans.
extended over sand bags. The thumb and
[Same as LE Q.5] middle fingers of the left hand are used to
palpate and identify the cricoid cartilage, ● More complicated management may be required for
which should be grasped throughout the severe diabetics or where a long operation is in-
operation. volved.
● The incision is made from the thyroid notch ● To control infection at the site of operation, the sur-
to a point one centimetre above the sternal geon must take measures by careful oral prophylaxis.
notch, through all the superficial tissues. ● The patient can resume his normal diet by providing
● In the technique of high tracheostomy, pre- dentures as quickly as possible.

tracheal fascia is incised at the level of cri-
Q.3. Haemophilia.
coids cartilage; while for low tracheostomy
technique, a dotted line indicates incision. Ans.
● In children, a low tracheostomy site is ad-
[Ref LE Q.5]
visable as there will be much bleeding due
to congestion. But if the incision is in the Q.4. Shock in oral surgery.
midline, there is no danger. The index finger
Ans.
of the left hand is placed in the wound to
identify and protect the cricoid cartilage. Shock
The incision is deepened on to the trachea. ● Shock is a pathophysiologic condition, clinically
● If necessary, the thyroid isthmus is divided recognized as a state of inadequate perfusion. Due to
and the second and the third tracheal rings inadequate blood flow, there is inadequate delivery
are incised. of nutrients to the tissues and inadequate removal of
● The tracheal incision is dilated with the cellular waste products from the tissue cells, which
handle. A rubber tube of half a centimetre results in disruption of vital organ functions.
diameter will serve to maintain the airway. Anaphylactic shock
● Care must be taken in placing the tube. ● When it occurs, it is accompanied by severe circula-
Once the tube is held in place, the emer- tory and respiratory collapse, urticaria, laryngeal
gency is over and respiration should start oedema, steep fall in BP, weak pulse, bronchospasm
and bleeding should be controlled. and loss of consciousness.
Q.2. Minor oral surgeries in diabetic patients. ● Syncope (vasovagal attack) is reversible, but anaphy-
laxis is irreversible. Hence, the treatment must be

Ans.
provided as an emergency to improve the prognosis.
Minor oral surgeries in diabetic patients Otherwise, it can be fatal.
● Under local anaesthesia, when a surgical procedure ● Immediate emergency treatment includes the follow-
is to be carried out in a diabetic patient, he should ing:

be on his normal diet and insulin at the usual time ● Injection epinephrine 1:1000, 0.5–1.0 mL subcu-
and the operation should commence after about 1 h. taneously.

It is not necessary to use adrenal-free anaesthetic ● Maintenance of ventilation with oxygen under
solutions, but neither the operation must not be un- pressure.
duly prolonged nor the meals and snacks on the ● If severe bronchospasm develops, then 250–500 mg
patient’s schedule be missed. of aminophylline is given intravenously.

● Diabetics, who are on insulin or have to undergo ● Resuscitation methods like cardiac massage and
general anaesthetic treatment, need to be admitted to mouth to mouth breathing, if necessary.

hospital where advice of the physician is sought. ● Without any delay, immediate medical consultation
Those on long-acting insulin are changed to soluble and hospitalization must be arranged to save the life
form and till midnight on the day before the opera- of the patient. Anaphylaxis may even be due to the
tion, the most severe diabetics will receive their drug preservatives added in the local anaesthetic.
normal insulin and carbohydrate. They should be
operated first on the next morning and be given only Q.5. Hyperparathyroidism.
a saline infusion during the operation, after which,
Ans.
blood sugar estimation is immediately performed
before administering the necessary insulin and glu- Hyperparathyroidism
cose by infusion. ● Hyperparathyroidism is an uncommon disease and
● Till the normal balance is resumed postoperatively, occurs due to an increased activity of parathyroids
careful monitoring of the patient is continued. and manifests as hypercalcaemia.
Causes ● The A and B antigens are inherited as Mendelian

● Single chief cell adenoma is the most common dominants.
cause. ● Type A individuals have A antigen, type B individu-
● It can be due to diffuse hyperplasia involving all als have B antigen, type AB have both antigens and
four glands. type O have neither antigens.
● Very rarely it is due to the carcinoma arising in the ● These antigens are present in many tissues including
parathyroid glands. blood.

Clinical features ● When blood is transfused into an individual with an
● Common in females. incompatible blood type, the red blood cells aggluti-
● Female/male ratio is 2:1. nate and haemolyse. Free haemoglobin is liberated
● Age is 20–60 years with the most common being into the plasma.
fifth decade. ● The severity of transfusion reaction ranges from as-
● Incidence is 1:1000 patients. ymptomatic to severe jaundice and renal tubular

● The most common presentation is asymptomatic damage with anuria to death.
hypercalcaemia and renal stones. ● Persons with type AB blood group are universal re-
● Bones – excessive skeletal decalcification, bony cipients, because they have no circulating agglutinins
pains, pathological fractures and subperiosteal and can be transfused with any type of blood without
erosions. delaying a transfusion reaction due to ABO compat-
● Renal disease – Renal ischaemias and hypertension ibility.
● Abdominal groans – Calcium stimulates gastrin ● Type O are universal donors, because they do not
that is a powerful stimulator of acid that causes have A and B antigens and hence can be given to
pain in abdomen and pancreatitis. anyone without any transfusion reactions.
● Corneal calcification seen on split lamp examina- ● In order to avoid complications, blood should always
tion. be transfused after cross-matching.

● Proximal myopathy and muscle wasting.
Types Q.7. Indications for blood transfusion.

● Primary hyperparathyroidism
Ans.
● Secondary hyperparathyroidism
● Tertiary hyperparathyroidism
Blood transfusion
Investigations ● When blood is transfused into an individual with
I. Hyperparathyroidism an incompatible blood type, i.e. an individual who
● Serum calcium, phosphate and albumin
has agglutinins against red cells in the transfu-
● Serum PTH assay
sion, dangerous haemolytic transfusion reactions
● Alkaline phosphatase
occur.
● X-ray of bones
● When the recipient’s plasma has agglutinins against
II. Localizing parathyroid glands the donor’s red cells they agglutinate and haemolyse.
● Ultrasound of neck
The free haemoglobin is liberated into the plasma. The
● Thallium and technetium subtraction scan
severity of transfusion reaction may vary from asymp-
Treatment tomatic to severe jaundice and renal tubular damage
● Single adenoma: Excision of the gland. However,
with anuria to death.
another normal parathyroid gland is also removed ● Persons with types AB blood group can be given
for histopathological study. blood of any type, as they are universal recipients
1 3
● Diffuse hyperplasia: 3 /2 or 3 /4 parathyroids are
since they have no circulating agglutinins.
removed and a small piece is autotransplanted ● Type O individuals are universal donors and type O
into the forearm muscle tissue. blood can be given to anyone without any transfusion
● Carcinoma: All four glands should be removed
reaction.
along with the thyroid tissue. ● Blood should never be transfused without being
Q.6. Blood groups. cross-matched.

Indications
Ans. ● When there is excessive blood loss due to haem-
Blood groups and transfusion orrhage and there are symptoms of hypovolae-
● Individuals are divided into four major types of mic shock, whole blood transfusion may be in-
blood groups. dicated.
Fresh whole blood contains all the factors for

●
Situation Antibiotic Regimen
coagulation.
Standard general Amoxicillin Adults, 2.0 g and
● When specific blood components are not available
prophylaxis children, 50 mg/kg
to treat the patient’s haemostatic defect, whole orally 1 h before
blood may be used. procedure
Autologous blood transfusion Cannot use oral Ampicillin Adults, 2.0 g i.m./
● Recently, a procedure that has become popular is medications i.v. and children,
to transfuse the patient’s own blood in elective 50 mg/kg i.m./i.v.
surgeries. within 30 min be-
● In this procedure, patient’s own blood is drawn
fore procedure
prior to surgical procedure and then his blood is Allergic to penicil- Clindamycin Adults, 500 mg
infused back during a surgery, if a transfusion is lin and children, 20
mg/kg orally 1 h
needed.
before procedure
● 1000–1500 mL of blood can be withdrawn over a
3 week period in patients on iron therapy. Or cephalexin, Adults, 2.0 g and

cephadroxil children, 50 mg/kg
● Banking one’s own blood has become popular to
orally 1 h before
avoid fear of transmission of AIDS by heterozy- procedure
gous transfusions.
Or azithromycin or Adults, 500 mg
Q.8. Hepatitis B infection. clarithromycin and children, 15
mg/kg orally 1 h
Ans. before procedure
[Ref LE Q.3] Allergic to penicil- Clindamycin Adults, 600 mg

lin and unable to and children, 15
Q.9. Bacterial endocarditis. take oral medica- mg/kg i.v. 1 h be-
tions fore procedure
Ans.
Or cephazolin Adults, 1.0 g and
children, 25 mg/kg
i.m./i.v. within 30
{SN Q.8} min before proce-
dure
Bacterila endocarditis
● Infective endocarditis is a microbial infection of
endocardium affecting the heart valves and endo- Q.10. Cricothyrotomy.

cardium.
Ans.
● Damage to the myocardial endothelium allows for
the deposition of platelets and fibrin to form the Cricothyrotomy

nonbacterial thrombotic vegetation. ● Cricothrotomy is an alternative to tracheostomy for
● Persistent bacteremias results from the microor- routine laryngeal fractures and fracture of the maxilla.
ganisms re-entering the blood from infected car- ● If the patient is unconscious or has showed signs of
diac lesions. Antibiotic prophylaxis is recom- altered consciousness, then this is the most frequent
mended for the patients with the risk. indication to provide an airway by way of endotra-
cheal intubation.
Endocarditis prophylaxis is recommended for:

● Dental extractions and minor oral surgical procedures {SN Q.2}
● Periodontal surgical procedures, e.g. scaling and root
● In rare and unlikely circumstances that the methods fail
planning to ensure an adequate airway, a surgical cricothyrotomy
● Dental implant surgeries
is easily performed through the cricothyroid membrane
● Re-implantation of avulsed tooth
and after dilation of the opening, a small endotracheal
● Endodontic instrumentation or surgery extending be-
tube or tracheostomy tube can be inserted.
yond the apex ● This is a technique that can be rapidly carried out
● Initial placement of orthodontic bands
with low morbidity and without requiring the skills
● Local anaesthetic injection (intraligamentary injections)
and equipment needed to perform a tracheostomy.
● Oral prophylaxis where bleeding is anticipated
Q.11. Types of haemorrhage. 4. Diphenhydramine (Benadryl)

● After the administration of any drug, if the patient
Ans.
develops allergic reaction like urticaria and pruri-
[Ref LE Q.8] tis with or without respiratory distress, this is
useful.
Q.12. Contents of medical emergency drug tray in den-
● This drug is indicated in the treatment of extrapy-
tal office.
ramidal reactions like spasm of neck muscles,
Ans. restlessness, trismus and Parkinson-like movement
following phenothiazine group of drugs like chlor-
The following are the important criteria to be taken
promazine.
into account when selecting appropriate emergency
5. Diazepam
drugs:
● It is a popular anticonvulsant drug. It is relatively
i. Drugs which are to be considered essential for the first
safe if given intramuscularly or intravenously.
line management of medical emergencies, i.e. drugs
6. 5% dextrose solution
which will act within the first 15–20 min of an emer-
● Most of the drugs in emergency situations can be
gency as an adjunct to basic life support and other life
conveniently given through intravenous route. Fluid
saving measures.
replacement is equally important in emergency situ-
ii. Drugs which can be used by a dental practitioner at the
ations. Hence, 5% glucose solution must be readily
dental clinic set up.
available.
Contents of medical emergency drug tray in dental
7. Methylprednisolone sodium succinate
office
● It is an important drug in the management of anaphy-
1. Adrenaline (epinephrine)
laxis, acute adrenocortical insufficiency and cardiac
● It is required for treating anaphylaxis, cardiac arrest
arrest.
and shock.
● Dose: 125 mg i.v. This is the drug of choice in
● In such conditions, administration of adrenaline may
patients who are on long-term steroid therapy and
interfere with venous return and tissue perfusion.
collapse in the dental chair.
There is a possibility of precipitation of ventricular
fibrillation in the ischaemic and irritable myocar-
dium.
● The build-up of lactic acid from hypoxic tissues re-
Emergency drugs
quire compensatory measures. Route of ad-
● i.v. sodium carbonate is useful as adjunctive therapy. Drugs Formulations ministration Indication
However, adrenaline in grave emergencies including 1. Oxygen Cylinders Inhalation All emergen-
anaphylaxis has proved to be a drug of choice. cies
2. Aromatic spirit of ammonia 2. Adrena- 1 mg in 1 mL Intramuscu- Anaphylaxis
● It is useful in cases of syncope. After positioning the line (1:1000 lar
patient with elevation of legs, inhalation of spiritus solution)
ammonia is helpful. 3. Hydrocor- 100 mg Intramuscu- Anaphylaxis
● It stimulates trigeminal nerve endings, resulting in tisone powder plus lar and adrenal
reflex stimulation of vasomotor and medullary respi- Sodium 2 mL distilled crisis
ratory centres. succinate water
3. Nitroglycerin (glyceryl trinitrate) 4. Glucose Powder Oral Diabetic hy-
● It is useful to relieve the anginal pain. poglycaemia
● It is believed to dilate the coronary artery, so that (conscious)
pain due to myocardial ischaemia is relieved. Since 5. Aspirin 300 mg Oral Myocardial
the shelf life is only 6 months, periodically, expiry dispersible Infarction
date of the drug must be monitored. tablets
● 0.6 mg tablet held under the tongue with the patient 6. Chlorphe- 1 mg in 1 mL Intramuscu- Anaphylaxis
in a semi-prone or sitting position provides relief niramine solution lar
from pain within 23 min. maleate
● Elimination of stressful situations and reassurance 7. Glucagon 1 mg powder Intramuscu- Diabetic
and administration of oxygen are equally important plus 1 mL, lar hypoglycae-
under such emergency situations. Failure to respond sterile water mia (uncon-
scious)
indicates that it is a case of myocardial infarction.
Route of ad- ● AIDS virus is found in all the body fluids like blood,
Drugs Formulations ministration Indication saliva, tears, urine, etc.
8. Solbuta- 0.1 mg per Inhalation Asthma
mol dose
inhaler Some of the oral manifestations of HIV are
● Kaposi sarcoma.
9. Glyceryl 0.5 mg tablet Sublingual Angina
● Candidiasis.
trinitrate or 0.4 mg per
● Oral hairy leukoplakia.
dose spray
● HIV associated periodontal diseases.
10. Mid- 10 mg in Intramuscu- Status
● Other opportunistic infections.
azolam 2 mL solution lar epilepticus
● The main clinical sign noted in children and in earlier
stages of the disease is parotidenlargement, which is
bilateral and associated with cervical lymphadenopathy
Q.13. Describe briefly the management of a hyperten-
● As HIV progresses, salivary glands are infiltrated
sive patient for teeth extraction in dental chair.
with CD8 lymphocytes leading to diffuse infiltrative
lymphocytosis syndrome resulting in salivary gland
Ans.
enlargement.
Drug therapy aims at: ● Patients are at a risk of B cell lymphoma.
i. Peripheral resistance ● Xerostomia is experienced by HIV-associated patients
ii. Cardiac output, since the maintenance of BP de- with the cause being drugs, oral diseases and progres-
pends on both these factors sion of the HIV diseases.
Management of hypertensive patient ● The symptoms include dryness of the mouth, predis-
i. Anxiety reduction protocol should be fol- position to fungal diseases and dental caries and
lowed. infection.
ii. The appointment should be in the mornings
and mostly should be of short duration. Q.15. Haemophilia A.
iii. Vasoconstrictors should be used as minimally Ans.
as possible.
iv. No elective procedures in uncontrolled diabe- [Same as SE Q.3]
tes and hypertension.
Q.16. Haemophilia patient for dental extraction.
v. Hypertensive patient is a potential bleeder.
vi. Monitor patient’s medications. Ans.
vii. Patients on diuretics develop dry mouth.
viii. Terminate the appointment, if the patient is [Same as SE Q.3]
overstressed.
Q.17. Management of anaphylactic shock.
ix. Patients on medication without any renal or
cardiac problem can be treated. Ans.
Q.14. Oral manifestations of HIV infection. [Same as SE Q.4]
Ans.
Q.18. Hyperparathyroidism investigations.
Ans.
{SN Q.6}
[Same as SE Q.5]
● AIDS is an infectious disease of the immune system.
This is considered to be the final stage of the chronic, Q.19. Blood grouping and transfusion.
progressive disease, believed to be caused by AIDS
virus known as human immunodeficiency virus Ans.
(HIV).
[Same as SE Q.6]
● The envelope of HIV is made of lipids of the host
cell membrane, proteins and glycoproteins specific Q.20. Autologous blood transfusion.
to HIV.
● Inside the envelope, nucleocapsid contains single Ans.
stranded RNA molecule.
[Same as SE Q.7]
Q.21. Blood transfusion reactions. Ans.

Ans.
Blood transfusion products Indications
[Same as SE Q.7] Plasma and platelet products Postpartum haemorrhage
Q.22. Prophylaxis for subacute bacterial endocarditis. Whole blood Haemorrhagic shock
Ans. Packed red blood cells Haematemesis
[Same as SE Q.9] Erythrocytes Severe anaemia
Q.23. Postextraction haemorrhage management. Q.6. HIV.

Ans. Ans.
[Same as SE Q.11] [Ref SE Q.14]
Q.7. Post-HIV exposure prophylaxis.
SHORT NOTES:
Ans.
Q.1. Define tracheostomy and mention five of its indica-
tions.
Type Drugs Regimen
Ans.
Basic (28 days) Zidovudine 1 600 mg/day
[Ref SE Q.1] lamivudine (300 mg b.i.d.,
200 mg t.i.d. or
Q.2. Cricothyroidotomy. 100 mg 4 hourly)
1150 mg
Ans.
Expanded As above 1 indi- 800 mg 8 hourly,
[Ref SE Q.10] (28 days) navir or nelfinavir 750 mg t.i.d or
or neviriapine 200 mg b.i.d.
Q.3. Define shock.
Ans. Q.8. Bacterial endocarditis.
[Ref LE Q.7] Ans.
Q.4. Neurogenic shock. [Ref SE Q.9]
Ans. Q.9. Hyperthyroidism.
Neurogenic shock Ans.
● Vasovagal syncope or emotional fainting most com-
monly seen in dental clinics is caused by excitation Hyperthyroidism

● Hyperthyroidism is a type of thyrotoxicosis, in which
of the parasympathetic nerves to the heart and vaso-
dilator nerves to the skeletal muscle, thereby slowing there is increased thyroid synthesis and secretion by
the heart and reducing the arterial pressure. the thyroid gland.
● Causes of thyrotoxicosis include autoimmune dis-
● There is a decrease in cerebral blood flow below a
critical level and the patient usually falls down. Con- ease like Graves disease, lymphocytic thyroiditis,
sciousness returns almost immediately and within a multinodular goitre and subacute thyroiditis.
● Rapid pulse; tremor; eyelid lag; warm, moist and
short period of time the victim appears to be com-
pletely recovered. hyperpigmented skin; weight loss; palpitation; tachy-
● The early signs and symptoms include pale or ashen
cardia; excessive sweating; and sometimes exoph-
grey skin, heavy perspiration, nausea, tachycardia thalmos.
and feeling of warmth in neck or face. Q.10. Hyperventilation.
● The late symptoms show coldness in hands and feet,
hypotension, bradycardia, dizziness, visual distur- Ans.

bance, pupillary dilation, hyperpnoea and loss of Hyperventilation
consciousness. ● Hyperventilation is a hysteria anxiety component
Q.5. Name four blood products that can be transfused manifested at the conscious level.
● It results in respiratory alkalosis.
parenterally with one indication for each.
● Decreased blood and ionized calcium leads to par- Secondary haemorrhage

aesthesia and numbness of extremities and perioral ● It occurs 4–10 days after the surgical procedure. Dur-
region, cramps and even convulsions. ing the immediate postoperative period if the blood
Management clot gets infected by Streptococci, then the toxins
● Reduction of anxiety level. like fibrinolysin dissolves the clot, thereby wound
● Advising the patient to hold the breath to reverse starts bleeding profusely.
the respiratory alkalosis. ● Sometimes, onset of acute Vincent infection may
● Reassurance of the patient and regulation of also result in secondary haemorrhage. A course of
breathing. appropriate antibiotics with haemostatic measures
● Patient is made to sit in the upright posture. will arrest such a haemorrhage.
● Hospitalization, if necessary.
Q.14. Reactionary haemorrhage.
Q.11. Anaphylaxis.
Ans.
Ans.
Reactionary haemorrhage
Anaphylaxis ● Reactionary haemorrhage occurs due to the following
● Anaphylaxis is the type I allergic reaction. reasons:

● The specific antibody is cell bound to mast cells. i. Reactionary vasodilation of vessels which are con-
● Antigen triggers the release of substances producing tracted during surgery, because of the use of vaso-
vasodilation, contraction of bronchial muscles and constrictors with local anaesthetic drugs.
increased capillary permeability. ii. The blood clots are yet to be matured and contracted
a few hours after extraction.
Q.12. Haemophilia.
The patient may disturb the clot
Ans. a. By vigorously gargling with warm liquids
b. By the application of heat inducing local hy-
Haemophilia
peraemia
● Haemophilia is due to an inherited X-linked reces-
c. Due to the rise of blood pressure after surgery
sive character, which clinically manifests only in
d. Due to violent exercise resulting in general
males.
peripheral vasodilation with alcohol triggering
● It is known to be transmitted through clinically nor-
the reactionary bleeding
mal female carriers.
● It is a disorder of blood coagulation characterized by Q.15. Tracheostomy.
the tendency to bleed excessively and prolonged co-
Ans.
agulation time.
[Same as SN Q.1]
Q.13. Secondary haemorrhage.
Ans.
Topic 19
Minor Oral Surgical Procedures
and Orthognathic Surgery
LONG ESSAYS:
1 . Describe the technique of apicoectomy. Enumerate the indications and complications of apicoectomy.
2. Describe various orthognathic surgeries of maxilla. Describe in detail Le Fort I osteotomy.
SHORT ESSAYS:
1 . Cleft lip and cleft palate.
2. Indications and technique of augmentation genioplasty.
3. Principles of flap design and types of flap.
4. BSSO.
5. How will you evaluate a patient for orthognathic surgery?
6. Name the procedure to correct mandibular defects.
7. Enumerate various principles of intraoral flap designing and name various mucoperiosteal flaps employed in
oral surgery. [Same as SE Q.3]
SHORT NOTES:
1 . Apertognathia.
2. Maxillary osteotomies. [Ref LE Q.2]
3. Torus palatinus.
4. Wassmund’s technique.
5. Cleft lip and palate protocol.
6. What are the preoperative methods of estimation of results in orthognathic surgeries?
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Describe the technique of apicoectomy. Enumerate Teeth with deep periodontal pockets and grade III
l
the indications and complications of apicoectomy. mobility (pre-existing bone loss)

● When traumatic occlusion cannot be corrected
Ans.
● Short root length
Apicoectomy ● Acute infection which is nonresponsive to the treatment
● Apicoectomy, apical surgery, endodontic surgery, ● Root tips close to the nerves, e.g. mental nerve, infe-
root resection and root amputation are the terms rior alveolar nerve or in maxilla close to the maxil-
which are used for surgery involving the root apex to lary sinus
treat the apical infection. Procedure
● It is the cutting off of the apical portion of the root Three accepted procedures
and curettage of periapical necrotic, granulomatous, i. Root canal filling and immediate apicoectomy
inflammatory or cystic lesions. and curettage.
Indications ii. Root canal filling is done several days/weeks/
● Apical anomalies of root tip – Dilacerations, intraca- months earlier followed by apicoectomy and
nal calcification and open apex curettage.
● Presence of lateral accessory canal apical region iii. Increase in the periapical lesion even after root
perforations canal filling and draining sinus. May be due to
● Roots with broken instruments/over fillings faulty filling, which is redone and then followed
● Fracture of apical third of the root by root amputation and curettage.
● Formation of periapical granuloma/cyst draining Steps
sinus tract/nonresponsive to RCT ● Local anaesthesia with infiltration technique
● Extension of root canal sealant cement filling beyond ● Mucoperiosteal flap – Either semilunar or sub-
the apex marginal envelop flap with extension of at least

● Teeth with ceramic crowns one tooth on either side.
● When patient with chronic periapical infection will ● Submarginal envelop flap is known as Leubke
not be available for follow-up Ochsenbein flap design.

Contraindications ● It is indicated when the aesthetics of gingival
● Presence of systemic diseases like leukaemia, uncon- margin cannot be compromised.

trolled diabetes, anaemia, thyrotoxicosis, etc. ● Raise the mucoperiosteal flap with periosteal
● Teeth damaged beyond restoration elevator.

Retract the flap away with Langenback retractor.

●
● Inferior positioning of maxilla
Identify the apex in the intact buccal plate and
●
● Levelling of maxilla
create a bony window with surgical bur over the
● Superior repositioning of the maxilla
root apex area. Care should be taken not to dam-
● Superior positioning of maxilla, leaving the nasal
age adjacent structures.
floor intact (horseshoe-shaped osteotomy)
● Locate the apex.
● Section the root tip horizontally. No bevel angle is
advocated for sectioning (0 to 10 degrees). Le Fort I osteotomy

● Remove all periapical granulation tissues with Indications
angulated curettes. ● Low midface hypoplasia
● Use hot burnisher to seal the root tip. ● Maxillary hypo/hyperplasia
● Close flap and suture. ● Vertically short or long midface
Retropreparation ● For correcting cant of occlusion
● Ultrasonic tip is used for retropreparation. ● Cleft patients with midface deficiency
● The tip is at the apical opening of the canal and Incision

guided gently deeper into the canal as it cuts. ● A horizontal incision is made in the buccal sulcus
● Once the retropreparation is completed, the pre- through the periosteum just above the apices of
pared cavity is inspected. the teeth.
● The gutta-percha at the base is re-condensed with ● Incision extends from the zygomatic buttress to
small mm microplugger. the midline and to the opposite side of zytgomatic

● The aim of placing root-end filling material is to buttress region.
establish an apical seal that inhibits the leakage of ● In the midline, in the region of the frenum, the
residual irritants from the root canal into the sur- incision is curved into a small V to accommodate
rounding tissues. the frenum.
● A wide variety of retrograde filling materials have Procedure
been used, such as gutta composite resin, polycar- Osteotomy cuts
boxalate cement and silver points. ● Bone cut is made 5 mm above the apices of the
● For the defect in the periapical region, hydroxy- canine and molar teeth.
apatite can be packed to enhance the bony ● The cut is started high in the aperture area and
healing. extended posteriorly sloping downwards and

Complications backwards to the tuberosity area.
Intraoperative ● Bone cuts can be made with burr or with a
● Bleeding control with local application of adrena- Stryker saw. Where the reduction of the verti-
line pack 1:1000 and pressure pack/gel foam cal height of the maxilla is required, the wedge
● Damage to the neighbouring root bone to be removed is collected and preserved
● Entry into sinus/inferior alveolar canal to be used as free bone graft.
Postoperative ● Once the lateral cuts are completed, an osteo-
● Abscess formation tome is used along the lateral wall of the piri-
● Fenestration and sinus tract formation form aperture to separate the dentoalveolar
● Increased mobility of the tooth part from the rest of the maxilla.
● The nasal septum is separated from maxilla by
Q.2. Describe various orthognathic surgeries of maxilla.
using a notched nasal septal chisel directed
Describe in detail Le Fort I osteotomy.
along the floor of the nose.
Ans. ● A finger is placed along the junction of the
hard and soft palate to confirm the separation.

● The maxillary tuberosity is then separated
{SN Q.2} from the pterygoid plates using a curved Tess-
Various maxillary osteotomies ier osteotome, which is directed downwards
● Segmental maxillary osteotomy and medially.
● Posterior maxillary osteotomy ● With firm pressure applied over the anterior
● Total maxillary surgery alveolus, the maxilla can be down-fractured to

● Le Fort I complete the separation.
● Maxillary advancement ● The maxilla is positioned using a splint in the
preplanned position and fixed using bone plates.

● After the osteotomy cuts are made, the maxilla ● There is convergence of the fibres of levator veli
may be mobilized and repositioned superiorly, palitini, palatopharyngeus and uvular muscles to
inferiorly, anteriorly and posteriorly. form a compact bundle, which is inserted into the
● Maxilla can also be positioned to correct cant postnasal edge of cleft and posterior edge of hard
of occlusion. palate. The levator veli palatini and tensor veli
● Wound is closed. palatini are thinner hypoplastics in cleft palate.
Complications ● In clefts of hard palate, there is deficiency of
● Injury to Stensen’s duct muscle and bone; whereas in cleft of soft palate,
● Infraorbital nerve traction injury there is deficiency of mucosa and hypoplasia of
● Unanticipated fractures muscles which are abnormally inserted.
● Injury to maxillary artery and its branches Problems associated with cleft
● Lacrimal duct injury i. Associated deformities of vital organs like heart or
● Avascular necrosis airways, requires urgent attention of paediatrician to
● Maxillary sinusitis alleviate threat of life and future complication
● Velopharyngeal insufficiency ii. Speech problems
● Nasal septal deviation and buckling iii. Ear infections
● Flaring of alar base iv. Cosmetic defects
● Arteriovenous fistula Management
Sequence of procedure
1. Primary
SHORT ESSAYS: ● Closure of lip
Q.1. Cleft lip and cleft palate. ● Closure of palate
2. Secondary
Ans.
● Closure of palatal fistulae
Internationally approved classification ● Pharyngoplasty
A. Group I cleft of the anterior (primary) palate ● Alveolar bone grafting
a. Lip: Unilateral – Rt/Lt and total/partial ● Orthodontics treatment
Bilateral ● Orthognathic procedures
b. Alveolus: Unilateral – Total/partial ● Rhinoplasty and scar revision of the lip
Bilateral Flaps for cleft lip used

B. Group II cleft of anterior and posterior (primary ● Tennison triangular flap
and secondary) palate ● Millard rotation advancement repair
a. Lip: Unilateral – Rt/Lt and total/partial Cleft palate repair

Bilateral ● Bardach’s two-flap technique
b. Alveolus: Unilateral – Rt/Lt and total/partial ● Cutting technique
Bilateral ● Salyer’s modified technique

c. Hard palate: Total/partial ● Oxford technique
C. Group III clefts of posterior (secondary) palate ● OSLO technique
a. Hard palate – Rt/Lt ● Delaire’s technique
b. Soft palate
D. Group IV rare facial clefts Q.2. Indications and technique of augmentation genio-
Bilateral cleft lip plasty.
● In complete cases, central frontonasal segment is
Ans.
not attached to the maxilla and so there is marked
forward projection of the premaxilla. Techniques of genioplasty
● The abnormal forward projection of the premaxilla i. Augmentation genioplasty
is due to a marked forward position of the alveolar ii. Reduction genioplasty
bone and the hypoplastic maxilla on both sides. iii. Straightening genioplasty
Cleft palate iv. Lengthening genioplasty
● When the muscles of the cleft palate are unable to Augmentation genioplasty
meet each other across the midline of the cleft, Augmentation genioplasty is used to increase projec-
they become reoriented towards a fixed point and tion. It can be done by:
stream towards half of the posterior nasal spine of ● Sliding horizontal osteotomy of the symphysis
their side of the defect. ● Using autogenous bone graft

Using alloplastic material like silastic and hy-

● iii. Three-sided rhomboid flap
droxyapatite iv. Semilunar flap
Augmentation genioplasty procedure Based on the position of incision, flaps may be:
● The entire border of the symphysis is degloved by i. Labial/buccal flaps
using V incision. ii. Palatal/lingual flaps
● The digastric muscles are separated from mandible Envelop flap
to reduce the tension after advancement. ● It is the most common type of flap.
● Periosteal releasing incision also should provide ad- ● The incision is made to any length depending on the
equate coverage after advancement. The AP dimen- amount of exposure needed intramsulcularly around
sion of the symphysis is about 8–12 mm, so the same the necks of the teeth along the free gingival margin
amount of advancement is possible. on the buccal or lingual aspect including the inter-
● The horizontal osteotomy cut is made at least 4–5 mm dental papillae.
below apices of canines. The cut is completed through ● The entire mucoperiosteal flap is raised by using
both buccal and lingual cortices. periosteal elevator to a point to the apical one-third
● The segment is mobilized inferiorly and forwardly of the tooth.
with the help of osteotome. This mobilized segment ● This is mainly used for the surgical extraction of a
is pedicled over geniohyoid muscles with some tooth or root.

amount of lingual periosteum. Two-sided triangular flap
● Any bony interference for advancement is removed ● In addition to the envelop flap, a vertical releasing
under direct vision. incision is used in order to have better access to the
● The mobilized segment should be then advanced to area.
desired position by using towel clips and then exter- ● This vertical releasing incision is made on one side
nal facial contour should be checked and the frag- of the envelop flap at the proximal or distal end, go-
ments are positioned to the final desired level. ing divergent towards the buccal vestibule forming
● It can be fixed to the superior body with two intraos- an obtuse angle at the free gingival margin.
seous wirings in canine region or two mini bone ● The vertical incision should be made in the inter-
plates. proximal area, as the tissues here are thick.

● With major advancement, the periosteal relaxing in- ● To avoid periodontal defect, the incision should
cision should be made prior to suturing. Suturing is never lie directly on the facial aspect of the tooth.
done in two/three layers. ● Once the incision is taken, then the two-sided trian-
● Alloplastic augmentation can be done using the same gular flap is reflected towards the base of the flap by
incision, but which is relatively short in length. using periosteal elevator.
● On both sides, little tunnelling is done to create a Three-sided rhomboid flap
pocket into which the onlay grafting material can be ● This is the modification of earlier flap to improve
slided for better fixation. visibility and access.

● An additional vertical incision is added in the oppo-
Q.3. Principles of flap design and types of flap. site direction from the earlier release.
● Here, care should be taken so that the base of the flap
Ans.
must be wider than the apex for good blood supply.
Principles of flap designing Semilunar flap
● Intraoral surgical flaps are made to gain surgical ac- ● Whenever the periapical area is required to be
cess to the area to be operated or to move tissues exposed to carry out periapical surgery, this is
from one place to another. designed.
Indications ● Again the base of the flap should be broader than the
● For basic oral surgical procedures to allow complete apex and the suture line should not lie on bony
visualization of the operative field and to access os- defect.
seous tissue, whenever required. ● The incision is taken at least 5 mm away from the
Types of flaps gingival margin.

1. Full thickness mucoperiosteal flap ● This flap is useful to avoid dam interdental papilla
2. Partial thickness mucoperiosteal flap and to prevent periodontal surgical defects.

Based on the number of sides, the flaps may also be of ● In case of crowding, suturing is not a problem with
the following types: this flap.
i. Envelop flap ● The only advantage of this flap is that it often lies on
ii. Two-sided triangular flap the defect.

Q.4. BSSO ● Two osteotomes are then inserted and used as levers
to separate the segments. Spreader can be used to
Ans.
finally separate the segments.
BSSO ● The same procedure is repeated on the other side. In
● Bilateral sagittal split osteotomy (BSSO) is a very case of advancement, the bony interferences should
popular and most versatile procedure performed on be checked and the distal fragment is advanced and
the mandibular ramus and body. locked into desired occlusion.
● First described by Trauner and Obwegeser and later ● The fixation of the fragments can be done by intraos-
modified by Dalpont, Hunsuck and Epker. seous wiring or lag screws or by bone plates.
● The osteotomy splits the ramus and the posterior Q.5. How will you evaluate a patient for orthognathic
body of the mandible sagittally, which allows either surgery?
setback or advancement.
Ans.
● This is a highly cosmetic procedure, as it is done
intraorally. 1. Patient concerns

● For mandibular advancement, there is no need for ● To determine the patient’s feelings about the existing
bone grafts. Thus, donor site morbidity and second problems and their expectations for treatment results
operative site for the bone graft is totally avoided. 2. Clinical evaluations
● Only drawback is the technique demands high level ● Facial form
of operative skill and experience, to minimize the ● Relationship of facial thirds
surgical complications. ● Relationship of soft tissues to dentition smile line,
Surgical procedure occlusal cant and dental midlines versus soft tissues
● A bite block is inserted on the side in-between the 3. Clinical measurements
upper and lower teeth for easy access and projecting ● Vertical dimension
the ramus anteriorly. ● Anteroposterior dimension
● An incision is made on the lateral aspect of the ante- ● Transverse dimension
rior of the ramus, overlying the external oblique ● Intra-arch dimension
ridge, from the midway up the ascending ramus to 4. Radiographical analysis

avoid buccal fat downward into vestibular depth till ● Cephalometric – Lateral and anteroposterior
mandibular first molar region. ● Orthopantomogram
● Medially the soft tissues are reflected, until the lin- 5. Dental study analysis
gual and the inferior alveolar nerve bundle and man- ● Accurate bite registration
dibular foramen is identified. Medial soft tissue dis- ● Two jaw cases require duplicate models
section is stopped slightly and superior to the lingula. Q.6. Name the procedure to correct mandibular defects.
● While the medial soft tissues are being retracted, the
Ans.
medial bone cut is made through only the lingual
cortex about 2 mm above the neurovascular bundle Procedures to correct mandibular defects
and just posterior to the lingual. Mandibular body osteotomies
● Following the completion of horizontal medial oste- i. Mandibular body osteotomies – Intraoral proce-
otomy, cut is then carried down the lateral-most as- dures
pect of the anterior border of the ascending ramus to a. Anterior body osteotomy
the region of the second molar. b. Posterior body osteotomy
● This osteotomy is made parallel to the lateral cortex. c. Midsymphysis osteotomy
● The bite block is removed and the periosteum from ii. Segmental subapical mandibular surgeries
the lateral aspect of the mandible is elevated in the a. Anterior subapical mandibular osteotomy
molar area till the inferior border of the mandible. b. Posterior subapical mandibular osteotomy
● For setback procedure, the vertical osteotomy cut is c. Total subapical mandibular osteotomy
taken laterally to second molar. However, in major iii. Genioplasties – Horizontal osteotomy in the chin
advancement cases, vertical cut is placed forward in region
the region of the premolar. a. Augmentation genioplasty
● Vertical cut is completed through the lateral cortex only. b. Reduction genioplasty
● The cut extends through both the cortical plates at c. Straightening genioplasty
the inferior border of the mandible. d. Lengthening genioplasty
● With osteotome, all bony cuts are checked for their Mandibular ramus osteotomies
completeness. i. Subcondylar ramus osteotomy
a. Extraoral subcondylar ramus osteotomy (subsig- 4. Total orthognathic surgery:

moid) ● Mandibular body osteotomies
b. Intraoral subcondylar ramus osteotomy (subsig- ● Mandibular ramus osteotomies
moid) ● Le Fort I maxillary osteotomy
c. Arching radial osteotomy – Extraoral andintra-

oral modified sagittal split osteotomy Q.2. Maxillary osteotomies.
Maxillary osteotomy procedures – Intraoral procedures Ans.
i. Segmental maxillary osteotomy procedures
a. Single tooth dento-osseous osteotomy [Ref LE Q.2]
b. Interdental osteotomies
c. Anterior maxillary osteotomy
d. Posterior maxillary osteotomy Ans.
ii. Total maxillary surgery – Le Fort I osteotomy
Torus palatinus
a. Superior repositioning of the maxilla
● Other name is maxillary tori.
b. Superior repositioning of the maxilla leaving
● Tori or exostosis can be described as projections of bone
nasal floor intact (horseshoe-shaped osteotomy)
on a ridge.
c. Advancement of maxilla
● It is a benign slow-growing bony projection of the pala-
● Simultaneous expansion of maxilla
tine process of maxilla and occasionally of the horizon-
● Simultaneous narrowing of maxilla
tal plate of the palatine bone.
d. Inferior repositioning of maxilla
● It occurs bilaterally along the median suture on the oral
● Levelling of maxilla
surface of the hard palate.
Q.7. Enumerate various principles of intraoral flap de- ● It is more prevalent in females.
signing and name various mucoperiosteal flaps em- ● Aetiology is unknown. Causes can be superficial trauma,
ployed in oral surgery. malocclusion, hereditary or a functional response to

mastication.
Ans.
Q.4. Wassmund’s technique.
[Same as SE Q.3]
Ans.
Wassmund’s technique
SHORT NOTES: Incision
Q.1. Apertognathia. ● Vertical incision is made in the premolar region.
● Small midline vertical incision is made to expose

Ans.
anterior nasal spine and nasal septum.
Apertognathia ● Premolars are extracted from both the sides.
● Open bite, where teeth in opposing jaw fails to ● Blood supply to the osteotomized segment will be
contact from the palatal mucoperiosteum.
Classification Procedure
1. Dentoalveolar Osteotomy cuts
2. Skeletal base ● Buccal bone cuts are made first through the socket
3. Combination of both of the extracted tooth vertically.

Aetiology ● The cut is then turned medially towards the piri-
Anterior open bite form aperture.

● Tongue thrust ● Care should be taken to protect the nasal mucosa.
● Thumb sucking ● The palatal cortical plate of the extracted premo-
Posterior open bite lar socket is cut vertically. This is then continued
● Deficient eruption of posterior teeth on the palatal bone by tunnelling under the palatal
● Facial asymmetry which develops after growth is mucoperiosteum.
completed ● The nasal segment is attached to the nasal aspect
Management of the hard palate and needs to be detached for

Management depends on cause of the defect immobilization of the palate.
1. Quitting habits ● The nasal septum is freed from the palate using a
2. Surgical method nasal septal chisel anteriorly through a midline

3. Segmental orthognathic surgery vertical buccal incision.
● If superior repositioning of anterior segment of ear infection, fistula repair, soft tissue lengthening
maxilla is required, length of nasal septum is re- and psychological evaluation.
duced using a rongeur. 7. Five to 6 years
● Segment is mobilized completely and reposi- ● Lip and nose revision, if necessary. Pharyngeal
tioned as desired and fixed using orthodontic surgery.

wires or with an arch bar. 8. At 7 years
● Mucoperiosteal flap is closed using simple inter- ● Orthodontic treatment phase I.
rupted suture. 9. Nine to 11 years

● Prealveolar bone grafting.
Q.5. Cleft lip and palate protocol.
10. Twelve to 18 years
Ans. ● Full orthodontic treatment phase II.
11. Fifteen to 18 years

1. Immediately after the birth
● At the end of orthodontic treatment, placement of
● Paediatric consultation, counselling, feeding instruc-
implants, fixed bridges and so on, for missing teeth.
tion and evaluation by geneticist to decide whether it
12. Eighteen to 21 years
is an isolated cleft or if the cleft is part of the syn-
● When most growth is completed. Surgical advance-
drome, and diagnosis of life expectancy of a child
ment of maxilla, if required.
and diagnostic tests.
13. Final nose and lip revision
2. Within first few weeks of life
● Rhinoplasty at 16–18 years.
● Team evaluation, including hearing testing.
3. At 10–12 weeks Q.6. What are the preoperative methods of estimation of

● Surgical repair of lip, 3–6 month in India. results in orthognathic surgeries?
4. Before age 1 year to 18 months
Ans.
● Team evaluation and surgical; repair of cleft palate
and placement of pressure equalization tubes. Various preoperative methods of estimation of results in
5. Three months after palate repair orthognathic surgeries are:
● Team evaluation for speech and language assess- ● Photographs
ment. ● Radiographs
6. Three to 6 years ● Study models
● Team evaluation – Medical and behaviour interven- ● Cephalometric analysis
tion as needed. Speech therapy, treatment for middle ● Mock surgery on models
Topic 20
Implantology and Miscellaneous
LONG ESSAYS:
1 . Define dental implant. Classify and discuss the indications, contraindications and complications.
2. Discuss the lymphatic drainage of face.
3. Evaluation of implant and the procedure of single tooth loss replacement with implant. [Same as LE Q.1]
4. Discuss in detail lymphatic drainage of head and neck and its relevance to neck dissection. [Same as LE Q.2]
SHORT ESSAYS:
1 . Classification of steroids.
2. Ampicillin.
3. Tetanus.
4. Analgesics.
5. Principles of antibiotic therapy.
6. Action, side effects and dosage of amoxicillin.
7. Prophylactic antibiotic protocol for high-risk patients.
8. Ibuprofen.
9. Tetracycline.
10. Classification of NSAIDs.
11. Corticosteroids in oral surgery.
12. Dental implants: indications and contraindications. [Ref LE Q.1]
13. Classification and indications of steroids. [Same as SE Q.1]
14. Analgesics in oral surgery. [Same as SE Q.4]
15. Antibiotics in oral surgery. [Same as SE Q.5]
16. Enumerate indications, doses and side effects of ibuprofen. [Same as SE Q.8]
SHORT NOTES:
1. Methicillin-resistant Staphylococcus aureus.
2. Little’s area.
3. Pentazocine.
4. Endosseous implants. [Ref LE Q.1]
5. Role of antibiotics in oral surgery.
6. Broad-spectrum penicillin.
7. Diclofenac sodium.
8. Cephalosporins.
9. Newer antibiotics.
10. Clark’s shift cone technique.
11. Aspirin: mechanism of action.
12. Apert syndrome.
13. Endosseous implants.
14. Osteointegration.
15. Types of implant supported prosthesis.
16. Metronidazole.
17. Uses of steroids in oral surgery.
18. Ketamine.
19. Amoxycillin.
20. Carotid ligation.
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Define dental implant. Classify and discuss the in-
dications, contraindications and complications. {SN Q.4}
Ans. i. Endosteal implants

● These are implants that are placed completely
Dental implant within the alveolar and basal bone.
● Dental implants are surgically fixed substitutes for roots ● These implants receive their support by osseoin-
of missing teeth. tegration with the alveolar bone into which they
● Embedded in jaw bone they act as anchors for a replace- are placed.
ment tooth, also known as crown or a full set of replace- ● They can be of different types depending on the
ment of teeth. shape that is used: blade type, root form, etc.
Classification of implants
I. Based on its placement in relation to bone
ii. Subperiosteal implants Reduced salivary flow is a relative contraindication

● These implants are placed just below the periosteum to implant placement.
and rest on sound bone. ● Macroglossia.}
● Instead of penetrating the alveolar bone they rest on Temporary medical contraindications
its surface. Certain conditions affecting the patient may be tem-
● They are inserted by a surgical procedure where the porary situations and serve as only relative contrain-
mucoperiosteum is reflected and the alveolar bone is dications to implant placement such as:
visualized. The implant is made to rest on the alveo- ● Acute inflammatory diseases or infections:
lar bone with its posts protruding from the surface of Sinusitis, bronchitis, etc. may be treated prior
the mucosa. to surgical placement of implant.
● These implants are indicated in case of an atrophic ● Pregnancy: Surgical procedure is best avoided
mandible where there is not enough bone for the during pregnancy usually due to stress factors
placement of an endosteal implant. and also because of the possibility of preg-
iii. Transosseous implants nancy associated gingivitis.
● These implants are used in the anterior region of the ● Medications: These include anticoagulants, im-
mandible. munosuppressants, etc. Treatment may be started

● It consists of a horizontal plate on which the body of after the medication has been discontinued.
the implant (pins or staples) are fixed. ● Poor patient compliance: The patient must be fully
prepared for the procedure. If not, other noninva-

[SE Q.12]
sive means of tooth replacement may be done.
{Indications for implants The general medical contraindications to placement
●
Completely edentulous patient of implants are
●
Partially edentulous patient ● General nutritional condition.
●
Partially edentulous jaw with distal free end situation ● Metabolic disorders such as diabetes and hyper-
●
Single missing/extracted tooth thyroidism must be controlled prior to treatment.
●
Replacement of teeth in an edentulous jaw with op- ● Haematological disorders: Disorders such as
posing natural teeth anaemia or any haemorrhagic diathesis repre-

● Patient unable to wear a removable denture prosthe- sent absolute contraindications to the procedure.
sis due to: ● Cardiac and circulatory disease: The patient
a. Parafunctional habits such as bruxism must be thoroughly evaluated prior to surgery

b. Gag reflex displacing the denture; patients not and the necessary precautions must be taken to
satisfied with removable denture prevent any complications.
c. Psychological causes preventing the use of a re- ● Osseous and metabolic disturbances: Osteopo-
movable denture rosis, osteogenesis imperfecta, etc. will ham-

d. Inadequate number of abutment teeth for the per the success of the implant.
placement of fixed partial denture ● Collagen disorders: Conditions such as sclero-
Contraindications for implant placement derma, rheumatoid arthritis represent contrain-
● Unfavourable intermaxillary relationships: In pa- dications.
tients with unsatisfactory intermaxillary relation- ● Dental implant as a potential bacterial focus:
ships, implant procedures should not be considered. Patient with a history of bacterial endocarditis
● Problematic occlusal and functional relationships. or with heart valve prosthesis presents a high-
● Pathologic conditions of the jaws: Cysts, tumours, in- risk of bacteraemia due to the dental implant.
flammatory manifestations, etc., form temporary con- Complications
traindications. Such patients should be re-evaluated I. Intraoperative complications
after treatment of the jaw condition. 1. Haemorrhage
● Radiation therapy in the jaw region: Implantation is 2. Nerve injury
usually avoided in such cases due to compromised 3. Perforation of antrum
vascularity and likely damage to the cells and associ- 4. Fracture of jaw
ated problems with wound healing. 5. Perforation into nasal cavity
● Pathologies affecting the oral mucosa: Leukoplakia 6. Complication due to improper placement
and lichen planus contraindicate implant procedures. ● Bone dehiscence
● Xerostomia: Salivary flow has a cleansing effect ● Damage to adjacent teeth
and reduces the bacterial count in the oral cavity. ● Lack of stability
II. Immediate postoperative complications ● Usually the distance between two implants should
1. Haematoma be as much as the diameter of the implant when
2. Oedema multiple implants are to be placed.
3. Infection ● Titanium instruments provided in the kit are used
4. Wound dehiscence for this procedure.

5. Mobility of implant ● A thread cutter or a screw tap is next used to pre-
III. Late complications pare the screw threads in the bone, if a screw type
1. Peri-implant pathology implant is used.
2. Fracture of implant ● The precise sized implant is then inserted care-
3. Sinusitis fully using a wrench to tighten it till the surface of

4. Nerve damage the implant is flushed with bone surface.
5. Mucosal irritation ● Cover screws are placed on the implant body.
Steps in placement of an implant ● These are placed so that the hollow cylinder of the
1. Incision implant is left intact without the growth of bone or

● A crestal incision with buccal-releasing incision, connective tissue into it. This allows the place-
buccally based flap or lingually based flap may be ment of the prosthetic part of the implant, when it
planned. is uncovered.
● The incision should be planned in such a way that 4. Uncovering the implant
after the implant is placed and the flap is replaced, ● In a two-stage implant, this second surgical proce-
it should cover the implant completely. dure is used to uncover the implant after the
2. Reflection of mucoperiosteal flap healing-in phase.
● Once the incision has been placed, the mucoperi- ● This is done usually about 3 months after place-
osteal flap is reflected using a periosteal elevator. ment of the implant in the mandible and after
● Care is taken not to button-hole the flap. 6 months in the maxilla.
● Care should also be taken not to strip the bone ● This procedure can be done under local anaesthesia.
excessively. Only as much as is required to place Various techniques may be employed:

the implant must be reflected to allow good peri- a. Use of crestal incision in the middle of the
osteal cover for the bone for good healing. keratinized mucosa and reflection of a buccal
3. Placement of implant and palatal/lingual flap. This is followed by
● The implant size is chosen, based on the radio- apical repositioning of the buccal flap.
graphic analysis of the amount of bone available. b. Use of tissue punch or soft tissue trephine for
● Care should be taken to choose the size of the implant uncovering the implant.
which has a gap of at least 2 mm from all important c. Electrosurgical uncovering of the implant.
anatomic structures and also the bone margins. Once the implant is uncovered, remove the cover
● The position and angulation of the implant as de- screw gently and test the osseous union of the im-
termined by the model analysis should be main- plant. The peri-implant soft tissue is checked.
tained when the implant is being drilled into place. Prosthetic treatment
● A stent is fabricated with acrylic. ● The prosthetic replacement is fabricated to suit the
● This is placed on the alveolar ridge and the exact occlusal configuration, as decided by the model
location of the implant is marked on the stent. analysis. This is then fixed on to the transmucosal
● A hole is then drilled in the stent in this accurate connector.
position and angulation. ● The implant can now be loaded by masticatory
● This stent is then used as a guide for the place- forces.

ment of the implants.
Q.2. Discuss the lymphatic drainage of face.
● Preparation of the implant bed is done using rela-
tively high-speed (max speed 2000 rpm) standard- Ans.

ized steel drills.
● The drills are made of specific sizes correspond-
Structure Lymph node Drainage
ing to the size of the implant.
Upper jaw Submandibular Deep cervical
● For minimal trauma, the drill is used with very slight
Upper jaw includ- nodes
axial force and under copious saline irrigation. ing teeth, gingivae Directly to the
● During drilling, the drill is moved up and down to and palate retropharyngeal
ensure adequate cooling of the bone that is being Lateral part of hard nodes
cut. palate
Structure Lymph node Drainage Structure Lymph node Drainage

Lower jaw Submental nodes Either to subman- Antrum Doubtful if it has
Anterior part of Submandibular dibular nodes and an external lym-
mandible, the inci- nodes then to deep cervi- phatic drainage,
sor teeth, gingiva cal or directly to but possibly sub-
and chin deep cervical mandibular nodes
Lower jaw includ- Deep cervical
Frontal and eth- Submandibular
ing remaining teeth
moidal sinuses nodes
gingivae
Eyelids and Parotid and sub- Deep cervical
Lip Submandibular Upper internal
conjunctiva mandibular nodes,
Upper lip and nodes jugular nodes
bular nodes
lateral parts of Submental nodes Either submandib-
lower lip Superficial cervical ular nodes and Orbit and content Preauricular group Deep cervical
Medial part of then to deep
lower lip cervical or directly Lacrimal gland Submandibular Deep cervical
Some part of upper to deep cervical nodes
lip Deep cervical Ear Preauricular and Nodes along exter-
Tongue Bilaterally to All lymph nodes Auricle mastoid nodes nal jugular vein
Tip submental nodes from tongue drains Lateral surface Parotid nodes Deep cervical
Anterior two-third Unilaterally to sub- into the jugulo- Middle ear Parotid and retro- Upper deep cervi-
Lateral part mandibular nodes omohyoid nodes Mastoid air cells pharyngeal nodes cal
Midline Overlaps bilater- and upper deep Mastoid nodes
Posterior third ally to submandib- cervical group Scalp Occipital, mastoid Deep cervical
ular nodes and parotid nodes
Bilaterally to
jugulo-omohyoid Front of scalp Submandibular Deep cervical
nodes nodes
Floor of the mouth Submental nodes Either to subman-

Anteriorly Submandibular dibular and then to Q.3. Evaluation of implant and the procedure of single
Remainder nodes deep cervical tooth loss replacement with implant.
Tonsils Jugulodigastric Ans.
nodes
Cheeks and buccal l Submandibular Deep cervical [Same as LE Q.1]
mucosa nodes and some
passing by buc- Q.4. Discuss in detail lymphatic drainage of head and
cal nodes neck and its relevance to neck dissection.
l Parotid nodes
l Direct to the su-

Ans.
perficial upper
[Same as LE Q.2]
deep cervical
nodes
Salivary gland Parotid nodes Dee cervical SHORT ESSAYS:
Parotid Chiefly to deep
Submandibular cervical chain Q.1. Classification of steroids.
Sublingual remainder to the
Anterior part submandibular
Ans.
Posterior part nodes Classification of steroids
Submandibular
nodes
A. Short-acting (8–12 h)
Upper deep I. Hydrocortisone
cervical group II. Cortisone
Nose Parotid group Deep cervical B. Intermediate-acting (18–36 h)
External and ante- I. Prednisolone
rior part II. Methylprednisolone
Root of nose and III. Triamcinolone
adjacent upper
C. Long-acting (36–54 h)
eyelids
I. Paramethesone
Posterior nasal II. Dexamethsone
cavity
III. Betamethasone
Indications for steroids v. Typhoid fever: Due to emergence of resistance, it is

i. Endocrinal now infrequently used when ciprofloxacin and
● Acute renal insufficiency other drugs cannot be given.
● Chronic adrenal insufficiency (Addison disease) vi. Bacillary dysentery: Shigella often responds to am-
ii. Nonendocrinal picillin, but many strains are now resistant. Quino-
● Arthritis – Rheumatoid arthritis lones are now preferred.
● Osteoarthritis vii. Cholecystitis: It is a good drug because high con-
● Rheumatoid fever centrations are attained in bile.
● Acute gout viii. Subacute bacterial endocarditis: Ampicillin 2 g i.v.
● Severe allergic reactions 6 hourly may be used in place of PnG. Concur-
● Bronchial asthma rently, gentamicin is advocated.
● Collagen diseases ix. Septicaemias and mixed-infection: Injected ampi-
● Eye diseases cillin may be combined with gentamicin or one of
● Renal diseases the newer cephalosporins.
● Skin diseases Adverse effects
● Gastrointestinal diseases ● Diarrhoea is frequent after oral administration.
● Liver diseases ● Produces high incidence of rashes, especially in pa-
● Haematologic disorders tient with AIDS, EB virus infections or lymphatic

● Lung diseases leukaemia.
● Organ transplantation ● Patient with immediate-type of hypersensitivity to
● Bell palsy PnG should not be given ampicillin.

● Acute polyneuritis
● Myotonia Q.3. Tetanus.

Ans.
Q.2. Ampicillin.
Tetanus
Ans.
● Tetanus is an acute infection of the nervous system
Ampicillin characterized by intense activity of motor neurons and

● Ampicillin is an extended-spectrum antibiotic resulting in severe muscle spasms.
grouped under aminopenicillins. ● It is caused by the anaerobic Gram-positive bacillus,
● Active against all organisms sensitive to PnG; Gram- Clostridium tetani that is commensal in human and ani-
negative bacilli, e.g. H. influenza, E. coli, Proteus, mal gastrointestinal tracts and soil.
Salmonella and Shigella. ● The exotoxin acts at the synapse of the interneurons of
Pharmacokinetics inhibitory pathways and motor neurons to produce

● Ampicillin is not degraded by gastric acid; oral ab- blockade of spinal inhibition.
sorption incomplete, but adequate. Clinical features
● Food interferes with absorption. ● Is characterized by lockjaw or spasm of masseter,
Doses which is the initial symptom.

Depending on the severity of the infection, ampicillin ● Dysphagia and stiffness or pain in the neck, shoulder
0.5–2 g oral/i.m./i.v. should be given every 6 hourly and or back muscle appears concurrently.
in children, 25–50 mg/kg/day. ● Rigidity interferes with the movements of chest and
Uses impairs cough and swallowing reflexes.

i. Urinary tract infection: In these infections, ampicillin ● Laryngeal spasms can lead to asphyxia.
is the drug of choice, but because of increased resis- ● Hands and feet are relatively spared and sustained
tance, flouroquinolone/cotrimoxazole is now preferred. contraction of facial muscles results in a grimaces or

ii. Respiratory tract infection: Include bronchitis, si- sneer called risus scardonicus.
nusitis, otitis media, etc. ● The contraction of muscle of the back produces an
iii. Meningitis: Ampicillin is used in combination with arched back called opisthonous.
third-generation cephalosporin/chloramphenicol Treatment
for initial therapy. General measures
iv. Gonorrhoea: It is one of the first line drugs for oral ● Aim of the treatment is to remove spores at the
treatment of nonpenicillinase-producing gonococcal site of the wound and prevent muscular spasms.
infections. A single dose of 3.5 g ampicillin plus 1 g ● Cardiopulmonary monitoring should be maintained.
probenecid is adequate and convenient for urethritis. Antibiotics should be given, such as
Penicillin 110–112 million units i.v. for 10 days Ibuprofen

Metronidazole 1 g every 12 h should be adminis- Mode of action
tered. ● Nonsteroidal anti-inflammation reduces pros-
● Clindamycin or erythromycin can be used as an taglandin activity in prostaglandin synthesis.

alternative for penicillin-allergic patients. Indications
● Antitoxins are injected to neutralize circulating ● Control postsurgical pain.
toxin with wound. Side effects

● Human tetanus immunoglobulin (TIG) 3000– ● Gastrointestinal problems like nausea, heart-
6000 units i.m. in individual doses. burn, vomiting and abdominal pain occur.
Prophylaxis ● In patients using ibuprofen for prolonged pe-
Wound debridement and booster doses of TT. riod like up to 1 year, more severe problems
Unimmunized individual such as gastric ulcer and bleeding can occur.
● Antitetanus serum 1500 units or TUG 250 units Contraindications
should be given. ● Allergic reactions to ibuprofen, other NSAIDs
and aspirin.
Q.4. Analgesics. ● Contraindicated in pregnant or nursing women.
Precautions
Ans.
● Ibuprofen inhibits platelet aggregation, but its
Analgesics effect usually causes small changes in bleeding

● Analgesics are the drugs that relieve pain regardless of time in normal patients.
its source and type. ● Patients on anticoagulant therapy or with in-
● Control of postoperative pain following oral surgery trinsic bleeding disorders can be at risk for
involves choosing the analgesic regime that is appropri- haemostatic problems with the concurrent use
ate for each patient. of ibuprofen.
● Analgesics can be divided into two groups based on ● While taking ibuprofen, patients with de-
their site of action: creased renal or liver function, heart failure or

i. Peripherally acting analgesics – NSAIDs who are under diuretic therapy can be at risk
ii. Centrally acting analgesics – opioids for liver dysfunction, renal failure and fluid
Nonsteroidal anti-inflammatory drugs (NSAIDs) and retention.
opioids
To adequately treat oral and maxillofacial surgery Q.5. Principles of antibiotic therapy.
patients, management of acute postsurgical pain is
Ans.
essential.
Advantages associated with use of NSAIDs General principles of antibiotic therapy
● For control of postsurgical pain, NSAIDs are ef- i. Empirical antibiotic therapy has a limited role in the
fective and useful analgesics and can be adminis- prevention of the management of infections.
tered in the form of oral tablets and syrups in re- ii. If no response is forthcoming within 3 days of therapy,
quired dosages. then organisms must be identified so that the antibiot-
● A main advantage of these agents is that there is ics can be chosen to act against susceptible organisms.
no risk of addiction and abuse potential is low. No single antibiotic is effective against the pathogens.
● The adverse effects associated with NSAIDs are Once the causative organisms are isolated, it becomes
rarely seen, especially when the patient is moni- critical to identify the appropriate antibiotic therapy.
tored postsurgically for unanticipated or continuing iii. The most common organisms are Streptococci, Staph-
pain. ylococci and bacteroides.
● Moreover, fewer adverse effects are seen in cyclo- iv. Culture of the organisms and antibiotic sensitivity test
oxygenase-2 pathway inhibitors. assume greater importance in patients with (a) com-
● NSAIDs have a topical effect when applied to a promised defences like diabetes, (b) immunosup-
surgical wound and a local effect when injected in pressed patients, (c) those who are vulnerable to infec-
or around an area of wounded tissue. tions like subacute bacterial endocarditis, (d) patients
● If the topical route of administration proves to be on dialysis, (e) patients who are on chemotherapy for
feasible, then it is possible that many of the ad- malignancy and (f) in geriatric patients.
verse effects associated with NSAIDs might be v. For the drug to be therapeutically effective, the antibi-
avoided. otics must be given in proper dose at proper intervals
through appropriate route, so that blood concentration Children, not aller- One hour before 50 mg/kg ampicil-
of the drug is maintained at the desired level. gic to penicillin procedure 50 mg/ lin i.m. or i.v. 30
vi. The drug which is least toxic, most economical and kg amoxicillin min prior to proce-
most effective must be chosen for the therapy. dure
vii. To avoid the development of resistant strains, the drug Children, allergic One hour before 30 min prior to
with least-spectrum must be chosen. to penicillin procedure procedure a dose
viii. The patient must be warned about the possibility of 20 mg/kg clinda- of 20 mg/kg i.v.
mycin clindamycin
the side effects and complications. If any such untow- Or Or
ard reactions develop, then the patient must discon- 50 mg/kg cepha- 30 min before pro-
tinue the therapy forthwith. lexin or cefadoxil cedure
ix. Caution must be exercised in using newer drugs. Pref- 1 h before proce- 25 mg/kg or i.v.
erence must be given to use the known drug with dure cefazolin
Or
proven effectiveness. 15 mg/kg azithro-
x. Wherever possible, judicious methods to accentuate mycin or clarithro-
the efficacy of antibiotics must be utilized. mycin 1 h before
procedure
Q.6. Action, side effects and dosage of amoxicillin.
Ans. Q.8. Ibuprofen.
Amoxycillin Ans.
Amoxycillin is a close congener of ampicillin, but similar to Ibuprofen
it in all respects, except Mode of action
i. Oral absorption is better and food does not interfere ● Nonsteroidal anti-inflammation reduces prosta-
with absorption. Higher and more sustained blood glandin activity in prostaglandin synthesis.
levels are produced. Indications
ii. Incidence of diarrhoea is less. ● Control postsurgical pain.
iii. It is less active against Shigella and H. influenzae. Side effects
Dosage ● Gastrointestinal problems like nausea, heartburn,
● Majority of cases resolve with 250–500 mg t.d.s. vomiting and abdominal pain occur.
given for 5 days. ● In patients using ibuprofen for prolonged period
● 0.25–1 mg t.d.s. oral/ i.m. amoxycillin like up to 1 year, more severe problems such as
(trade names: Novamox, Synamox 250, 500 mg cap, gastric ulcer and bleeding can occur.
125 mg/5 mL dry syrup; Contraindications
Amoxil, Mox 250, 500 mg Cap; 125 mg/5 mL dry ● Allergic reactions to ibuprofen, other NSAIDs
syrup; 250, 500 mg/vial injection; and aspirin
Amoxicillin 250 mg plus probenecid 500 mg tab ● Contraindicated in pregnant or nursing women
(also 500 mg plus 500 mg DS tab). Precautions
● Ibuprofen inhibits platelet aggregation, but its ef-
Q.7. Prophylactic antibiotic protocol for high-risk
patients. fect usually causes small changes in bleeding time
in normal patients.
Ans. ● Patients on anticoagulant therapy or with intrinsic
bleeding disorders can be at risk for haemostatic

Adult, not allergic 2.0 g amoxicillin 1 Within 30 min be- problems with the concurrent use of ibuprofen.
to penicillin h before procedure fore procedure 2 g ● While taking ibuprofen, patients with decreased
Adult, allergic to 600 mg clindamy- ampicillin i.m. or renal or liver function, heart failure or who are
penicillin cin 1 h before pro- i.v
cedure or 2 g Within 30 min
under diuretic therapy can be at risk for liver dys-
cephalexin 1 h be- before procedure function, renal failure and fluid retention.
fore procedure 600 mg clindamy-
cin i.v.
Q.9. Tetracycline.
Or Ans.
Within 30 min
before procedure ● The broad-spectrum bacteriostatic tetracycline antibiot-
1.0 g cefazolin ics have been employed extensively in the treatment of
i.m. or i.v.
infections.
● Their widespread use, and often misuse, has resulted in ii. Pyrazolone derivatives: Metamizol (Dipyrone) and
the appearance of a number of resistant bacterial strains, Propiphenazone
a fact that has reduced their clinical usefulness. iii. Benzoxazocine derivative: Nefopam
● Tetracyclines used for treatment of orodental infections
Q.11. Corticosteroids in oral surgery.
are tetracycline, minocycline and doxycycline.
● At best, the tetracyclines are fifth-choice antibiotics, be- Ans.
hind the penicillin, macrolides, cephalosporins and c1inda- Preoperative corticosteroids used
mycin in the treatment of acute orodental infections. ● Preoperative corticosteroids have been advocated for
● Tetracyclines may be useful in treating certain types of
reduction of pain, oedema and trismus, following oral
periodontal diseases. surgical procedures.
● A 2-week course of tetracycline therapy has been found
● Corticosteroids reduce the amount of inflammation as-
to be effective in patients with advanced periodontitis sociated with oral surgery, especially oedema.
unresponsive to conventional therapy alone. ● Objective evaluation of corticosteroid uses subsequently
● Odontitis and early onset periodontitis.
has shown consistent reductions in oedema.
● Higher concentration of tetracyclines, especially mino-
● No significant adverse reactions were noted with corti-
cycline, in gingival fluids, may help eradicate bacteria costeroid doses ranging from 80 to 625 mg hydrocorti-
resistant to concentrations that can normally be achieved sone equivalent anti-inflammatory dosage.
in the plasma. ● The use of preoperative corticosteroids appears to be a
● Studies of tetracycline and doxycycline have indicated
safe and rational method of reducing postoperative
enhanced repair and tissue regeneration of the periodon- complications.
tium and prevention of recurrent periodontitis in high- ● The potential for complications induced by preoperative
risk patients. corticosteroid use, such as adrenal suppression and de-
● At least a part of this beneficial effect is due to the tissue
layed wound healing, should also be considered.
collagenase-inhibiting effect of the tetracyclines, which ● In patients with prolonged steroid therapy, the adreno-
is relatively marked in the gingival crevice, because the cortical activity is suppressed; in such patients, supple-
drugs are concentrated several fold in sulcular fluid. mentary hydrocortisone should be given.
● Although, tetracyclines should not be used as a penicillin
● Prolonged presence of steroid in blood results in de-
substitute for prophylaxis against bacterial endocarditis. creased output of ACTH. This results in decreased func-
● Since many of the causative organisms are resistant,
tion and atrophy of the adrenal cortex.
they may have a role in preventing endocarditis after ● Rapid withdrawal of hydrocortisone results in adrenal
dental therapy. crisis. For the routine activity, level of secretion may be
Q.10. Classification of NSAIDs. sufficient.
Ans. ● But in case of stress as in any minor or major dental
surgical procedure, the adrenal cortex may be unable to

Classification of NSAIDs secrete more to cope up with the stress.
A. Nonselective COX inhibitor (conventional NSAIDs) ● Even minor surgery may prove disastrous. Therefore,
i. Salicylates: Aspirin such patients should be hospitalized and supplemented
ii. Propionic acid derivatives: Ibuprofen, Naproxen, with double the usual dose 2 days before surgery and
Ketoprofen and Flubiprofen 2 days after surgery.
iii. Anthranilic acid derivatives: Mephenamic acid ● Later on the dose is gradually tapered.
iv. Aryl-acetic acid derivatives: Diclofenac
v. Oxicam derivatives: Piroxicam and Tenoxicam Q.12. Dental implants: indications and contraindica-
vi. Pyrrolo-pyrrole derivatives: Ketorolac tions.
vii. Indole acetic acid derivatives: Indomethacin Ans.
viii. Pyrazolone derivatives: Phenylbutazone and oxy-
phenbutazone [Ref LE Q.1]
B. Preferential COX-2 inhibitors Q.13. Classification and indications of steroids.
Nimesulides, Meloxicam and Nabumetone
Ans.
C. Selective COX-2 inhibitors
Celecoxib, Rofecoxib, Valdecoxib and Etoricoxib [Same as SE Q.1]
D. Analgesic – Antipyretics with poor anti-inflamma- Q.14. Analgesics in oral surgery.
tory action
Ans.
i. Paraaminophenol derivative: Paracetamol (Acte-
aminophen) [Same as SE Q.4]
Q.15. Antibiotics in oral surgery. Antibiotics are chemical substances produced by microor-
ganisms, which has the capacity to inhibit the growth of or
Ans.
kill other organisms.
[Same as SE Q.5] Mechanism of action of antimicrobials
● Penicillin, cephalosporins, bacitracin and vancomycin
Q.16. Enumerate indications, doses and side effects of
inhibit the cell wall synthesis of microorganisms.
ibuprofen.
● Polymixin, collistin, polyene and antifungal antibiotics
Ans. inhibit the cytoplasmic membrane of the microorganisms.

● Aminoglycosides, tetracyclines, chloramphenicol, mac-
[Same as SE Q.8]
rolide antibiotics and lincomycin inhibit the protein
synthesis and cause impairment in the function of ribo-
SHORT NOTES: somes.
● Quinolones and metronidazole interfere in transcrip-
Q.1. Methicillin-resistant Staphylococcus aureus.
tion/translation of genetic information.
Ans. ● Sulphonamides and trimethoprim have antimetabolite
action.
● Also known as MRSA.
● Vidarabine and acyclovir binds to viral enzymes essen-
● It is emerging increasingly, because of indiscriminate
tial for DNA synthesis.
use of antibiotics.
● MRSA is responsible for more than 50% nosocomial Q.6. Broad-spectrum penicillin.
infections.
Ans.
● They are resistant to most of the antibiotics, because
they carry large plasmid-bearing resistance determi- 1. Aminopenicillins – Ampicillin

nants for MRSA. ● Active against Gram-negative bacilli, e.g. H. influen-
● Vancomycin is the drug of choice. zae, E. coli, Proteus, Salmonella and Shigella.
2. Carboxypenicillins
Q.2. Little’s area.
● Active against Pseudomonas aeruginosa and indole-
Ans. positive Proteus.

3. Ureidopenicillins
● The anteroinefrior part or the vestibule of the septum of
Piperacillin: Active against Klebsiella and is mainly
nose contains anastomoses between the septal ramus
used for neutropenic/immunocompromised patients
of the superior labial branch of the facial artery, branch
having serious Gram-negative infections and in burns.
of sphenoplatine artery and of anterior ethmoidal artery.
Meziocillin: Active against Pseudomonas and Klebsiella.
● These form a large capillary network called the Kies-
4. Mecillinam (Amdinocillin)
selbach’s plexus.
● It acts by inhibiting the bacterial cell wall synthesis.
● This is a common site of bleeding from the nose, i.e.
● It is active against Gram-negative bacilli, e.g. E. coli,
epistaxisis and is known as Little’s area.
Salmonella, Klebsiella and Enterobacter, but not
Q.3. Pentazocine. against Gram-positive cocci like Pseudomonas.
Ans. Q.7. Diclofenac sodium.
● This benzomorphine derivative has a potent analgesic Ans.
and a weak opioid antagonist activity.
Diclofenac sodium
● It does not cause diarrhoea.
● It is an analgesic–antipyretic anti-inflammatory drug.
● As an analgesic, it is half as effective as morphine, can
● It inhibits PG synthesis and has short-lasting antiplatelet
cause respiratory depression.
action.
● It has a shorter duration of action than morphine, hence
● It is well absorbed orally and has plasma half-life of 2 h.
is not recommended in myocardial infarction.
Adverse effects
Q.4. Endosseous implants. Adverse effects are generally mild.
● Dizziness
Ans.
● Nausea
[Ref LE Q.1] ● Headache
● Epigastric pain
Q.5. Role of antibiotics in oral surgery.
● Gastric ulceration and bleeding is less common
Ans. ● Rashes
Uses aerobic bacteria and some anaerobic bacteria involved

● Can be used in rheumatoid and osteoarthritis patient in orodental infections and may be useful in treating
● Toothache such infections.
● Bursitis
● Ankylosing spondylitis Q.9. Newer antibiotics.
● Dysmenorrhoea Ans.
● Post-traumatic and postoperative inflammatory con-
ditions such as pain and wound oedema ● Carbenicillin and ticarcillin are some of the recently
introduced antibiotics.
● These are similar to penicillin, which are useful against
Q.8. Cephalosporins.
Pseudomonas and other Gram-negative organisms in
Ans. hospital infections.
● Newer aminoglycosides like gentamicin and amikacin
Cephalosporins
● The cephalosporins comprise a group of beta-lactam
are also used in such hospital infections.
● Newer antitubercular drugs are rifampicin and ethambu-
antibiotics that structurally resemble the penicillin.
● There are over 20 cephalosporins in the market, of
tol in the form of multidrug therapy along with strepto-
which eight can be given orally. mycin and isoniazid.
● The mechanism of action of cephalosporins is almost
Q.10. Clark’s shift cone technique.
identical to that of the penicillin.
● Of the orally active cephalosporins, only cefaclor, cefu- Ans.
roxime and cefprozil have significant activity against ● Two radiographs are taken at different angles and the
anaerobes and are therefore preferred for orodental in- position of the object in question on each radiograph
fections. with reference structure is compared.
● Some first-generation cephalosporins, despite poor an-
● If the tube is shifted and directed at the reference object
aerobic activity, are used to treat dental infections such (apex of tooth) from more mesial angulation and the
as dentoalveolar abscess. object in question also moves mesially with respect to
● Their clinical effectiveness may be due to their activity
the reference object, the object lies lingual to the refer-
in killing aerobes that deplete oxygen in the local envi- ence object.
ronment and facilitate the growth of anaerobes. ● Alternatively, if the tube is shifted mesially and object
● The major problem with resistance has been with
in question moves distally, it lies on the buccal aspect of
Staphylococci, which are rarely present as aetiologic the reference object.
agent in orodental infections, but are important con-
taminants of surgical or traumatic skin wounds. Q.11. Aspirin: mechanism of action.
● A number of cephalosporins may reach therapeutic con-
Ans.
centrations in osseous tissues after administration of
usual doses and are useful for bone and joint infections ● Aspirin is an effective analgesic for mild to moderate
caused by susceptible microorganisms. Cephalexin, for degrees of pain.
example, has been shown in alveolar bone and is active ● Aspirin acetylate inhibits the enzymes cyclo-oxygenase
against various Gram-positive aerobic bacteria found in and TX-synthase, inactivating them irreversibly.
dental infections. ● Platelets are exposed to aspirin in the portal circulation,
● A cephalosporin would be an appropriate antibiotic for before it is deacetylated during first pass in liver; and
those rare infections known to be caused by a cephalo- because platelets cannot synthesize fresh enzyme,
sporin-susceptible strain of Klebsiella. Nevertheless, if TXA2 formation is suppressed at very low doses and till
penicillin are effective, cephalosporins offer no advan- fresh platelets are formed.
tage and should not replace the penicillin. ● Prolongation of bleeding time induced by aspirin lasts
● The bactericidal action of cephalosporins is beneficial for 5–7 days.

for patients with a compromised immune system. ● In vessel walls, aspirin also inhibits PGI2 synthesis.
● The restricted activity of the orally active first-genera- Since intimal cells can synthesize fresh enzymes, activ-
tion and third-generation cephalosporins against anaer- ity returns rapidly.
obes limits their usefulness in treating orodental infec- ● It is possible that at low doses TXA2 formation by
tions of anaerobic aetiology (e.g. periapical abscesses). platelets is selectively suppressed, whereas higher doses
● Some of the orally active second-generation cephalo- may decrease both TXA2 and PGI2 production.
sporins, such as cefaclor, cefuroxime and cefprozil, are ● The release of ADP from platelets is inhibited by aspirin
active against both Gram-positive and Gram-negative and their sticking, to each other also.
● Side effects: Sensitive reactions may manifest as Q.16. Types of implant supported prosthesis.
rashes, swelling, asthma and rarely anaphylaxis. In-
Ans.
gestion can promote nausea, vomiting, bronchospasm
and gastrointestinal bleeding due to erosion of mucous i. Single tooth replacements
membrane. ii. Partially edentulous segment restorations
● Precautions: Young children are highly susceptible to iii. Fully edentulous lower jaw
aspirin poisoning (therapeutic overdose). iv. Fully edentulous upper jaw
Q.13. Apert syndrome. Q.17. Metronidazole.
Ans. Ans.
Apert syndrome Metronidazole

● It is also called acrocephalosyndactyly. Metronidazole is a nitroimidazole, a powerful amoebi-
Skeletal deformity cide.
There is syndactyly (fusion of fingers) of second, third Mechanism of action
and fourth digit of hand and acrobrachycephaly (tower Susceptible microorganism reduces the nitro group of
skull). In some cases like kleeblattschadel deformity metronidazole by anitroreductase and converts it to a
(cloverleaf skull), the skull is ovoid, brachycephalic cytotoxic derivative, which binds to DNA and inhibits
and often presents a horizontal supraorbital groove. protein synthesis.
Facial deformities Pharmacokinetics
The middle third of face is underdeveloped. ● It is well absorbed and reaches adequate concentra-
Oral features tion in the CSF, and has a plasma half-life of 8 h.

● High palaptal vault and V-shaped maxillary ● It is metabolized in liver by oxidation and glucuroni-
alveolar ridge dase conjugation.

● Trapezooidal-shaped appearance of lip, when Adverse effects
lip is relaxed ● Nausea, anorexia, abdominal pain and most fre-
● There is posterior palatal cleft and bifid uvula quently metallic taste in mouth are most common.
● Retarded eruption and dental malocclusion ● Headache, stomatitis, glossitis, furry tongue, dizzi-
● Class II malocclusion ness, insomnia, ataxia and vertigo.

● Pruritis, urticaria and skin rashes also occurs.
Q.14. Endosseous implants.
Q.18. Uses of steroids in oral surgery.
Ans.
Ans.
● These are implants that are placed completely within
the alveolar and basal bone. Indications
● These implants receive their support by osseointegra-
A. Endocrinal
● Acute renal insufficiency
tion with the alveolar bone into which they are placed.
● Chronic adrenal insufficiency (Addison disease)
● They can be different types depending on the shape that
is used: blade type, root form, etc. B. Nonendocrinal

● Arthritis – Rheumatoid arthritis
Q.15. Osteointegration. ● Osteoarthritis
● Rheumatoid fever
Ans.
● Acute gout
Osteointegration ● Severe allergic reactions
● Osteointegration has been defined as the direct func- ● Bronchial asthma
tional and structural bond between organized vital ● Collagen diseases
bone and the surface of an inanimate, alloplastic ● Eye diseases
material. ● Renal diseases
Factors affecting osteointegration ● Skin diseases
● Occlusal load ● Gastrointestinal diseases
● Biocompatibility of the material ● Liver diseases
● Implant design ● Haematologic disorders

● Implant surface ● Cerebral oedema
● Implant bed (surgical site) ● Lung diseases
● Infection ● Organ transplantation

● Bell palsy ● It is slightly less active than penicillin V against Gram-

● Acute polyneuritis positive cocci, except enterococci for which it is more
● Myotonia active.
● Chemistry: Beta-lactam antibiotic.
Q.19. Ketamine.
● Source: Semisynthetic.
Ans. ● Mechanism of action: Inhibits cell wall synthesis.
● Major action: Antibiotic and bactericidal.

Ketamine
● Ketamine is highly lipid-soluble and gets rapidly dis- Q.21. Carotid ligation.
tributed into highly perfused organs and then redistrib-
Ans.
uted to less vascular structures.
● Ketamine hydrochloride given 1–2 mg/kg slow i.v. or Carotid ligation
10 mg/kg i.m. produces dissociative anaesthesia within Indications
3–5 min, which lasts for 10–15 min after a single injec- ● Bleeding from oral malignancies
tion. ● Slipping of superior pedicle of thyroid gland
Advantages ● Arteriovenous malformation of scalp
i. Provides analgesia and amnesia. It can be used as a Anaesthesia

sole agent for minor procedure. ● General anaesthesia
ii. Respiration is not depressed. It does not induce hy- Position of patient
potension. ● Supine with neck extended to opposite side
iii. Less likely to induce vomiting, and pharyngeal and Procedure

laryngeal reflexes are only slightly affected. ● Skin and platysma are cut along the line of inci-
iv. It is of particular value in children and poor-risk sion.

patients, and also in asthmatic patients, since it does ● Anterior border of sternomastoid is retracted pos-
not induce bronchospam. teriorly.

Disadvantages ● Internal jugular vein is identified.
● Hallucinations and involuntary movements may oc- ● Common carotid artery is found medial to IJV.
cur during recovery, if used as a sole agent. ● Bifurcation of the common carotid artery defined.
● May be dangerous in hypertensives, as it raises BP. ● External carotid artery is identified by its branches.
● Ketamine increases cerebral blood flow and intracra- ● Internal carotid artery has no branches in the
nial pressure. neck.

● Safeguard the hypoglossal nerve, which crosses
Q.20. Amoxycillin.
LCA and ECA just above hyoid bone.
Ans.
● Amoxycillin is effective against Gram-negative as well
as Gram-positive bacteria and most oral anaerobes.
Section I

of Previous Years
PART I: COMPLETE DENTURES

Topic 1 Introduction to Complete Dentures 771
Topic 2 Diagnosis and Treatment Planning 781
Topic 3 Diagnostic Impressions in CD, Mouth Preparation
for CD and Objective of Impression Making 798
Topic 4 Primary Impression in Complete Dentures and Lab
Procedures Prior to Master Impression Making 808
Topic 5 Secondary Impression in Complete Dentures and Lab
Procedures Prior to Jaw Relation 816
Topic 6 Maxillomandibular Relations 821
Topic 7 Lab Procedures Prior to Try-In 836
Topic 8 Lab Procedures Prior to Insertion and Complete Denture
Insertion 856
Topic 9 Relining and Rebasing in Complete Dentures 873
Topic 10 Special Complete Dentures and Miscellaneous 878
Section I

of Previous Years
Part I
Complete Dentures
Topic 1
Introduction to Complete Dentures
LONG ESSAYS:
1 . Define edentulism and explain briefly the mechanism of complete denture support in edentulous state.
2. Discuss in detail how you will manage mandibular poor foundation case for complete denture fabrication.
3. Enumerate the reasons for loss of teeth. What are the consequences of loss of teeth? What are the methods
of prosthodontic replacements?
4. Enumerate the reasons for loss of teeth. What are the consequences of loss of teeth? What are the methods of
prosthodontic replacements? [Same as LE Q.3]
5. Discuss mouth preparation of complete dentures. [Same as LE Q.2]
SHORT ESSAYS:
1 . Metallic denture base.
2. Preprosthetic surgery.
3. Vestibuloplasty. [Ref LE Q.2]
4. Preprosthetic surgical managements in complete denture. [Same as SE Q.2]
SHORT NOTES:
1 . Metallic denture base. [Ref SE Q.1]
2. Polished surface.
3. Advantages of metal bases. [Same as SN Q.1]
4. Polished surface of complete denture. [Same as SN Q.2]
771
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Define edentulism and explain briefly the mecha- ● Edentulous state – residual ridge receives vertical,
nism of complete denture support in edentulous state. diagonal and horizontal loads with small support
area and there is very less adaptation of supporting
Ans.
tissues to functional requirements resulting in bone
Edentulism resorption.
Edentulism is the state of being edentulous, i.e. without ● Further, the complete dentures move over their un-
natural teeth. derlying mucosa and bone during function, which
Edentulous state represents a compromise in mastica- causes tissue damage.
tory system integrity along with adverse functional and Factors which increase denture retention and prevent
aesthetic sequelae. ridge resorption (Brill, 1967)
Causes of edentulism/reasons for loss of teeth ● Maximal extension of denture bases.
● Traumatic injuries resulting from accidents, sports, etc. ● Maximal area of contact between the denture
● Loss of teeth due to dental diseases like caries, peri- base and mucous membrane.
odontal disease and failed endodontic treatment. ● Intimate contact of denture base and its basal seat.
● Pathosis like cysts and tumours cause destruction of ● Oral musculature – buccinator, orbicularis oris
alveolus and tooth loss. and intrinsic and extrinsic muscles of tongue
● Prophylactic tooth extraction done for tumour radiation (balancing of forces between that of tongue
therapy. and perioral musculature).
● Extraction of grossly malaligned teeth. ● Proper impression technique and design of
● Congenitally missing and failure of eruption of teeth. labial, buccal and lingual polished surface of
● Iatrogenic extractions. denture and dental arch form.
Mechanism of complete denture support in edentu- D. Psychological effect of edentulous state on retention
lous state ● Edentulous state leads to adverse psychological
A. Masticatory loads effect on patients, which may decrease salivary
Natural dentition: 44 lb (20 kg). secretion and thus decrease retention.
Complete denture: 13–16 lb (6–8 kg). ● Further, due to residual ridge reduction and diminished
● Depends on the consistency of food chewed. neuromuscular skills and dental reflex adaptation, and
Edentulous patients are instructed to chew soft pain and initial discomfort in wearing new dentures in
food, which places a lesser load on supporting edentulous state, there is an increase in parafunctional
tissues within the tolerance limit of tissues. movements placing more loads on supporting tissues
B. Area of support and more destruction.
● Less area of mucosal support available as compared ● Patient complains of sore tongue and develops a
to natural dentition. habit of thrusting the tongue forward against the
Edentulous maxillae: 22.96 cm2 denture.
Edentulous mandible: 12.25 cm2 ● Electromyography shows strong response of men-
Natural dentition of both jaws: 45 cm2 talis and lower lip in complete denture-wearers with
● As the residual ridge resorbs, the denture-bearing impaired retention and stability of lower denture.
area progressively decreases along with its tolerance ● Stress also increases the activity of temporalis and
for denture wearing, which further decreases if any masseter muscles, which causes tooth contact and
systemic disease such as anaemia, diabetes and hy- pressure and soreness of underlying mucosa due to
pertension is present. diminished blood supply.
C. Residual ridge ● Complete dentures should be designed so that the
● The residual ridge is a portion of the residual bone occlusal surface allow both functional and parafunc-
and its soft tissue covering remains after the removal tional movements of the mandible. Teeth should in-
of teeth. stead be arranged in ‘neutral zone’ balancing the
● It comprises of denture-bearing mucosa, submucosa, force between tongue and perioral musculature and
periosteum and underlying residual alveolar bone. not necessarily directly on the residual ridge.
This serves as the foundation for dentures. E. Effect on mastication and swallowing
● Dentulous state – bone receives tensile loads with ● Masticatory movement of tongue and cheek plays a
large supporting surface area. vital role in keeping the food bolus between the
occlusal surfaces of teeth. This aids in appreciating frequently used are silicone rubbers/acrylic
the flavour of food and is indirectly involved in sali- resins.
vary and gastric secretions, swallowing and digestion ● By keeping the dentures out of mouth during
of carbohydrates. night will give rest to supporting tissues and

● Maximal bite force in dentulous individuals is control the time during which load is applied to
5–6 times more as compared to in denture wearers. them. And, also tissues will get exposed to sa-
Thus, loss of teeth leads to diminished masticatory liva and get stimulated by tongue, lip and
efficiency and impaired swallowing and digestion. cheek activity.
● There are more tooth contacts on the nonchewing G. Changes in morphological facial height and temporo-
side as compared to chewing side, because of dis- mandibular joints (TMJs)
placement and tilting of denture during mastication. ● Residual ridge reduction causes a decrease in total
The presence of dentures (foreign object) in mouth facial height and increase in mandibular progna-
elicits a different stimulus to sensorimotor system thism.
and influences the cyclic masticatory stroke pattern. ● In complete denture-wearers, the anterior mandible
● During swallowing, there is greater transfer of loads height reduction is 6.6 mm which is about four times
to denture bases and then to underlying mucosa plac- more than that in maxillary process.
ing stress on them and causing their destruction. So, ● Any change in morphological facial height/jawbones
the complete denture occlusion should be compatible is transferred to TMJs. Tooth loss and incorrect or
with the forces generated by mandibular movements absence of prosthetic treatment results in pain, dys-
during deglutition. function and degenerative changes in TMJ.
● Artificial teeth must be placed within the confines of ● Centric relation is the most posterior relation of man-
the functional balances of oral musculature involved dible to the maxilla at established vertical relation. It
in mastication and deglutition. coincides with the reproducible posterior hinge posi-
. Distribution of stress in denture-supporting tissues
F tion of mandible and unconscious swallowing with
● During function, dentures are displaced against their mandible occurs at this position.
supporting tissues by placing pressure on them, ● In edentulous patients, it is difficult to accurately
which occludes its blood supply and tissue damage. record the centric relation and it is subjected to
Viscoelastic character of denture-supporting tissues change, as the vertical relation at which, it is estab-
● On placing the load, there is initial instantaneous lished keeps on changing due to the reduction in
elastic compression of soft tissues followed by ridge height, alterations in morphological facial
delayed elastic deformation that occurs slowly height and morphological changes in TMJ.
and continuously to diminish the rate as the dura- H. Cosmetic changes in edentulous state
tion of load is extended. ● Deepening of nasolabial groove.
● Once the load is removed, instant elastic decom- ● Loss of labiodental angle.
pression occurs followed by continued delayed ● Decrease in horizontal labial angle.
elastic recovery. ● Narrowing of lips.

● Histologically, altered morphology of stressed oral ● Increase in columella–philtral angle.
mucosa is seen, such as the decrease in the depth ● Prognathic appearance.
of epithelial ridges and obliteration of connective Treatment options for edentulous state
tissue papilla. Further, in elderly people, longer ● Preservation and prevention of what are remaining –
time is required in recovery of displaced mucosa. oral prophylaxis, and periodontal and endodontic
Pressure changes are subjected to force–time thresh- treatment.
old and thus dentist must try to minimize either or ● Post and core/crown.
both by following measures: ● Implants.
● Maximizing denture base coverage within the ● Fixed partial dentures.
morphological and functional limits of oral tis- ● Cast removable partial dentures.
sues decreases force per unit area. ● Overdentures.
● Developing an optimal denture occlusion, de- ● Immediate dentures.
creasing the occlusal table and educating the ● Complete dentures.
patient about decreasing parafunctional habits. ● Implant retained dentures.
● Use of resilient denture base lining materials,

Q.2. Discuss in detail how you will manage mandibu-
which permit a wider distribution of occlusal
lar poor foundation case for complete denture fabri-
forces and increases the thickness of oral tissue
cation.
by serving as an analogue of mucoperiosteum
with its relatively low elastic modulus. Most Ans.
Mandibular poor foundation Nonsurgical methods

● Good and healthy supporting tissue as well as soft and These include as follows:
bony tissue foundation is a prerequisite to success of A. Rest for denture-supporting tissues
complete denture treatment. Several preexisting condi- It can be achieved by the following:
tions in mouth can interfere with fabrication and use of a. Leaving the dentures out of mouth for a period of time.
complete denture, which need to be corrected. b. Use of tissue conditioners – temporary soft liners.
● Management of poor mandibular foundation case for c. Finger massage of the oedematous and enlarged
complete denture fabrication can be categorized into denture-bearing mucosa.
following: ● These procedures promote recovery of de-
I. Nonsurgical methods. formed and damaged tissues due to old den-

II. Surgical methods. tures back to their normal form. Before taking
III. Combination method. impression for new denture fabrication, old den-
tures should be left out of mouth for 48–72 h to
I. Nonsurgical methods allow soft-tissue recovery. When recovery time
A. Rest for denture-supporting tissues. is prolonged, keeping dentures out of mouth is
B. Occlusal correction of old prosthesis. not feasible. Tissue conditioners are used in
C. Good nutrition. such situations.
D. Conditioning of patient’s musculature. These are made of a polymer powder and an aro-
II. Surgical methods matic ester–ethanol mixture (Braden, 1970). They
A. Procedures to improve bony foundation remain soft for several days while the tissues are
i. Retained dentition. recovering. Their uses include as follows:
ii. Removal of pathologic bony conditions. ● Recovery of deformed tissues.
iii. Techniques to deal with mandibular alveo- ● Liners for surgical splint.
lar excess. ● Stabilization of trial denture base.
iv. Techniques to deal with excessive alveolar ● Determination of optimal arch form and
bone resorption neutral zone.

a. Techniques to reduce alveolar atrophy. ● As functional impression materials in refit-
b. Techniques to correct alveolar atrophy. ting complete dentures.

c. Techniques to compensate for alveolar B. Occlusal correction of old prosthesis
atrophy. ● With use, occlusal surface of denture wears down
B. Procedures to improve soft tissue foundation leading to decrease in vertical dimension and over-
i. Hypermobile tissue correction. closure. This places more stress on supporting tis-
ii. Excision of fibrous hyperplasia of the retro- sues and causes their damage.
molar pad and epulis fissuratum. Restoration of vertical facial height can be done using
iii. Hyperplastic maxillary tuberosity excision. resilient lining materials. Their uses include:
iv. Hyperplastic palatal mucosal correction. ● Recovery of tissues of TMJ.
v. Frenectomy for hyperplastic lingual frenum. ● To estimate the amount of vertical facial height that
C. Procedures to improve ridge relationships can be tolerated by patient.

i. Maxillary advancement procedures ● To permit some movement of denture base, so that
ii. Maxillary retrusion procedures its position becomes compatible with existing
iii. Mandibular advancement procedures occlusion.
iv. Mandibular retrusion procedures: C. Good nutrition
● Subcondylar osteotomy ● Good nutrition is mandatory mainly for elderly pa-
● Sagittal (ramus) osteotomy tients, who are malnourished because of which extra
● Vertical osteotomy of ramus stress is placed on tissues leading to denture failure.
D. Implants Taking proper diet history and emphasizing on good
● Subperiosteal nutritional programme is what is required.
● Transosteal D. Conditioning of patient’s musculature
● Endosteal ● Some patients are unable to follow instructions and
● Mucosal inserts coordinate jaw movements, which create problems

● Ramus inserts during denture fabrication, e.g. during impression
● Endodontic implants making and recording jaw relations.
● For such patients, mandibular jaw exercises pro- ii. Cortical alveoloplasty
gramme should be done which allow relaxation of ● It is done when urgent denture fabrication is required.
muscles of mastication, improve their coordination ● It aims at primary closure of extraction socket for
and prepare the patient psychologically for pros- bone remodelling.

thetic treatment. ● Following extraction, crestal incision is made and
Surgical methods any bony projections removed and smoothened.

● Preprosthodontic surgical procedures are designed to ● If multiple extractions are done, then soft tissues on
facilitate fabrication of prosthesis or to improve the mesial and distal side of the socket are trimmed and
prognosis of prosthodontic care. the wound is then closed by sutures.
● Some conditions of patient’s mouth, such as atrophy of iii. Intercortical alveoloplasty
alveolar ridges and hyperplasia of soft tissues, require ● Also known as Dean’s alveoloplasty, crush tech-
surgical correction in order to establish good denture nique and interseptal alveoloplasty.
base foundation. ● Done in case of prominent anterior ridged, which
A. Surgical procedures to improve mandibular denture causes undercut thereby causing problems during den-
base foundation ture fabrication and use.
a. Procedures to improve bony foundation ● Interradicular septa are removed with a rongeur till
i. Retained dentition the base of the socket and then vertical bone cuts are
● Retained dentition can be seen in radiographs. They made bilaterally in the canine region.
are of two types: ● Then, using finger pressure, labial cortical plate is
a. Unerupted teeth. fractured inward and bone step distal to canine is

b. Retained roots. rounded off. Wound suturing is done to prevent
● Above, if present, should be removed prior to labial bone from springing back.
prosthetic treatment in order to prevent their pos- b. Reduction of knife edge/irregular/sharp mylohyoid
sible transformation into pathosis such as cyst or ridge
tumour. They are left as such, if it is asymptomatic ● Following extreme alveolar atrophy, the mandibular
for several years and removal can cause lot of ridge becomes sharp causing pain while wearing
bone loss. denture. In this case, an incision is made slightly
ii. Removal of pathologic bony conditions below the crest, flap is reflected and sharp edges are
● If any odontogenic cyst present, then it can transform removed with side-cutting ronguer and smoothened
into tumour and cause bone destruction. with bone file.
● It should be explored surgically and examined In case of sharp mylohyoid ridge, it should be removed if
microscopically. Treatment includes small cyst – ● Overlying mucoperiosteum is thin and prone to den-
enucleation. ture irritation.

● Large cyst – marsupialization for shrinkage, bone ● Creates undercuts.
fill-in, and to prevent surgical fracture and damage to ● Mylohyoid muscle hyperactivity causes denture dis-
adjacent vital structures. placement.

● In case of tumour, radiographic and histological ex- Procedure
amination should be done followed by immediate Crestal incision is made and flap is reflected to the
surgical treatment during which maximum amount lingual side. At its point of attachment, mylohyoid
of residual ridge should be preserved. muscle is detached. Exposed mylohyoid ridge is
iii. Techniques to deal with mandibular alveolar excess trimmed and smoothened. During healing, muscle
a. Alveoloplasty reattaches. Vital structures should be preserved.
The surgical smoothening and shaping of the alveolar c. Genial tubercle reduction or reattachment
ridge is done prior to denture placement. During alveo- Prominent genial tubercle after ridge resorption causes
loplasty, minimum amount of bone should be removed. problem in denture construction.
Types of alveoloplasty include the following: Procedure
i. Simple compression ● Removal of tubercle and allowing genioglossus mus-
● It is simple and effective and done after routine ex- cle to reattach.
tractions. ● Removal of tubercle and repositioning of genioglos-
● Following extraction, there is expansion of buccal sus muscle with percutaneous sutures held with cot-
and lingual cortical plate. Compression of bone re- ton roll under the chin.
duces the size of wound, promotes healing and al- ● Detachment of tubercles using osteotome and bur
lows favourable remodelling of bone. cut as guide, along with its attached muscle and
repositioning to inferior border of mandible held in B. Techniques to correct alveolar atrophy

place by wire ligature. ● Either by replacing lost bone (augmentation) using
Sometimes, the tubercles can serve as shelf on which natural/synthetic graft or regenerating the lost bone.
dentures can rest and increase the area for denture Various graft materials used are as follows:
support and thus not requiring removal. i. Rib graft – from fifth to ninth rib.
d. Removal of mandibular torus ii. Iliac crest graft – material of choice.
Indications iii. Particulate bone and marrow.
● Interfere with denture fabrication. iv. Hydroxyapatite – biocompatible, nonresorbable,
● Mucosa overlying torus is ulcerated and healing is nonosteogenic mineral similar to bone and tooth.
slow. Favours normal bone healing around the material
● They are large and interfere with speech and and promotes direct chemical bonding to particles
deglutition. without an intervening fibrous capsule.
Procedure v. Tricalcium phosphate – resorbable and has os-
● Crestal incision is made and envelope flap is re- teogenic potential.
flected without tearing the thin mucosa. Techniques
● Torus is cleaved carefully from mandible using os- a. Direct augmentation of mandibular ridge with rib graft
teotome malleted at its junction. ● In addition to ridge augmentation, this procedure rein-
● In case of unclear junction, slot can be made using forces severely atrophic mandible in danger of fracture.
bur for osteotome positioning or the torus can be re- Procedure
moved entirely using bur. ● Two 15 cm length segments are obtained from fifth
● At the end, stent is placed over the surgical area to to ninth ribs. First segment is contoured by vertical
prevent haematoma formation. scoring (kerfing) on its inner aspect to increase flex-
e. Alveolar repositioning ibility. Second segment is cut into 4–6 mm size
● For better retention and stability, alveolar bone pieces for packing.
should be aligned over basal bone. Mandibular sub- b. Augmentation of the inferior border
apical osteotomy is done for the above purposes. Submandibular incision is made to place the rib graft.
● The repositioned segments are stabilized using Vestibuloplasty is done after 3–6 months.
splints or treatment dentures held in place by perial- Advantage: Extraoral surgery, so that interim denture
veolar wires. can be placed immediately.
iv. Techniques to deal with excessive alveolar bone Disadvantage: Extraoral scar, chances of facial shape
resorption alteration and damage to sensory or motor nerve caus-
A. Techniques to reduce alveolar atrophy ing lip biting.
● If root forms of teeth without periodontal disease are c. Augmentation with pedicle and interpositional bone
left in alveolus, hen bone resorption is greatly re- grafts
duced. Based on this, following techniques can be It is graft placed between two segments and bone
used: is attached to its own blood supply leading to less
a. Overlay dentures resorption.
Dentures are fabricated over modified endodonti- Three techniques:
cally treated teeth. i. Horizontal osteotomy with interpositional bone
b. Submucous vital root retention graft
● Roots are reduced to 2 mm below the alveolar ● Vertical height of the bone should be sufficient
crest and primary water tight closure of overly- to cut the bone horizontally. Incision is placed
ing mucosa is done which causes the root to lower to ridge crest. Lingual tissues are not
remain vital. disturbed to maintain the blood supply.
● A layer of bone with periodontal ligament ● Bone is cut horizontally and the graft material
forms and covers the reduced root. is sandwiched between the two segments and
Dentures are placed after 6 weeks of above proce- stabilized using transosteal wires. Horizontal
dure achieving balanced occlusion. cut is either placed above or below the inferior
c. Root cone implants alveolar canal.
● Hydroxyapatite root cone implants are placed ii. Vertical or visor osteotomy
in fresh sockets to reduce ridge resorption to a ● Indicated when insufficient bone height is
great extent. Implant is placed 2 mm below the present for horizontal cut, but bone width is
bone crest. adequate (approximately 10 mm).
● Mandible is split vertically and buccolingually iii. Epithelial graft vestibuloplasty

and the lingual section is raised to increase the It is a secondary epithelialization procedure,
height. which uses skin or oral mucous membrane graft
● Particulate bone marrow graft is placed facially to to cover the exposed tissue.
raise the lingual segment to fill the gap and to cor- Indications
rect contour and is secured with transosteal wires. ● To increase support, stability and retention of den-
● There may be chance of damage to nerve re- ture in case of severe resorption of mandibular ridge.
sulting in paraesthesia, so utmost care must be ● When high muscle attachment interferes with
taken. development of adequate border seal, sufficient

iii. Combined vertical and horizontal osteotomies. bone height of 1.5 cm should be present for this
d. Ridge augmentation with synthetic grafts, i.e. hydroxy- procedure. It is the most favourable and predict-
apatite and tricalcium phosphate (subperiosteal tunnel) able of all vestibuloplasties.
● Bilateral vertical incisions are made just anterior to Contraindications
mental foramen. ● Patients who can be treated using conventional
● Subperiosteal tunnelling is done on ridge crest fol- complete denture techniques.

lowed by filling the material using syringe. ● Should not be done for neurotic, psychotic and
● Incision is closed and material is moulded to the depressed patients.

shape of ridge using finger pressure. After 10 weeks, ● For patients with neuromuscular disorders, pa-
vestibuloplasty is done. tients with poor health, geriatric patients and for
e. Labial augmentation of undercut anterior ridge those having unfavourable surgical risk.
● Materials used: Gelatin sponge, oxidized cellu- ● Insufficient vertical height and severe prognathism
lose, tantalum mesh, cartilage, bone and hydroxy- cases.}

apatite (preferred). b. Lowering the mental foramen
● Midline vertical incision is made, bilateral subperiosteal ● In case of severe mandibular resorption, mental
tunnelling is done till the canine region and graft is placed foramen shifts close to the ridge crest which
into the tunnel to fill the undercut. causes in discomfort during denture wearing.
C. Techniques to compensate for alveolar atrophy Procedure
Crestal incision is made to expose the mental
[SE Q.3] foramen. Neurovascular bundle is lifted with
{a. Vestibuloplasty the help of nerve hook and a vertical groove
Vestibuloplasty is defined as a surgical procedure de- extending 5–10 mm inferiorly is made with
signed to restore alveolar ridge height by lowering fissure bur. Freed nerve is placed in new posi-
muscles attaching to the facial, labial and lingual as- tion and held there with haemostatic gauze.
pects of the jaws. B. Procedures to improve soft tissue foundation
Objectives i. Hypermobile tissue correction
● To extend the denture-bearing surface for additional It is a pendulous rim of tissue, which forms on the
support and retention. crest of mandibular alveolar ridge.
● To reposition muscle attachments from the crest of Techniques to reduce it include the following:
the ridge. a. Nonsurgical
● To provide a better foundation for the fabrication of Modified impression technique is used to record
better functional prosthesis. the hypermobile tissue without pressure.
Three basic techniques b. Surgical
i. Mucosal advancement ● Two oblique incisions are made parallel to al-
It involves dissection and advancement of sub- veolar crest. Resultant wedge of tissue is dis-
epithelial connective tissue and placement of an sected using periosteal elevator. In presence of
overextended surgical stent. sharp, thin underlying alveolar ridge, minor
ii. Secondary epithelialization alveoloplasty can be done. The wound is then
It involves use of an apically repositioned flap, closed using sutures.
which is sutured to periosteum to desired depth. ● Thin band of tissue present on mandibular al-
Healing occurs by granulation and secondary veolar crest ridge can be excised using scissors
intention. and healing occurs by secondary intention.
It can be done in presence of hyperplastic and c. Sclerosing technique
hypermobile ridge tissue. In order to counteract In this technique, the soft hyperplastic tissue is
relapse, overcorrection should be done beyond converted into firm fibrous tissue by injecting
the required sulcus depth. sclerosing solution into it.
Procedure Presurgical procedures

● Two to four millilitres of sodium morrhuate i. Model surgery is performed on casts of patient jaws.
5% are injected into hyperplastic tissue under ii. Fabrication of gunning splints on preoperatively
local anaesthesia. altered casts.
● The needle is inserted at midline of labial as- iii. Psychological evaluation of patient’s ability to
pect of ridge and directed posterolaterally at cope up with the stress of surgery.
ridge base just below the periosteum. Simulta- Surgical techniques to improve ridge relationship (for
neously while withdrawing needle, solution is mandible)
deposited. Next injection can be made more a. Mandibular advancement procedures
posteriorly. ● Sagittal osteotomy or its variations, such as
● Similarly, it is repeated on the other side and vertical L, modified C or sliding osteotomy is
finally solution is infiltrated directly into the performed through intraoral approach for man-
hyperplastic tissue. Patient is instructed not to dibular advancement.
wear the denture for 4–6 weeks. ● For advancements greater than 8 mm, bone
ii. Excision of fibrous hyperplasia of the retromolar grafting is done. Skeletal fixation for 6–8 weeks
pad is required.
● It interferes with closure of maxillary denture b. Mandibular retrusion procedures
and limits the complete posterior extent of lower Mandibular setback is done by following tech-
denture. niques:
● An elliptic/wedge excision with thinning of flap ● Subcondylar osteotomy: In this, ramus is sec-
is done. tioned from sigmoid notch obliquely to poste-

● Lingual flap thinning should be done carefully to rior aspect of ramus either through an extraoral
prevent damage to lingual nerve. or intraoral approach.
iii. Frenectomy for hyperplastic lingual frenum ● Sagittal (ramus) osteotomy: Intraoral approach.
● Short lingual frenum-ankyloglossia/tongue-tie Horizontal bony cut is made half way through
creates difficulty in speech and causes denture ramus thickness on its medial aspect. Vertical
instability. It can be diagnosed by asking the pa- cut is then made on the lateral aspect at the
tient to touch the incisive papilla with the tip of junction of ramus and body. This technique is
tongue and notice the tension and amount of dis- indicated when extreme (10 mm) setback of
placement of lower denture. mandible is required and symmetry is present.
Procedure ● Vertical osteotomy of ramus: Ramus is sec-
● Bilateral lingual nerve block along with local tioned vertically from the mandibular notch
infiltration is given to achieve haemostasis. down over the mandibular foramen to the
● Tongue is protruded out and a transverse inci- lower border of mandible.
sion is made in middle of ventral aspect of
At the end of all the above procedures, skeletal inter-
tongue and the carbuncles of the submandibu-
maxillary fixation is required for approximately 1 month.
lar ducts.
Surgical splints should be worn until definitive complete
● For extra length of tongue, some fibres of
dentures can be given.
genioglossus can be sectioned. The resulting
diamond-shaped defect is closed as linear Q.3. Enumerate the reasons for loss of teeth. What are
incision with interrupted sutures. the consequences of loss of teeth? What are the methods
● Denture should be made before performing of prosthodontic replacements?
the procedure, so that it can serve as a stent to
Ans.
prevent relapse in future.
C. Procedures to improve the ridge relationship Edentulism is the state of being edentulous, that is without
● Ideally, there should be class I relationship between natural teeth. Edentulous state represents a compromise in
upper and lower arch for normal function and aes- masticatory system integrity along with adverse functional
thetics. If any jaw discrepancy is present, such as and aesthetic sequelae.
mandibular prognathism, then there will be extra Reasons for loss of teeth
stress placed on upper arch causing its faster re- Teeth are lost due to various reasons which are as follows:
sorption and also poses difficulty in denture con- i. Traumatic injuries resulting from accidents, falls,
struction, speech, mastication, and affects patient’s violent sports, etc.
appearance. ii. Dental diseases like caries which destroy the tooth.
iii. Diseases of gingiva such as periodontal disease, be used for support in overlay dentures, root
which destroys the encircling bone and leads to cone implants, etc.
loosening of teeth. iii. Implants: These are used for replacement of
iv. Extraction of teeth due to infections resulting from single/multiple teeth, provided adequate bone
caries, periodontal diseases and failed endodontic and no contraindications are present and patient
treatment. can afford it.
v. Destruction of bone and eventual loosening and loss iv. Fixed partial dentures: Single/multiple (limited)
of teeth due to pathosis such as cysts, malignancies teeth can be replaced by fixed bridge. It is not a
and tumours. favourable treatment in case of long-span eden-
vi. Prophylactic tooth extraction done for tumour radi- tulousness, due to more stress application on the
ation therapy. prosthesis abutment. Success depends upon the
vii. Extraction of grossly malaligned teeth, if orthodon- size, location, number and health of abutment
tic treatment cannot be done to realign it correctly. teeth.
viii. Congenitally missing teeth as in partial anodontia v. Cast removable partial denture: It is useful in
(some teeth are missing) or total anodontia (all teeth case of long edentulous span. It consists of
are missing). clasps, rests and guiding planes which together
ix. Failure of eruption of teeth – impacted teeth. provide adequate retention, stability, and sup-
x. Iatrogenic extractions – rarely wrongly removed by port to partial denture. Initially, temporary/
the dentist due to wrong diagnosis. treatment partial denture (TPD) made of acrylic/
Consequences of loss of teeth plastic is given prior to construction of perma-
It refers to changes that occur when teeth are lost. They nent one. In some places, people use TPD as
vary from tooth to tooth and from patient to patient. definitive prosthesis, which can lead to damage
Sometimes, changes are rapid within a short period of of residual ridge if used for prolonged periods.
time while sometimes very slow. vi. Overdenture: It is a good alternative to total
These are as follows: extraction, when few healthy teeth, such as ca-
i. Resorption: It is the first change to occur. Re- nines and premolars are remaining. After their
modelling of bony socket takes place until it appropriate treatment, they are reduced in height
converts into rounded edentulous ridge. It can and denture is fabricated and placed over these
range from little remodelling to extreme resorp- teeth.
tion of ridge. vii. Immediate denture: It is a type of complete den-
ii. Tilting: Empty space present can cause the adja- ture, which is placed in patient’s mouth imme-
cent teeth to tilt/trip, which can be extreme in diately after extraction of all his teeth. These
some cases. prevent the patient to bear the embarrassing
iii. Drifting: It refers to bodily migration of teeth period of being without teeth.
into edentulous space and its closure. If loss of viii. Complete denture (full denture): It is the tradi-
teeth occurs at very young age, the drifted tooth tional prosthodontic treatment.
permanently occupies the place of missing tooth. ix. Denture relies on residual ridge for support and
iv. Occlusal disharmony: It is due to tilting and drift- retention.
ing. Occlusal contacts between maxillary and x. Ease in fabrication, but it leads to gradual reduc-
mandibular teeth get disrupted resulting in occlu- tion in ridge over years, which is fast in some
sal interferences, which causes pain/discomfort/ patients and slow in some.
occlusal wear and in extreme cases, cause dam- xi. Implant retained denture: Full implant sup-
age to TMJ. ported/partial implant and partial ridge sup-
Methods of prosthodontic replacements in case of ported. Require surgery for placement and are
tooth loss expensive. But, provides better retention and
It should be done in a logical and conservative functional dentures.
sequence. xii. Maxillofacial prosthesis: This branch deals with
i. Preservation and prevention: Preservation of prosthetic replacement of other areas of mouth
what is remaining is of utmost importance and and face lost due to trauma/disease along with
should be practiced first before replacement. It teeth. It includes obturators, prosthetic eyes,
includes oral hygiene instructions, scaling and ears, nose and other parts of the maxillofacial
root planning, restorations, periodontal therapy region. Materials used range from hard acrylic-
and endodontic treatment, etc. like materials to soft latex, which can be charac-
ii. Post and core/crowns: Viable roots may be pre- terized and coloured to resemble natural and
served and restored with post and core and can life-like as possible.
xiii. Splints and stents: These are adjuncts to certain ● It includes following procedures:
treatment, but not actually prostheses. Splint is a A. Procedures to improve bony foundation
rigid/flexible device that maintains in position a i. Retained dentition: Above, if present, should
displaced/movable part and also used to keep in be removed prior to prosthetic treatment in or-
place and protect an injured part. Stent is used to der to prevent their possible transformation into
hold a graft in place and provide support for an pathosis such as cyst or tumour.
anastomosed structure. ii. Removal of pathologic bony conditions: If
any odontogenic cyst is present, then it can
Q.4. Enumerate the reasons for loss of teeth. What are transform into tumour and cause bone destruc-
the consequences of loss of teeth? What are the methods tion. It should be explored surgically and exam-
of prosthodontic replacements? ined microscopically.
Ans. iii. Techniques to deal with mandibular alveolar
excess
[Same as LE Q.1]
Alveoloplasty
Q.5. Discuss mouth preparation of complete dentures. Alveoloplasty is the surgical smoothening and
Ans. shaping of the alveolar ridge prior to denture place-
ment. During alveoloplasty, minimum amount of
[Same as LE Q.2] bone should be removed.
Types include:
SHORT ESSAYS: a. Simple compression.
b. Cortical alveoloplasty.
Q.1. Metallic denture base. c. Intercortical alveoloplasty.
Ans. iv. Techniques to deal with excessive alveolar
bone resorption
Metallic denture base
a. Techniques to reduce alveolar atrophy: If
Metallic denture bases are fabricated using gold, gold
root forms of teeth (without periodontal dis-
alloys, cobalt-chromium or nickel–chromium alloys.
ease) are left in the alveolus, then bone re-
Advantages
sorption is greatly reduced. Based on this,
following techniques can be used:
{SN Q.1} i. Overlay dentures.
● Heavy mandibular dentures leading to improved ii. Submucous vital root retention.
retention and stability. iii. Root cone implants.
● Good sensory interpretation due to high thermal b. Techniques to correct alveolar atrophy:
conductivity. Either by replacing lost bone (augmentation)
● Strong even in thin sections and are very comfortable using natural/synthetic graft or by regenerat-
for the patient. ing the lost bone.
● Easy maintenance. v. Techniques to compensate for alveolar atrophy
Vestibuloplasty
It is a surgical procedure designed to restore
Disadvantages
alveolar ridge height by lowering muscles at-
● Expensive as compared to acrylic resin denture
taching to the facial, labial and lingual aspects
bases.
of the jaws.
● More time is required for fabrication.
Three basic techniques are as follows:
● Requires refractory cast material.
Mucosal advancement.
● Difficult fabrication.
Secondary epithelialization.
● Rebasing cannot be done.
Epithelial graft vestibuloplasty.
Q.2. Preprosthetic surgery. B. Procedures to improve soft tissue foundation
i. Hypermobile tissue correction.
Ans.
ii. Excision of fibrous hyperplasia of the retromo-
Preprosthetic surgery lar pad and epulis fissuratum.
● Preprosthodontic surgery is defined as surgical proce- iii. Hyperplastic maxillary tuberosity excision.
dure designed to facilitate fabrication of prosthesis or to iv. Hyperplastic palatal mucosal correction.
improve the prognosis of prosthodontic care. v. Frenectomy for hyperplastic lingual frenum.
Q.3. Vestibuloplasty. Polished Surface

Polished surface is also called CAMEO surface. It is
Ans.
that portion of a surface of denture that extends in an oc-
[Ref LE Q.2] clusal direction from the border of the denture and includes
Q.4. Preprosthetic surgical managements in complete the palatal surfaces. It is part of the denture base, which is
denture. usually polished and it includes the buccal and the lingual
surfaces of the teeth.
Ans. It should be well polished to prevent accumulation of
[Same as SE Q.2] food debris.
The polished surface is divided into:
● Facial surface (both maxillary and mandibular denture).
SHORT NOTES: ● Palatal surface (maxillary denture).
● Lingual surface (mandibular denture).

Q.1. Metallic denture base.
Ans. Q.3. Advantages of metal bases.
Fabrication using gold, gold alloys, cobalt–chromium or Ans.

nickel–chromium alloys. [Same as SN Q.1]
[Ref SE Q.1] Q.4. Polished surface of complete denture.
Q.2. Polished surface. Ans.
Topic 2
Diagnosis and Treatment Planning
LONG ESSAYS:
1. Discuss in detail the clinical significance of the following for ensuring the success of complete denture treatment:
a. Pre-extraction records.
b. Examination, diagnosis and treatment planning.
2. What do you understand by the term ‘examination of the patient’? Name the objectives of examination of a
patient. Discuss in detail the clinical significance of anatomical landmarks of edentulous maxilla and mandible.
3. Discuss the significance of case history recording, diagnosis and treatment planning in the fabrication of com-
plete dentures prosthesis. [Same as LE Q.1]
4. Diabetic patient aged 65 years with few teeth remaining comes to your dental college/hospital for dental pros-
thesis. Discuss the treatment planning and special steps to be taken by you for the management of the patient.
[Same as LE Q.1]
5. With the help of diagram, discuss the denture-bearing area of edentulous mouth. Give the clinical importance
of posterior palatal seal and retromolar pad. [Same as LE Q.2]
SHORT ESSAYS:
1 . Importance of preprosthetic evaluation of the edentulous area before making impression.
2. Why complete radiographic examination should be made for an edentulous mouth?
3. Discuss the examination, diagnosis and treatment planning in complete denture patients.
4. Mental attitude of patients.
SHORT NOTES:
1 . House classification of mental attitudes. [Ref SE Q.4]
2. Undercuts in complete denture. [Ref LE Q.1]
3. Importance of full mouth intraoral radiographs in edentulous patients. [Ref LE Q.1]
4. What are the soft tissues covering the hard palate and their relevance to complete dentures?
5. Soft palate.
6. Mental attitudes of patients. [Same as SN Q.1]
7. Muscles of the soft palate. [Same as SN Q.5]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Discuss in detail the clinical significance of the follow- spring pressure gauge controls pressure. An incisor
ing for ensuring the success of complete denture treatment: attachment records position of central incisors. Re-
cords are noted and compound nosepiece is pre-
a . Pre-extraction records.
served for reassembly after extraction.
b. Examination, diagnosis and treatment planning.
● Willis gauge: One arm contacts the base of the nose
Ans. and the other arm is moved along the side, until it
touches the base of the chin. It is not an accurate
Complete denture treatment
method.
For ensuring success of complete denture treatment,
● Sorensen’s profile guide: It is one of the devices for
the clinical significance of (a) pre-extraction records and
recording facial measurement.
(b) examination, diagnosis and treatment planning are
described. Examination, diagnosis and treatment planning
Pre-extraction records ● For success of prosthetic treatment, a careful, correct
Following are the pre-extraction records which provide and complete examination along with diagnosis is im-
valuable information about the patient dentition and facial portant followed by providing the patient with best pos-
profile before extraction: sible treatment plan in accordance with his/her age,
i. Profile radiographs: These are made with teeth in occlu- physical, mental and financial status.
sion and compared with those made with occlusal rims
in position. It has the following disadvantages: {Following steps in sequential manner should be car-
● Distorted image.
ried out for examination and diagnosis:
● Time-consuming.
i. Recording the general information.
● Radiation hazards.
ii. Recording the chief complaint and assessing the
ii. Profile photographs: These can be compared before and patient’s expectations.
after treatment, but profile angles can change with iii. Recording the relevant medical history.
change in patient’s posture. iv. Recording current medication.
iii. Articulated casts: With teeth in occlusion, measure- v. Recording the relevant dental history.
ments are made between stable landmarks, i.e. between vi. Performing thorough visual and manual examination
upper and lower frena. of the mouth, the head and the neck regions.
iv. Lead wire silhouettes: These are adapted to patients, vii. Performing radiographic examination.
before extraction and outline is transferred to cardboard viii. Referring for additional tests, if required, e.g. blood,
and cut out, after extraction cut out is placed against sugar and urine tests.
patient’s profile to check vertical relation. It is not com- ix. Referring for medical consultation (when indicated).
monly used now. x. Referring for a second opinion and opinion from other
v. Acrylic facemasks (Swenson’s technique): It is not a dental specialists (when required).
practical method. Before extraction, it is made using xi. Making alginate impressions and preparing mounted
facial impression and cast. study models (when indicated).
vi. Facial measurements: xii. Discussing the diagnosis, treatment planning and
● Dakometer: Instrument is positioned on the bridge
prognosis with the patient.
of the nose with impression compound and chin xiii. Finalizing the fees and obtaining the informed
piece is screwed, until it touches the chin front. A consent.
i. Recording the general information the demands of the patient, but must not
The first step in patient evaluation can be done by the consider, if unreasonable.
dentist itself, reception staff or by asking the patient to c. Indifferent
fill the form. ● Patient has a questionable prognosis.
a. Name: To add personal touch and to build confi- ● Patient lacks motivation and is not very in-
dence with patient, he/she should be addressed by terested in treatment.

his/her name. ● Patient tries to find mistakes in treatment
b. File/record number: It is necessary for maintain- and blames dentist for any mishap.
ing records. ● Patient does not cooperate and follow in-
c. Age: It is important to note age, because: structions and is forced by his relatives,
● As age advances, capacity of tissues to with- spouse, etc., for dental treatment.
stand stress reduces. ● Such patient is difficult to manage. Patient
● Healing capacity of denture-bearing and other should be well educated about the treatment
tissues of body decrease with age. and motivated to develop interest in the
● In elderly patient, diseases like diabetes and treatment. If no improvement is observed,
hypertension are prevalent. then it is better to postpone or refuse the
d. Race: Some diseases are present only in certain treatment.
race and also selection to denture teeth and den- d. Hysterical
ture base colour varies with race of patient, e.g. ● Patient is easily excited, highly apprehen-
dark-skinned individuals have more pigmentation sive and emotionally unstable.

of gingiva. ● Patient rarely cooperates with the dentist.
e. Sex: Women and young men are more concerned ● Patient has unfounded complaints and unre-
about aesthetics and appearance. alistic expectations.

f. Older individuals are mainly concerned with ● Lot of time and patience is required to man-
comfort and function. age such patient.

g. Occupation: Person’s job also determines the aes- ● Medical consultation might be required for
thetic requirements of prosthesis. the systemic problems, if present.

h. Address and telephone number: It should be noted e. Sceptical
to contact the patient during the treatment and in ● Patient has had bad results from previous
case of emergency. treatment and is doubtful whether his prob-

i. Previous dentist (if any): Recording this, serves as lems can be solved.
a dental record in case of forensic evidence or in ● Patient has unfavourable conditions like
medicolegal cases. Also, pretreatment records can resorbed ridges and poor health.
be obtained. ● Patient may be in psychological stress due
Psychological evaluation to recent death of a close relative, etc.

The ‘House classification’ of mental attitude of patient ● First, psychological management is required
by M.M. House classifies denture patients into differ- for such patient before dental treatment.
ent groups, based on their personality as follows: Kindness, care and sympathy should be of-
a. Philosophical fered and condition should be dealt with pa-
● Patient has best mental attitude required for tience and good attention, in order to restore
denture treatment. his confidence.
● Patient is well motivated and realizes his ii. Recording the chief complaint and assessment of
part in treatment. patient’s expectations
● Patient cooperates with the dentist and ● Chief complaint should be recorded in patient’s own
learns to adjust. words.

● Patient is rational, sensible, calm and com- ● Reason for seeking prosthodontics treatment should
posed in difficult situations. be evaluated. Some need it for aesthetics, while some
b. Exacting (critical) for better function.
● Patient is methodical and precise. ● Expectations of the patient from the treatment should
● There is need to explain each step of the be asked and if not realistic, the patient should be
procedure in detail to the patient. explained and motivated for the treatment.
● He sometimes proposes treatment plan to iii. Recording the medical history
the dentist and makes severe demands. Aim
● Patient should be managed with extra care, ● To diagnose any systemic problem that might
effort and patience. Dentist must listen to affect the treatment.

● To deal with any medical emergency during the IX. They should be carefully diagnosed and ap-
procedure. propriate precautions must be taken by dentist
● In case of presence of transmissible disease, suit- for himself as well as for laboratory personnel
able disinfection steps can be taken. and for other patients.
● Medical consultation is required for patients with iv. Recording current medication
serious systemic problems before starting the The patient might be taking medication for any systemic
treatment. disease present which may affect the dental treatment.
Certain medical conditions that can be present are as i. Insulin: It is taken to treat diabetes mellitus.
follows: When injected local anaesthetic during treat-
I. Diabetes: If affects the wound healing capacity ment, the patient may go into hypoglycaemic
of the tissues and chances of infection increase. shock due to decrease in blood glucose levels. It
It should be dealt properly if any preprosthetic should be assured that patient has eaten meal
surgery is planned. before treatment and in case of shock he should
II. Cardiovascular disorders: Management includes be given glucose immediately.
the following: ii. Anticoagulants: Aspirin and dicoumarol are pre-
● Short appointments with premedication in scribed in stroke and cardiovascular diseases.
patients with history of angina and car- Consulting the physician is mandatory, in case if
diac arrest. Adrenaline-free local anaes- preprosthetic surgery or deep scaling is required.
thetic is injected, if required. In case of iii. Antihypertensives: They cause dryness of mouth
elective surgery, medical consultation is and postural hypotension (fainting or dizziness
done first. on standing up).
● Antibiotic prophylaxis in conditions like iv. Anti-Parkinsonism agents: Artane and norflex
rheumatic heart disease and congenital heart can cause dryness of skin and mucosa. Behav-
disorder, and in case of any surgery or tooth ioural changes and confusions may be seen.
extraction that needs to be done. v. Corticosteroids: These are given in case of aller-
● In case of increased blood pressure, first, gies and arthritis.
medical consultation should be done. v. Recording the dental history
III. Joint diseases: Osteoarthritis of temporoman- i. History of tooth loss
dibular joint (TMJ) may pose problems during ● Teeth lost due to periodontal reason – poor ridges.
denture construction and special trays for im- ● Teeth lost at different time intervals – uneven
pression recording may be required in case of ridge levels.

inadequate mouth opening. Jaw relations may ● Loss of lower posterior teeth – supraeruption of
be difficult to record. upper posterior teeth with overhanging tuberos-

IV. Skin diseases: Painful mucosa may be present ity and ridge.
in case of certain skin disorders like pemphi- ii. Experience with old dentures
gus. So, rest should be given to tissues in- ● Information on old dentures should be recorded,
between while using dentures. so that if any problem is present, then it can be
V. Neurological disorders: For example, Bell palsy avoided in new dentures. Patient should be in-
and Parkinsonism. Patient is unable to cooper- formed that due to continued resorption, reten-
ate with dentist’s instructions and finds diffi- tion of new denture may decrease and relining
culty in maintaining denture and oral hygiene and rebasing is required in the first 6 months
and assistance may be required for that. when rate of bone loss is at the maximum.
VI. Oral malignancies: If present, require surgical iii. Performing oral examination
removal of the affected part and construction of Extraoral examination
denture with added obturator or maxillofacial i. General appearance of face is noted for healthy
prosthetics. or for any signs of malnourishment seen.
VII. Radiation therapy might be required. Treatment ii. Facial symmetry, form and profile: Outline of
must be postponed, until tissues regain health face is important to select tooth shape.
after radiation and after denture fabrication. Classification of frontal face form by House, Frush and
Tissues must be closely monitored for any signs Fisher
of radiation necrosis. a. Square.
VIII. Transmissible diseases: For example, TB, b. Square-tapering.
AIDS, SARS, hepatitis, and herpes might be c. Tapering.
present. d. Ovoid.
Classification of lateral face form by Angle c. Class 3 – poor. In cases of stroke, paralysis and
a. Class 1– normal. Parkinsonism, patients find difficulty in adapting
b. Class 2 – retrognathic. to new dentures.
c. Class 3 – prognathic. v. Speech evaluation: It is classified as normal and
i. Skin: Shade selection of teeth is done in accordance affected.
with skin colour. Patients with speech impediments require special
● Pale skin – signs of anaemia. attention while placing the front teeth and forming
● Indians – darker skin ranging from dark brown to the palatal portions of upper denture.
white. vi. TMJ evaluation: Patient is examined for TMJ disor-
ii. Palpation of head and neck regions: It is done to check ders like pain or difficulty in opening the mouth.
for any enlarged lymph node/mass. Jaw movements such as opening it wide and clos-
● Enlarged tender nodes – infections. ing, moving from left to right and then finally for-
● Hard attached nodes – tumour (primary or sec- wards and backwards are performed and if any un-
ondary through metastasis). coordinated jerky movements are present, it
iii. Lip indicates difficulty in recording jaw relations.
● Lip length classification: Long, medium or short. Intraoral examination
Short lips – more denture base seen while Examination of mouth and ridge is done for any condition
smiling and talking, so longer teeth need to be that might affect, compromise or even enhance the outcome
selected. of the treatment.
Long lips – vice versa. Tooth visibility can- I. Cheeks
not be used as a guide to anterior tooth posi- Importance
tioning. ● Forms peripheral seal of the denture. The draping or
● Lip thickness placement of the cheek tissues over the buccal

Thin lips – sensitive to small changes in anterior flanges of the dentures.
tooth position. ● Opening of Stenson’s ducts (parotid gland) present
Thick lips – give dentist more flexibility in ante- as a raised papilla on the cheek opposite the maxil-
rior tooth positioning. lary second molar in edentulous individuals.
Indians – have fuller lips with maxilla being ● It is also the location for many lesions like
slightly prognathic. a. Lichen planus.

● Lip mobility: It is classified as: b. Submucosal fibrosis: It is found in paan chewers.
a. Class 1 – normal. Here, the mucosa appears pale and feels leathery
b. Class 2 – reduced mobility and less display of to touch. Mouth opening is limited.
front teeth. c. White lesions of the buccal mucosa: Differen-
c. Class 3 – paralysis. tial diagnosis includes lichen planus, leukopla-
Mobility of lip may be affected in stroke victims. kia or fungal lesions.
Paralysis of one half of lip will cause droop- d. Malignancies: Squamous cell carcinoma is most
ing of mouth and facial asymmetry on af- common. Premalignant changes like leukoplakia
fected side. and erythroplakia are seen. Palatal changes due
● Lip support: It is classified as: to reverse smoking are seen in people of Andhra
a. Adequately supported. Pradesh.
b. Inadequately supported. II. Tongue
Lip is supported by teeth. So, when teeth are ● Favourable tongue – average-sized, freely moves
lost, there is a collapse of the lip. and covered by healthy mucosa.

● Smile line or lip line: Based on the extent of lips ● Importance: It helps in denture stability by control-
displaced on smiling, a patient is said to have ling the dentures during functions like speech, mas-
a. A high lip line (patients have gummy smile tication and swallowing.
due to more display of gums and teeth). ● Examination is done using a gauze pad to grasp and
b. Low lip line. hold the tongue.

c. Normal or medium lip line. a. Tongue size
iv. Neuromuscular evaluation: Various mandibular move- Classification
ments are done to determine neuromuscular coordina- i. Normal: With normal function.
tion. It is classified as: ii. Large: After the loss of teeth (especially lower
a. Class 1 – excellent. posteriors) the tongue may spread out and en-
b. Class 2 – fair. large, which may make denture construction
difficult. Tongue biting can occur. It may vii. Candida albicans: Chronically ill or severely
slowly regain its normal size after a period of debilitated geriatric patients may have can-
wearing complete dentures. dida infections, characterized by curdy white
Management of large tongue can be done as follows: patches which come off when wiped with
● The occlusal plane may be lowered. gauze.
● Narrower teeth may be used. III. Frenal attachments
● The intermolar distance may be increased Frenum is defined as a fold of mucosa at different loca-
(within limits). tions in the sulcus region of the maxillary and man-
● The lingual cusps may be grinded off. dibular ridge.
● Setting of a second molar may be avoided. Labial frenum: It runs from lip portion of the sulcus
b. Tongue position and is attached to the residual alveolar ridge.
Classification (Wright’s classification) Buccal frenum (right and left): It appears as a single
Normal: Normal size and function. Favourable fold or multiple folds.
prognosis. It fills the floor of the mouth and is Classification
confined by the mandibular teeth. The lateral a. Class 1 – sulcal/low attachment (favourable).
borders rest at the level of the mandibular occlu- b. Class 2 – attaches midway between sulcus and crest
sal plane, while the dorsum is raised above it. The of the ridge.
apex rests at or slightly below the incisal edges of c. Class 3 – crestal or near crestal attachment (high)
the mandibular anterior teeth. – unfavourable.
Class 1: Retracted (not too favourable). It is re- It affects the prognosis of the denture by causing a
tracted exposing the floor of the mouth till the deep notching of denture affecting its seal and re-
molar area. The lateral borders are raised above tention, and denture borders may cause irritation
the mandibular occlusal plane. The apex is pulled and ulceration of the frenum. A surgical correction
down into the floor of the mouth which is also (frenectomy) is indicated.
pulled downwards. IV. Floor of the mouth
Class 2: Retracted (not too favourable). The It affects the prognosis of mandibular denture, if:
tongue is tense and retruded backward and up- ● It is near ridge crest/hyperactive, denture retention
ward. The lateral borders rest above the mandibu- and stability is less.
lar occlusal plane. The tip is pulled into the body ● Sometimes, the floor of the mouth is near/on the
of the tongue and is almost invisible. The floor of ridge when the resorption in sublingual and mylo-
the mouth is raised and tense. hyoid region is extreme.
c. Tongue mucosa V. Maxillary tuberosity
Normal tongue mucosa shows filiform and fungi- If enlarged and undercuts present, then it can pose
form papillae on dorsal surface, and the colour is problems like:
a healthy pink. ● Back end of occlusal place needs to be placed low
Variations that may be seen are as follows: ● Less space for all molars arrangement
i. Bald or smooth tongue – due to atrophy of ● Undercut present can make denture removal and
the filiform papilla. Seen occasionally in the insertion difficult

elderly and in patients with iron or vitamin Management
deficiency. Radiographic examination to determine whether
ii. Geographic tongue. enlargement is bony/fibrous/combination followed
iii. Hairy tongue. by surgical removal.
iv. Red and inflamed tongue – may be indicative VI. Hard palate
of vitamin B12 deficiency. Classification based on the shape of palatal vault:
v. Caviar tongue: This is a nodular enlargement a. Class 1: U-shaped. Most favourable for retention
of the veins on the under surface of the and stability.
tongue (lingual varicosities). It is seen in el- b. Class 2: V-shaped. Not very favourable. Slight
derly. Occasionally, varicosities may indicate movement of the denture can break the seal and
a cardiovascular or pulmonary problem. reduce retention. May be associated with a tapered
vi. Coated tongue – indicative of patient’s poor arch.
oral hygiene. Heavy white or stained deposits c. Class 3: Flat or shallow vault. Not very favourable.
may be seen on unhygienic tongue, often seen Usually accompanied by resorbed ridges and poor
in the elderly due to reduced salivary flow. resistance to lateral forces.
VII. Palatal torus b. Class 2: Tapered/v-shaped associated with

It is a large, hard bony rounded projection on the high arched palate. Less retention and stability.
hard palate. c. Class 3: Ovoid – less common.
It is located posterior to rugae region in the mid- Variation in above occur due to difference in
line. If located more posteriorly, then it may inter- resorption pattern.
fere with peripheral seal placement so should be c. Arch size discrepancy
removed surgically. Size can be small to very This causes difficulty in stability and arrangement
large. of teeth.
Classification Causes
a. Class 1: Absent/minimal. ● Congenital.
b. Class 2: Moderate. ● Trauma: Trauma to TMJ during growth
c. Class 3: Large. phase, e.g. forceps delivery and fall can re-
VIII. Mandibular tori tard mandibular growth.
Small, pea-sized bony prominences are seen on the lin- ● Severe class 2 and class 3 malocclusion.
gual side of mandibular ridge in the bicuspid region. If ● Severe resorption; Maxilla becomes small and
large, surgical removal is required. mandible becomes wide with resorption lead-
IX. Smoker’s palate (stomatitis nicotina) ing to arch size discrepancy.
Palatal (hard and soft) changes seen in heavy tobacco d. Arch relationship
smokers present as grey patches with nodular centre Classification
and red inflamed openings of mucous glands may be i. Anterior arch relationship
seen distributed on the lesion. Class 1: There is a normal anterior horizontal
X. Soft palate overlap (over jet) of around 2–8 mm, when
Anatomy of soft palate determines the extra area the teeth are set.
available for retention and the width of posterior Class 2: Excessive horizontal overlap. Lower
palatal seal area. anterior teeth are located posterior to the up-
Classification per anterior teeth in excess of 8 mm.
Based on angulation between soft and hard palate, it Class 3: The lower incisors may be in an edge
is classified as: to edge incisal relationship or may be anterior
a. Class 1: Soft palate is horizontal curving gently to the maxillary incisors.
downwards. Class II and III relationships are usually seen in
b. Most favourable with more surface area for reten- relation to arch size discrepancies. Teeth ar-
tion and provides wider seal and muscular activity rangement would result in a more buccal loca-
is minimal. tion of the mandibular functional cusps in rela-
c. Class 2: Soft palate turns downwards at 45o angu- tion (cusp to cusp or crossbite) to the maxillary
lation to the hard palate. It has features between cusps, and may be associated with large man-
class 1 and class 3. dible/an underdeveloped maxilla/both. Occa-
d. Class 3: Soft palate turns sharply downwards at sionally, cases with combinations, e.g. a class I
70o angulation to the hard palate, deep-shaped anterior ridge relationship and a unilateral or
palate. Less favourable due to greater movement bilateral posterior class III relationship are en-
of soft palate during function and has narrow seal countered anterior to the maxillary incisors.
area. ii. Posterior arch relationships
XI. Residual alveolar ridge Class 1: Posteriorly, normal functional and
Studying of anatomy and quality of residual ridge is nonfunctional cusp relationship present.
important. Class 2: Routine teeth arrangement would
a. Arch size result in more lingually located mandibular
Classification by Engelmeier is based on length cusps (scissor bite), unilateral or bilateral and
and width of the edentulous arch. associated with an underdeveloped mandible.
a. Class 1: Large, greater support and retention iii. Interarch space
due to large surface area. The amount of space available to set teeth
b. Class 2: Average. depends on the amount of space present be-
c. Class 3: Small, less support and retention. tween the upper and the lower ridges.
b. Arch form The interarch space is classified as:
Classification by House: A. Normal.
a. Class 1: Square – favourably shaped and more B. Excessive.
surface area. Most common. C. Reduced.
iv. Residual ridge size Management: Wide variety of methods ranging

It is based on height and bulk. There are three from modified impression techniques to surgery is
types: available.
a. Average ridge: It offers adequate support to vi. Bony prominences
dentures. Manual palpation of sulcus areas, ridge crest and
b. Large/bulky ridge: It is seen in freshly ex- slopes, and the palatal areas is done to identify any
tracted but healed sites. Enough space might bony prominences/sharp areas present which can
not be present to set the teeth. make denture wearing uncomfortable/painful.
c. Small, flat or resorbed ridge: It is due to ex- Common bony prominences seen are as follows:
treme resorption and offers poor retention and a. Midpalatine raphe: These are present along
support to the denture. the midline of the palate, may be very promi-
v. Residual ridge (cross-sectional contour) nent in some individuals and needs relief.
Ideal ridge: Well-developed high ridge with b. Bony spicules and sharp ridge crest: The resorp-
broad crest and parallel sides. tion process can result in a knife-edged or spiny
Types: Based on shape (cross-sectional contour), ridge crest, either relieved or removed surgically.
it is classified as follows: c. Sharp mylohyoid ridge: Resorption of the
a. U-shaped: Good prognosis. Favourable for lower ridge can result in a prominent mylohy-
retention and support. oid ridge which can cause pain, if not relieved.
b. V-shaped or tapered: Favourable prognosis. d. Palatal foramen: Borders are sometimes
Commonly seen in the mandibular arch. raised and sharp.
c. Knife-edged: Poor prognosis. The resorptive e. Prominent genial tubercle: Extreme resorp-
process often leaves sharp knife-edged ridges, tion can also result in the genial tubercles
usually seen in the mandibular arch and is becoming prominent.
unfavourable for dentures. Crest has to be f. Bony fragments: Bone fragments which might
relieved to avoid soreness. have fractured during extraction may be found
d. Flat: Poor prognosis. The resorptive process occasionally extruding through the mucosa.
continues until there is little or no ridge g. Fractured root pieces: Fractured root fragments
remaining. may be occasionally felt just below the mucosa.
e. Inverted: Poor prognosis. Caused by extreme h. Tori: Small maxillary tori may be included in
resorption, especially in the mandible. The the denture with relief provided.
resorptive process extends into the body of i. Larger tori require surgical removal. The
the mandible. same is true for mandibular tori. Large tori
f. Undercut: Potential for difficulties. The un- might interfere with the mandibular denture
dercut ridge (if severe) can present problems retention, whereas smaller tori may be in-
during denture construction and for subse- cluded in the denture with adequate relief.
quent use. Insertion and removal of the den- vii. Undercuts
ture may be difficult or can cause damage to Undercuts present on ridge can cause difficulty
the tissues in its path. in denture removal.
Other configurations seen are as follows: Common location may be present in any part of
i. Irregular knife-edged ridges (due to bony the ridge. Some common locations are as follows:
spicules). ● Occasionally, labial or lingual slopes of the
ii. Bulky irregular ridges with undercut sides mandibular anterior ridge.
are seen in the freshly extracted. ● Labial portion of the maxillary anterior ridge.
iii. Ridges. ● Buccal to the maxillary tuberosity region.
iv. Soft tissue support for the ridge ● Retromylohyoid area of the lower ridge.
This can be examined by palpation. Management
It should be firm and resilient and covering mu- If isolated, anterior undercut poses no problem.
cosa should be firmly attached and keratinized.
Types: Based on nature of supporting soft tissue, {SN Q.2}
it is classified as follows:
Some undercuts may be managed by relieving the inside
1. Firm and resilient.
portion of the denture.
2. Flabby and hypermobile: This offers poor
A unilateral posterior undercut does not pose much
support, because the denture bases shift dur-
problem, as the path of insertion can be varied.
ing masticatory function.
Fractured roots or teeth lying close to the surface may

A bilateral severe undercut poses a problem. Surgical
be removed surgically, if the patient is fit for surgery.
elimination of one of the undercut (usually the more
However, deep-seated retained teeth or root fragments
severe one) is indicated and insertion and frequent abra-
may be left alone, if they are asymptomatic as it could
sion of the mucosa can lead to ulceration and pain.
result in undue bone destruction, reduce the height of
Classification
the residual alveolar ridge, and cause undue trauma to
Undercuts may be:
the patient.
a. Unilateral or bilateral.
Additional supplemental radiographs are as follows:
b. Labial or lingual.
i. Periapical radiographs.
c. Mild, moderate or severe.
ii. Occlusal view radiographs.
iii. Lateral cephalometric radiograph (cephalogram).}
Saliva Additional tests and medical consultation
Saliva is important for tissue health and denture reten- ● Additional tests like a routine blood test, blood
tion. Consistency and amount of saliva are recorded. and urine sugar levels and medical consultation
Consistency with a physician may be required when indicated.
a. Thin serous: Favourable for denture retention. ● When writing to the physician, a proper referral is
b. Thick mucus: Difficult to work with and displaces prepared outlining the signs and symptoms of the
the denture. case.
c. Mixed: Equal mixture of the above two. ● Any doubts or suspicions the dentist has requiring
Amount clarification and the nature of the proposed dental
a. Normal: Ideal for denture retention. treatment, as to whether it involves surgical or non-
b. Excessive: Makes denture construction difficult. surgical procedures are also clearly mentioned.
c. Reduced: Results in dry mouth/xerostomia and Diagnosis
decreased denture retention. ● The determination of the nature of a disease.
Leads to soreness of tissues and coated tongue. It is ● Diagnosis involves thorough analysis of all the fac-
seen after radiation therapy, usage of certain drugs, tors, which can affect the success of treatment. This
etc. Salivary substitutes are used for treatment. includes both systemic and local factors and mental
[SE Q.2] condition of the patient. Certain conditions could
make the outcome of treatment less satisfactory.
{XII. Radiographic examination ● A well-made denture can fail, because the dentist
It is done to rule out any bony conditions that could did not diagnose a complicating factor at the time
affect the treatment. A panoramic radiograph (also of the initial examination. The prosthodontic di-
known as orthopantomograph or OPG) is routinely agnostic index (PDI) is a useful tool to determine
done. It serves as a useful conjunct in addition to the diagnosis and prognosis of denture treatment.
history and physical examination. PDI for complete edentulism
It is developed by the American College of Prosth-
{SN Q.3} odontists.
The system classifies edentulous patient treatment
Diagnosis of following can be done using radiograph:
complexity using four diagnostic criteria:
● Bone pathosis.
a. Mandibular bone height
● Cysts.
b. Maxillomandibular relationship
● Tumours.
c. Maxillary residual ridge morphology
● Retained roots or teeth.
d. Muscle attachments
● To study the periodontal condition of the remain-
These four criteria identify patients as:
ing teeth when present.
a. Class 1 (ideal or minimally compromised)
● Bony fractures.
b. Class 2 (moderately compromised)
● To study soft tissue thickness.
c. Class 3 (substantially compromised)
● To study the extent of bone resorption.
d. Class 4 (severely compromised)
● To determine thickness of the body of the mandible.
PDI for the edentulous class 1 patient
● To locate the mandibular canal and its proximity to
A patient who presents with ideal or minimally com-
the ridge crest.
promised complete edentulism can be treated suc-
● To locate the maxillary sinuses.
cessfully by conventional prosthodontic techniques.
● To plan surgeries.
Class 1 patient exhibits the following:
● To see remaining bone density and quality.
a. A residual mandibular bone height of at least
● As treatment records.
21 mm measured at the area of least vertical
● For patient education.
bone height.
b. A maxillomandibular relationship permitting d. Muscle attachments that exert a significant

normal tooth articulation and an ideal ridge compromise on denture base stability and
relationship. retention.
c. A maxillary ridge morphology that resists hor- Treatment plan
izontal and vertical movement of the denture The sequence of procedures planned for the treat-
base. ment of a patient after diagnosis is as follows:
d. Muscle attachment locations conducive to den- ● Diagnosis and treatment planning should be
ture base stability and retention. done before initiation of treatment. All the find-
PDI for the edentulous class 2 patient ings of the case are analysed and the most suit-
A patient who presents with moderately compro- able treatment plan is determined which includes
mised complete edentulism and continued physical premedication, consultation and treatment in-
degradation of the denture-supporting anatomy. volving other specialists.
Class 2 patient exhibits the following: ● It is explained to the patient in a simple and
a. A residual mandibular bone height of 16–20 mm straight forward manner including all the factors
measured at the area of least vertical bone that might complicate the treatment (if any). The
height. patient is encouraged to speak and clear any
b. A maxillomandibular relationship permitting doubts that he/she might have about the treatment.
normal tooth articulation and an appropriate Alternate treatment plan
ridge relationship. Patient might not agree to the suggested treatment
c. A maxillary residual ridge morphology that plan, due to various reasons:
resists horizontal and vertical movement of the ● The patient is not prepared to undergo surgery
denture base and or other dental procedures due to personal

d. Muscle attachments that exert limited compro- reasons.
mise on denture base stability and retention. ● The patient does not have time to complete the
PDI for the edentulous class 3 patient suggested treatment plan.

A patient who presents with substantially compro- ● If the suggested treatment plan is too expen-
mised complete edentulism and who exhibits the sive, cheaper alternative needs to be consid-
following: ered and the recommended treatment plan has
a. Limited interarch space of 18–20 mm and/or to be altered accordingly (within limits).
temporomandibular disorders. ● The alternative treatment plan may be less than
b. A residual mandibular bone height of 11–15 mm ideal, but if it is necessary due to above rea-
measured at the area of least vertical bone height. sons, then we should try to achieve best possi-
An Angle class I, II or III maxillomandibular rela- ble result.
tionship. Refusal of treatment
c. Muscle attachments that exert a moderate ● It is the duty of the dentist to respect the patient’s
compromise on denture base stability and wishes and include it in the treatment plan when-
retention. ever possible.
d. A maxillary residual ridge morphology provid- ● But, if patient’s demands are unreasonable or
ing minimal resistance movement of the denture against professional judgements or ethics, then
base. the dentist may refuse treatment or refer him to
PDI for the edentulous class 4 patient another dentist for a second opinion.
A patient who presents with the most debilitated form Prognosis
of complete edentulism, where surgical reconstruc- It is a forecast to the probable result of a disease or a
tion is usually indicated and specialized prosthodon- course of therapy.
tic techniques are required to achieve an acceptable Special points to be remembered in management of dia-
outcome and exhibits the following: betes patient are as follows:
a. A residual mandibular bone height of 10 mm ● Diabetes affects the wound-healing capacity of the
or less, tissues and chances of infection increase. Should

b. An Angle class I, II or III maxillomandibular be dealt properly if any preprosthetic surgery is
relationship. planned.
c. A maxillary residual ridge morphology provid- ● Insulin used to treat diabetes mellitus, when in-
ing no resistance to movement of the denture jected along with local anaesthetic during treat-
base and ment, patient may go into hypoglycaemic shock
due to decrease in blood glucose levels. It should

be assured that patient has taken meal before
treatment and in case of shock, glucose should be
given immediately.
Q.2. What do you understand by the term ‘examina-
tion of the patient’? Name the objectives of examina-
tion of a patient. Discuss in detail the clinical signifi-
cance of anatomical landmarks of edentulous maxilla
and mandible.
Ans.
Diagrams are as follows:
Fig. 2.3 Anatomical landmarks of edentulous mouth.
Examination of patient
Following are the objectives of examination of the patient:
i. Recording the general information.
ii. Recoding the chief complaint and assessing
patient’s expectations.
iii. Recording the relevant medical history.
iv. Recording current medication.
v. Recording the relevant dental history.
vi. Performing thorough visual and manual exami-
nation of the mouth and head and neck regions.
vii. Performing radiographic examination.
viii. Referring for additional tests, if required, e.g.
blood, sugar and urine.
Fig. 2.1 Maxillary denture foundation showing functions of various ix. Referring for medical consultation (when indi-
areas. cated).
x. Referring for a second opinion and opinion
from other dental specialists (when required).
xi. Making alginate impressions and preparing
mounted study models (when indicated).
xii. Discussing the diagnosis, treatment planning
and prognosis with the patient.
xiii. Finalizing the fees and obtaining the informed
consent.
Clinical significance of anatomical landmarks of max-
illa and mandible
A. Maxilla
I. Supporting structures
i. Residual alveolar ridge
● The crest and part of the slope have compact
type of bone, covered with a layer of fibrous con-

nective tissue which is attached firmly and there-
fore best able to support a denture. With resorp-
Fig. 2.2 Mandibular denture foundation showing functions of various tion, this area gradually reduces in size thus
areas. reducing the support.
● Function ● Its location varies in the edentulous mouth. It may

It is the primary stress-bearing area. Extra stress be on the crest of the ridge after resorption has
may be placed on the crest during impression occurred.
procedures. ● It covers the incisive foramen through which the
ii. Rugae area nasopalatine nerves and vessels pass.

● It is series of ridges in the anterior part Significance: Relief area: Relief is provided in the
of the hard palate and made up of keratinized fi- final impression to prevent pressure on the emerg-
brous connective tissue. ing nasopalatine nerves and vessels. Denture pres-
Function: It is the secondary stress-bearing area sure on the papilla can cause paraesthesia, pain,
because it resists the forward movement. It should burning sensation and other vague complaints.
be recorded without pressure. If the tissue distorts vi. Zygomatic process (malar process)
while making the impression, then it can rebound ● It is located buccal to the first molar region. It is a
and the denture unseated. hard area that may become prominent in mouth
iii. Median palatine raphe that has been edentulous for a long time, covered
● It is present as a slightly raised bony ridge along by thin, loosely attached mucosa.
the midline of the hard palate. ● Function relieved when prominent, to prevent
Significance soreness.
It is the relief area for two reasons. They are as vii. Maxillary tuberosity
follows: ● It is the posterior most part of the maxillary edentulous
a. The mucosa covering it, is thin and nonre- ridge. When the maxillary teeth extrude, (when oppos-
silient, pressure on which can lead to sore- ing mandibular teeth are lost), it becomes very large
ness and severe pain. and hangs down with the extruding teeth. This region
b. If not adequately relieved, then it can act as may be covered with excess hypermobile tissue.
a fulcrum point and cause rocking of the Significance:
c. Dentures. a. It should be covered in the impression.
iv. Hard palate b. An overhanging tuberosity can interfere
● Soft tissues serve as a cushion between the hard den- with the location of the occlusal plane and
ture surface and the bone. It varies in thickness in reduce the space available for the denture
different parts of the oral cavity. and should be surgically reduced.
● Over hard palate, keratinized epithelium is pres- c. A hypermobile tuberosity can interfere with
ent. Soft tissue consists of mucosa and submucosa. denture stability.
● Mucosa of hard palate is masticatory type and d. Teeth are not set on the tuberosity region.
firmly attached, which is best suited for denture II. Limiting structures (valve seal areas)
support. These are the tissues which define the boundary of den-
● Hard palate is divided into two parts: tures.
a. Anterolateral: Submucosa contains adipose ● Provide retention to denture by providing a seal
tissue. against entry of air, e.g. the facial sulcus, the

Significance: It forms part of the secondary posterior palatal seal area and the alveololingual
retentive area. sulcus.
b. Posterolateral region (glandular region): It is ● Prevents the entry of food.
located on either side of the midline of the ● Histology: The vestibule is lined by nonkera-
posterior region of the hard palate. Mucous tinized epithelium. The submucosa is thick and
glands are thick and cover the blood vessels contains loose areolar tissue and elastic fibres.
and nerves come from the greater palatine fo- The limiting structures are as follows:
ramen. i. Labial frenum
Significance: It is the secondary retentive area. ● Fold of mucous membrane in the midline.
It should not be compressed. Otherwise, it can ● Starts superiorly from lip’s inner surface as
interfere with the function of mucous glands fan-shaped structure and converges near its at-
leading to their excessive secretion and inac- tachment on labial side of ridge. It has no ac-
curacy in recording of impression details. tion of its own.
v. Incisive papilla Significance: Relief area
● A small tissue projection located immediately ● Recorded as narrow notch labial notch in
behind and between the central incisors in dentu- the impression. If not relieved, then it causes
lous mouth. irritation.
● If present close to ridge crest, then it affects viii. Pterygomandibular raphe

denture seal and retention and thus frenec- ● Extends from hamulus to distolingual corner
tomy needs be done. of retromolar pad. Buccinators attach to its

ii. Buccal frenum distal part.
● Fold of mucous membrane on buccal side. Significance:
● May be present as single fold/double fold/ ● If denture is overextended beyond the ham-
broad and fan-shaped. ular notch, and mouth opened wide, then
● Related to three muscles: raphe pulls forward injuring the tissues.
a. Caninus (levator anguli oris): It is attached ix. Palatine fovea
beneath the frenum and affects its position. ● These are two small indentations in the poste-
b. Orbicularis oris: It pulls it forward. rior palate in the midline.

c. Buccinator: It pulls it backward. ● Formed by joining together of several mucous
Significance: Relief area. gland ducts. May be prominent or barely visible.

● Recorded as buccal notch in the impres- Significance:
sion, in its functional form (e.g. during ● Close to vibrating line and present in soft
chewing and smiling), failure to do so can tissue.

lead to denture dislodgement during mouth ● Serves as a guideline for posterior border
functions. of denture (posterior vibrating line is 2 mm

iii. Labial vestibule anterior to foveae).
● Sulcus area between labial and buccal frenum x. Posterior palatal seal area
and forms part of valve seal area. ● It is the area between anterior and posterior
Significance: vibrating lines.

● Accommodates labial flange of denture. ● It is in the shape of Cupid’s bow.
● Provides valve seal. ● Along with pterygomaxillary seal, it forms the
● Affects patient appearance: posterior part of valve seal.

● If flange is thick, then lips bulge out. Function:
● If flange is thin, then one can see unsup- ● To attain seal, extra pressure can be applied
ported lips. here.

iv. Buccal vestibule ● Marks the posterior limit of denture.
● Extends from buccal frenum to hamular notch B. Mandible

and forms part of vale seal area. I. Supporting structures
Significance: i. Residual alveolar ridge
● Provides peripheral seal. ● It is covered by keratinized layer and firmly at-
● Accommodates buccal flange of denture. tached to periosteum.

● It is affected by the action of masseter and ● It is sometimes loosely attached and movable.
coronoid process. ● Bone is cancellous, spongy and trabeculated in

v. Coronoid process nature.
● Located buccally in the maxillary tuberosity Functions:
region. ● Secondary relief area: Due to the presence
Significance: of cancellous bone, it does not provide good

● It affects the buccal flange of denture as the support.
mandible moves forward, side to side or ● If it is sharp, spongy and full of nutrient canals,
opens wide. then it should be relieved during impression.

● When distal flange is too thick, it dislodges ii. Slopes of the residual alveolar ridge
the denture. ● Covered by a thin plate of cortical bone and func-
vi. Masseter muscle tions as secondary stress-bearing area.

● It reduces the space when contracted under iii. Buccal shelf area
heavy biting pressure. ● It is supporting structure of mandible.
vii. Pterygomaxillary notch ● Boundaries:
● Located distal to maxillary tuberosity, be- ● Anteriorly: Buccal frenum.
tween the tuberosity and hamular process of ● Posteriorly: Retromolar pad.

pterygoid plate. ● Medially: Crest of the ridge.
Significance: ● Laterally: External oblique line.
● Forms the posterior limit of denture. ● Inferior part of buccinator is attached to this area,
● Pterygomaxillary seal can be obtained by but as the fibres run horizontally, it does not in-
placing extra pressure in this region. terfere with the denture.
● Histology: Mucosa is less keratinized and loosely iii. Labial sulcus/vestibule

attached. ● Extends between labial and buccal frenum.
Functions: Significance:
● It serves as the primary stress-bearing area, be- ● Accommodates the labial flange of denture
cause it is at right angles to vertical which is shallow in extension because of the

● Occlusal loads and is covered with dense fibres of orbicularis oris and incisivus labii
smooth cortical bone. inferioris running close to ridge crest.
iv. Mylohyoid ridge ● Forms part of valve seal area.
● Bony ridge found on the lingual side of the mandible. iv. Buccal vestibule
● Begins from third molar region, sloping down- ● Extends from buccal frenum to outside back cor-
wards and forwards. ner of reteromolar pad.

● Provides attachment to mylohyoid muscle. ● Lower part of buccinator is attached to it in molar
● Covered by soft tissue and examined by palpa- region, but as the fibres are horizontal it do not
tion method. displace the lower denture.
● Determines the height of lingual flange. ● Forms part of valve seal.
● In case of severely undercut ridge, it is diffi- ● Accommodates the buccal flange of denture.
cult to insert and remove denture. v. External oblique ridge

● Bulbous irregular ridge/thin, sharp ridge can ● Its palpation helps to know the amount of re-
cause soft tissue irritation and needs to be cor- sistance offered by the border tissues in this
rected surgically. region.
v. Mental foramen vi. Masseter muscle influence area
In case of extremely resorbed ridge, it comes to ● Its contraction pushes inward against the bucci-
level of ridge crest near the premolar region and nators muscle and affects the distobuccal corner
needs to be relieved. Pressure on mental nerve can of the denture which should converge rapidly to
lead to numbness of lip. avoid displacement.
vi. Torus mandibularis vii. Distal border of denture
● Cause is unknown. It is limited by:
● Present as rounded bony prominences in premo- ● Ramus of mandible.
lar region in some individuals. ● Buccinator is at its attachment to pterygoman-
● Located midway between soft tissue of the floor dibular raphe.

of mouth and ridge crest. ● Internal and external oblique ridge as it as-
● Size varies from pea to hazelnut. cends the ramus.

● Relief area: It is covered by thin layer of mu- ● If denture border is overextended here, then it
cous membrane which may get irritated by the causes soreness and limits the buccinator
denture. muscle function.
● Surgical removal of large tori is required, as it viii. Retromolar pad
interferes with peripheral seal. ● It is triangular pad of soft tissue at the distal end
II. Buccal limiting structures of mandible of the mandibular ridge.

i. Labial frenum ● It is covered with nonkeratinized epithelium.
● Band of fibrous connective tissue to which orbi- Contents:

cularis oris is attached. ● Glandular tissue.
● Sensitive and active and should be relieved to ● Temporalis tendon.
prevent soreness and to maintain the peripheral ● Buccinator fibres enter it from buccal side.
seal. ● Superior pharyngeal constrictor enters it from
ii. Buccal frenum lingual side.

● Connected to maxillary buccal frenum as a con- ● Pterygomandibular raphe enters it from back
tinuous band via modiolus at the corner of the inside corner.

mouth. Significance:
● Denture borders should not be overextended in ● Forms part of valve seal area.
this region, as fibres and muscular tissues ac- ● Provides border seal.
tively pull in this region which can cause denture ● Extra pressure on the pad to be avoided, to not
displacement. to injure the muscle fibres.

ix. Pear-shaped pad iv. Mylohyoid muscle

● Retromolar papilla is present in the region of ● It originates from mylohyoid line.
third molar distally, after whose loss it remains ● It is the most active muscle of the floor of the
fused to scar. mouth.

● It is pear-shaped unlike retromolar pad, which is Extensions:
soft and readily displaced. ● Posteriorly – 1 cm distal to mylohyoid ridge
Lingual limiting structures of mandible end.

i. Retromylohyoid curtain ● Anteriorly – up to midline.
● Wall of mucous membrane which limits the disto- ● Medially – both sides of mylohyoid join to
lingual part of denture flange. form the floor of the mouth.

● Supported superiorly by superior constrictor and ● In anterior region, it lies deep to sublingual
lingually by anterior tonsillar pillar. gland.

Significance: Significance:
● Accommodates the distolingual part of denture. ● It influences the lingual flange of denture.
● It should be carefully border moulded to ● When it is relaxed, a space exists between
avoid soreness and displacement of denture, the flange and the mucus membrane and
as it pulls forward when the tongue thrust out. contact occurs only when the tongue is
ii. Alveololingual sulcus (lingual vestibule) raised out.
● Also called lingual vestibule-limiting structure of v. Mylohyoid ridge
mandible. ● It provides attachment to mylohyoid muscle.
● It extends from lingual frenum anteriorly to retro- Significance:

mylohyoid curtain posteriorly. ● Denture border should extend below this ridge
● It is divided into three parts: otherwise there will be soreness, denture dis-
a. Anterior part placement, and loss of seal.
● It extends from lingual frenum to premylo- ● In extreme resorption, ridge becomes prominent
hyoid fossa. and should be surgically corrected/relieved by

● It is the shallowest portion of the lingual flange. impression.
b. Middle part vi. Genial tubercles
● It extends from premylohyoid fossa to distal ● It is present as a hard projection in the midline on
end of mylohyoid ridge. lingual side of mandible.

● It slopes towards the tongue. ● It becomes prominent in severe resorption cases.
● It allows room for action of mylohyoid ● It is either visible or felt on palpation.
muscle. Significance:
● Increased flange height, as it can be ex- ● If prominent, then it should be relieved to
tended beyond the muscle attachment. avoid pain and soreness.

● It allows floor of mouth to rise without dis- ● Denture border should rest on soft tissues
placing the denture. around the periphery of tubercles.
● It provides room for tongue rest on flange ● They can be surgically relocated.
leading to retention. vii. Sublingual gland region

● It avoids impingement of sublingual gland ● It rests anteriorly on the mylohyoid muscle.
and submaxillary duct. ● It comes close to ridge crest, when the floor of
c. Posterior region (retromylohyoid fossa region) mouth is raised limiting the height of lingual
● It extends from the end of mylohyoid ridge flange in this region.
to retromylohyoid curtain. ● S-shape of the lingual flange is due to activity of
● Posterior region slopes away from tongue mylohyoid muscle, which when contracted raises
and towards the ridge. the area between premylohyoid and retromylohy-
● It guides the tongue on top of the lingual oid fossa resulting in characteristic ‘S’ curve.
flange.
iii. Lingual frenum Q.3. Discuss the significance of case history recording,
● It is attached to the tongue anteriorly.
diagnosis and treatment planning in the fabrication of
● It is active and resistant.
complete dentures prosthesis.
Significance: Ans.
● If not relieved, it causes soreness and dislodge-
ment of denture. [Same as LE Q.1]

Q.4. Diabetic patient aged 65 years with few teeth remain- ● Making alginate impressions and preparing mounted
ing comes to your dental college/hospital for dental pros- study models (when indicated).
thesis. Discuss the treatment planning and special steps to ● Discussing the diagnosis, treatment planning and
be taken by you for the management of the patient. prognosis with the patient.
● Finalizing the fees and obtaining the informed consent.
Ans.
Q.2. Why complete radiographic examination should be
[Same as LE Q.1] made for an edentulous mouth?
Q.5. With the help of diagram, discuss the denture- Ans.
bearing area of edentulous mouth. Give the clinical im-
portance of posterior palatal seal and retromolar pad. [Ref LE Q.1]
Ans. Q.3. Discuss the examination, diagnosis and treatment

planning in complete denture patients.
[Same as LE Q.2]
Ans.
Examination, diagnosis and treatment planning in com-
SHORT ESSAYS: plete denture patients
Q.1. Importance of preprosthetic evaluation of the eden- ● For success of prosthetic treatment, a careful, correct
tulous area before making impression. and complete examination, and diagnosis is impor-
tant followed by providing the patient with the best
Ans.
possible treatment plan in accordance with his age,
Importance of preprosthetic evaluation of edentulous area physical, mental and financial status.
before making impression is as follows: Examination and diagnosis should be carried out in the
● To determine that no mental or physical condition following sequential manner:
exists which would contraindicate the wearing and i. Recording the general information.
use of the denture itself. ii. Recoding the chief complaint and assessing
● A review of past and current medical history with patient’s expectations.
particular attention to any condition that might in- iii. Recording the relevant medical history.
crease the surgical risk. iv. Recording current medication.
● To assess the nutritional status. v. Recording the relevant dental history.
● To conduct an intraoral examination and assess the vi. Performing thorough visual and manual exami-
need for surgery, as well as to rule out nonsurgical nation of the mouth and head and neck regions.
alternatives. vii. Performing radiographic examination.
● To evaluate the TMJ and jaw relationship. viii. Referring for additional tests, if required, e.g.
● To carry out additional diagnostic procedures like blood, sugar and urine.
radiographic studies, and blood and urine analyses. ix. Referring for medical consultation (when indicated).
● Dental model evaluation and mock surgery on the x. Referring for a second opinion and opinion
diagnostic casts to get an idea about the actual sur- from other dental specialists (when required).
gery results. xi. Making alginate impressions and preparing
Preprosthetic evaluation should be carried out in the fol- mounted study models (when indicated).
lowing sequential manner: xii. Discussing the diagnosis, treatment planning
● Recording the general information. and prognosis with the patient.
● Recoding the chief complaint and assessing patient’s xiii. Finalizing the fees and obtaining the informed
expectations. consent.
● Recording the relevant medical history. Diagnosis
● Recording current medication. ● The determination of the nature of a disease is
● Recording the relevant dental history. known as diagnosis.
● Performing thorough visual and manual examination ● Diagnosis involves thorough analysis of all the fac-
of the mouth and head and neck regions. tors which can affect the success of treatment. This
● Performing radiographic examination. includes both systemic and local factors and mental
● Referring for additional tests, if required, e.g. blood, condition of the patient. Certain conditions could
sugar and urine. make the outcome of treatment less satisfactory.
● Referring for medical consultation (when indicated). ● A well-made denture can fail, if the dentist cannot
● Referring for a second opinion and opinion from diagnose a complicating factor at the time of the
other dental specialists (when required). initial examination.
● The PDI is a useful tool to determine the diagnosis

c. Indifferent
and prognosis of denture treatment.
● Patient has a questionable prognosis.
PDI for complete edentulism
● Patient lacks motivation and is not very interested
It was developed by the American College of Prosth-
in treatment.
odontists. The system classifies edentulous patient treat-
● Patient tries to find mistakes in treatment and
ment complexity using four diagnostic criteria:
blames dentist for any mishap.
a. Mandibular bone height
● Patient does not cooperate and follow instructions
b. Maxillomandibular relationship
and is forced by his relatives, spouse, etc., for
c. Maxillary residual ridge morphology
dental treatment.
d. Muscle attachments
● Such patient is difficult to manage. Patient should
These four criteria identify patients, as:
be well educated about the treatment and motivated
Class 1 (ideal or minimally compromised)
to develop interest in treatment. If no improvement
Class 2 (moderately compromised)
is observed, then it is better to postpone or refuse
Class 3 (substantially compromised)
the treatment.
Class 4 (severely compromised)
d. Hysterical
Treatment plan
● Patient is easily excited, highly apprehensive and
The sequence of procedures planned for the treatment
emotionally unstable.
of a patient after diagnosis is as follows:
● Patient rarely cooperates with the dentist.
● Diagnosis and treatment planning should be done
● Patient has unfounded complaints and unrealistic
before initiation of treatment. All the findings of the
expectations.
case are analysed and the most suitable treatment plan
● Lot of time and patience is required to manage
is determined, which includes premedication, consul-
such patient.
tation and treatment, involving other specialists.
● Medical consultation might be required for the
● It is explained to the patient in a simple and
systemic problems, if present.
straight forward manner, including all the factors
e. Sceptical
that might complicate the treatment (if any). The
● Patient has had bad results from previous treat-
patient is encouraged to speak and clear any
ment and is doubtful whether their problems can
doubts that he/she might have about the treatment.
be solved.
Q.4. Mental attitude of patients. ● Patient has unfavourable conditions like resorbed
ridges and poor health.

Ans.
● Patient may be in psychological stress, due to
recent death of close relative, etc.

{SN Q.1} ● First, psychological management is required for
The House Classification of Mental Attitude of Patient such patient before dental treatment. Kindness,
by M.M. House classifies denture patients into different care and sympathy should be offered and condi-
groups based on their personality as: tion should be dealt with patience and good atten-
a. Philosophical tion, in order to restore his confidence.
● Patient has best mental attitude required for
denture treatment.
● Patient is well motivated and realizes his part in
SHORT NOTES:
treatment. Q.1. House classification of mental attitudes.
● Patient cooperates with the dentist and learns to
Ans.
adjust.
● Patient is rational, sensible, calm and composed [Ref SE Q.4]
in difficult situations.
b. Exacting (critical) Q.2. Undercuts in complete denture.
● Patient is methodical and precise. Ans.
● Need to explain each step of the procedure in
detail to the patient. [Ref LE Q.1]

● Patient sometimes proposes treatment plan to the
Q.3. Importance of full mouth intraoral radiographs in
dentist and makes severe demands. edentulous patients.
● Patient should be managed with extra care, effort and
patience. Dentist must listen to the demands of the Ans.

patient, but must not consider them, if unreasonable. [Ref LE Q.1]
Q.4. What are the soft tissues covering the hard palate ● Superior surface of the palatine aponeurosis –
and their relevance to complete dentures? levator veli palatini and the palatopharyngeus.
● Inferior surface of the palatine aponeurosis –
Ans. palatoglossus.
● Numerous mucous glands and some taste buds
Soft tissues and their relevance to complete dentures
● Soft tissues serve as cushion between the hard den-
are present.
ture surface and the bone. It varies in thickness in Muscles of the soft palate
different parts of the oral cavity. Over hard palate, i. Tensor palati (tensor veli palatini) – thin, triangular
keratinized epithelium is present. Soft tissue consists muscle.
of mucosa and submucosa. Functions:
● Mucosa of hard palate is masticatory type and firmly
a. It tightens the soft palate, chiefly the anterior part.
attached, which is best suited for denture support. b. It opens the auditory tube to equalize air pressure
● Hard palate is divided into two parts:
between the middle ear and the nasopharynx.
I. Anterolateral ii. Levator palati (levator veli palatini) – cylindrical
● Submucosa contains adipose tissue.
muscle that lies deep to the tensor veli palatine.
● Significance: It forms part of the secondary
Functions:
retentive area. a. It elevates soft palate and closes the pharyn-
II. Posterolateral region (glandular region) geal isthmus.
● It is located on either side of midline of the posterior
b. It opens the auditory tube, like the tensor veli
region of the hard palate. Mucous glands are thick palatini.
and cover the blood vessels and nerves coming from iii. Musculus uvulae – longitudinal strip placed on one
the greater palatine foramen. side of the median plane, within the palatine apo-
Significance: neurosis, which pulls up the uvula.
It serves as secondary retentive area. It should not be iv. Palatoglossus – pulls up the root of the tongue, ap-
compressed otherwise it can interfere with the func- proximates the palatoglossal arches and thus closes
tion of mucous glands leading to their excessive secre- the oropharyngeal isthmus.
tion and inaccuracy in recording of impression details. v. Palatopharyngeus – pulls up the wall of pharynx
and shortens it, during swallowing.
Q.5. Soft palate.
Q.6. Mental attitudes of patients.
Ans.
Ans.
Soft palate
Soft palate is a fold of mucous membrane consisting of [Same as SN Q.1]
following parts:
Palatine aponeurosis – flattened tendon of the tensor Q.7. Muscles of the soft palate.
veli palatini, which forms the fibrous basis of the palate. Ans.
● Near the median plane, aponeurosis splits to
enclose the musculus uvulae. [Same as SN Q.5]
Topic 3
Diagnostic Impressions in CD, Mouth Preparation
for CD and Objective of Impression Making
LONG ESSAYS:
1 . Define complete denture retention. Enumerate various factors of retention.
2. Define impression. Discuss biological considerations for a maxillary impression.
3. Define impressions in prosthodontics. Why is it called as biological? Discuss the principles and objectives of
impression making in complete denture prosthesis.
4. Describe in brief the principles and objectives of maxillary final impression for complete edentulous patients.
[Same as LE Q.3]
SHORT ESSAYS:
1 . Importance of preprosthetic evaluation of the edentulous area before making impression.
2. Diagnostic cast and its uses.
3. What are the objectives of complete denture prosthodontics? Explain them.
SHORT NOTES:
1. Preprosthetic surgery.
2. Mandibular stress-bearing areas.
3. Buccal shelf area.
4. Incisive papilla.
5. Muscles of the soft palate.
6. Alveolingual sulcus.
7. Muscles of mastication and facial expression.
8. Balanced occlusion.
9. Retromolar pad.
10. Anterior reference points.
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Define complete denture retention. Enumerate var- ● Thick and ropy saliva accumulates between the tis-
ious factors of retention. sue surface of the denture and the palate, leading to
loss of retention.
Ans.
● Thin and watery saliva is ideal.
Retention ● Ptyalism leads to gagging.
Retention is defined as that quality inherent in the pros- ● Xerostomia produce soreness and irritation.
thesis, which resists the force of gravity, adhesiveness of Physical factors
foods, and the forces associated with the opening of the Physical factors which control retention are as follows:
jaws (GPT). i. Adhesion
It is the ability of the denture to withstand displacement It is defined as physical attraction of two unlike mol-
against its path of insertion. ecules to each other (GPT).
Factors affecting retention are as follows: ● Saliva plays an important role in adhesion. It
A. Anatomical factors. wets the tissue surface of denture and the mu-
B. Physiological factors. cosa forming a thin film between them, which
C. Physical factors. helps to hold the denture to the mucosa. In
D. Mechanical factors. patients with xerostomia, adhesion does not
E. Muscular factors. play a major role.
Anatomical factors ● Amount of adhesion present is proportional to
Anatomical factors which affect retention are as follows: the denture base area.
i. Size of the denture-bearing area: It increases with ii. Cohesion
increase in size of the denture-bearing area. ● It is defined as the physical attraction of like mol-
2
● Maxillary denture-bearing area: 24 cm . ecules to each other (GPT).
2
● Mandible denture-bearing area: 14 cm . ● Cohesive forces act within the thin film of
Hence, maxillary dentures have more retention saliva. Watery serous saliva forms a thinner
than mandibular dentures. film and is more cohesive than thick mucous
ii. Quality of the denture-bearing area: The displa- saliva.
cability of the tissues influences the retention of ● Cohesive forces increase with increase in den-
the denture. Tissues displaced during impression ture-bearing area.
making will lead to tissue rebound during denture iii. Interfacial surface tension
use, leading to loss of retention. It is the tension or resistance to separation possessed
Physiological factors by the film of liquid between two well-adapted sur-
● Saliva retention depends upon viscosity of saliva. faces (GPT).
To obtain maximum interfacial surface tension: ● This property is called the natural suction of a
● Saliva should be thin and even. denture. Hence, atmospheric pressure is referred
● Perfect adaptation should be present between to as emergency retentive force or temporary re-
the tissues and the denture base. straining force.
● The denture base should cover a large area. ● Retention produced by an atmospheric pressure
● There should be good adhesive and cohesive is directly proportional to the denture base area.
forces, which aid to enhance interfacial sur- Mechanical factors
face tension. Mechanical factors which control retention are as follows:
● It plays a major role in retention of maxillary ● Undercuts.
denture and is dependent on the presence of ● Unilateral undercuts aid in retention.
air at the margins of liquid and solid contact ● Bilateral undercuts interfere with denture insertion
(liquid air interface). and require surgical correction.

● If there is no liquid–air interface, then there will ● Retentive springs.
be no surface tension. This phenomenon is seen ● Magnetic forces: Intramucosal magnets aid in in-
in mandibular dentures where there is excess creasing retention of highly resorbed ridges.
saliva along the denture borders with minimal ● Denture adhesives: These are available as creams/
interfacial surface tension and no retention. gels/powders. They are coated on tissue surface
● Stefan’s formula to calculate interfacial sur- before wearing.
face tension: ● Suction chambers and suction discs: These are used
F 5 (3/2 3 3.14 3 kr4/h3) 3 v, where: in maxillary dentures to aid in retention by creating

F – Interfacial surface tension. an area of negative pressure but avoided nowadays
k – Viscosity of the interposed liquid (saliva). due to their potency of causing palatal hyperplasia.
r – Denture surface area. Muscular factors
h – Width of the space between the denture ● Muscles exercise supplements retentive force on the
base and the mucosa. denture.

v – Velocity of the displacing force. ● There is a balance between the forces acting from the
F decreases with the increase in h. buccal musculature and the tongue which is obtained
Increase in r increases the F. in the neutral zone and thus, the artificial teeth should
A slow and steady increase in v will have be arranged in neutral zone to achieve better retention.
least resistance from interfacial surface ● Occlusal plane should be parallel to residual ridge
tension than a rapid v. and divide the interarch space equally.

iv. Capillarity or capillary attraction
It is defined as that quality or state, wherein surface Q.2. Define impression. Discuss biological considerations
tension causes elevation or depression of the surface for a maxillary impression.
of a liquid that is in contact with a solid (GPT). Ans.
Factors which improve capillary attraction and thus
retention are as follows: Impression
● Closeness of adaptation of denture base to soft Impression is a negative likeness or copy in reverse of
tissue. the surface of an object, which is an imprint of the teeth
● Greater surface of the denture-bearing area. and adjacent structures used in dentistry (GPT).
● Thin film of saliva should be present. Biological considerations of maxillary impression
v. Atmospheric pressure and peripheral seal Supporting structures
● Peripheral seal is the area of contact between i. Residual alveolar ridge
the peripheral borders of the denture and the ● The crest and part of the slope has compact type of
resilient-limiting structures. bone, covered with a layer of fibrous connective

● It prevents air entry between the denture surface tissue which is attached firmly and therefore best
and the soft tissue maintaining a low pressure in able to support a denture. With resorption, this area
space between the above two. gradually reduces in size thus reducing the support.
● To achieve good peripheral seal, the denture bor- ● Function
ders should rest on soft and resilient tissues It serves as the primary stress-bearing area. Extra-
which allow movement of mucosa along with the stress may be placed on the crest during impres-
denture base during function. sion procedures.
● When displacing forces act on denture, a partial ii. Rugae area
vacuum is produced between the denture and the ● It is a series of ridges in the anterior part of hard pal-
soft tissues, which aids in retention. ate, made up of keratinized fibrous connective tissue.
● Function Significance
It serves as secondary stress-bearing area because ● Relief area: Relief is provided in the final im-
it resists the forward movement. It should be re- pression to prevent pressure on the emerging
corded without pressure. If the tissue distorts nasopalatine nerves and vessels. Denture pres-
while making the impression, then it can rebound sure on the papilla can cause paraesthesia,
and unseat the denture. pain, burning sensation and other vague com-
iii. Median palatine raphe plaints.
● Present as a slightly raised bony ridge along the vi. Zygomatic process (malar process)
midline of the hard palate. ● It is located buccal to the first molar region. It is
● Significance a hard area that may become prominent in

It is the relief area for two reasons: mouths that have been edentulous for a long
● The mucosa covering it, is thin and nonresil- time, covered by thin, loosely attached mucosa.
ient, pressure on which can lead to soreness ● Function: Is relieved when prominent, to pre-
and severe pain. vent soreness.

● If not adequately relieved, then it can act as vii. Maxillary tuberosity
a fulcrum point and cause rocking of the ● It is the posterior most part of the maxillary eden-
dentures. tulous ridge. When the maxillary teeth extrude

iv. Hard palate (when opposing mandibular teeth are lost), it be-
● Soft tissues serve as cushion between the hard comes very large and hangs down with the ex-
denture surface and the bone. It varies in thick- truding teeth. This region may be covered with
ness in different parts of the oral cavity. Over excess hypermobile tissue.
hard palate, keratinized epithelium is present. Significance
Soft tissue consists of mucosa and submucosa. a. It should be covered in the impression.
● Mucosa of hard palate is masticatory type and b. An overhanging tuberosity can interfere with
firmly attached, which is best suited for denture the location of the occlusal plane and reduce
support. the space available for the denture and should
Hard palate is divided into two parts: be surgically reduced.
a. Anterolateral: Submucosa contains adipose c. A hypermobile tuberosity can interfere with
tissue. denture stability.
Significance d. Teeth are not set on the tuberosity region.
● It forms part of the secondary retentive Limiting structures (valve seal areas)
area. ● These are the tissues which define the boundary of
b. Posterolateral region (glandular region) dentures.

● Located on either side of midline of the ● They provide retention to denture by providing a seal
posterior region of the hard palate. Mucous against entry of air, e.g. the facial sulcus, the poste-
glands are thick and cover the blood vessels rior palatal seal area and the alveololingual sulcus.
and nerves, coming from the greater pala- ● They prevent the entry of food.
tine foramen. ● Histologically, the vestibule is lined by nonkera-
Significance tinized epithelium. The submucosa is thick and con-

● It serves as the secondary retentive area. It tains loose areolar tissue and elastic fibres.
should not be compressed otherwise it can i. Labial frenum
interfere with the function of mucous ● Fold of mucous membrane in the midline.
glands leading to their excessive secretion ● Starts superiorly from lip’s inner surface as fan-
and inaccuracy in recording of impression shaped structure and converges near its attach-
details. ment on the labial side of the ridge. It has no ac-
v. Incisive papilla tion of its own.
● A small tissue projection located immediately Significance: It serves as relief area.
behind and between the central incisors in dentu- ● It is recorded as narrow notch or labial notch in
lous mouths. the impression. If not relieved, causes irritation.

● Its location varies in the edentulous mouth. It ● If present close to ridge crest, then it affects
may be on the crest of the ridge after resorption denture seal and retention and thus frenectomy
has occurred. should be done.
● It covers the incisive foramen through which the ii. Buccal frenum
nasopalatine nerves and vessels pass. ● Fold of mucous membrane on buccal side.
● May be present as single fold/double fold/broad Significance

and fan-shaped. ● If denture is overextended beyond the hamular
● Related to three muscles: notch, and mouth opened wide, then raphe
a. Caninus (levator anguli oris): It is attached pulls forward, injuring the tissues.
beneath the frenum and affects its position. ix. Palatine fovea
b. Orbicularis oris pulls it forward. ● These are two small indentations in the posterior
c. Buccinator pulls it backward. palate in midline.
Significance: It serves as relief area. ● These are formed by joining together of several
● It is recorded as buccal notch in the impres- mucous gland ducts.
sion in its functional form (e.g. during ● These may be prominent or barely visible.
chewing and smiling), failure to do so can Significance
lead to denture dislodgement during mouth ● These are close to vibrating line and present in
functions. soft tissue.
iii. Labial vestibule ● They serve as guideline for posterior border of
● It is the sulcus area between labial and buccal denture (posterior vibrating line 2 mm anterior
frenum and forms part of valve seal area. to foveae).
Significance x. Posterior palatal seal area
● It accommodates labial flange of denture. ● It is an area between anterior and posterior vibrat-
● It provides valve seal. ing lines.
● It affects patient’s appearance: ● It is in the shape of Cupid’s bow.
If flange is thick, then lips bulge out. ● Along with pterygomaxillary seal, it forms the
If flange is thin, then one can see unsup- posterior part of valve seal.
ported lips. Function
iv. Buccal vestibule ● To attain seal, extra pressure can be applied
● It extends from buccal frenum to hamular notch here.
and forms part of valve seal area. ● It marks the posterior limit of denture.
Significance
● It provides peripheral seal.
Q.3. Define impressions in prosthodontics. Why is it
● It accommodates buccal flange of denture.
called as biological? Discuss the principles and objectives
● It is affected by the action of masseter and
of impression making in complete denture prosthesis.
coronoid process. Ans.
v. Coronoid process
● It is located buccally in the maxillary tuberosity Impression
region. Impression may be defined as a negative likeness or
Significance copy in reverse of the surface of an object, which is an
● It affects the buccal flange of denture as the imprint of the teeth and adjacent structures for use in
mandible moves forward, side to side or dentistry (GPT).
opens wide. It is called as biological, because it records the living
● When distal flange is too thick, it dislodges tissues of the oral cavity some in functional form and
the denture. some in relaxed state.
vi. Masseter muscle Principles of impression making
● It reduces the space when contracted under heavy i. Oral tissues must be healthy.
biting pressure. ii. It should include all the basal seat areas within the
vii. Pterygomaxillary notch limits of health and function of the supporting and
● It is located distal to maxillary tuberosity, be- limiting tissues.
tween the tuberosity and the hamular process of iii. The borders must be in harmony with the anatomi-
pterygoid plate. cal and the physiological limitations of the oral
Significance structures.
● It forms the posterior limit of denture. iv. Physiological type of border moulding should be
● Pterygomaxillary seal can be obtained by performed.
placing extra pressure in this region. v. Sufficient space should be provided within the
viii. Pterygomandibular raphe impression tray for the selected impression
● It extends from hamulus to distolingual corner of material.
retromolar pad. vi. Impression must be removed from the mouth with-
● Buccinators attaches to its distal part. out damaging the mucosa.
vii. Selective pressure should be applied on the basal C. Physical factors

seat during impression making. Physical factors which control retention are as follows:
viii. Guiding mechanism should be provided for correct a. Adhesion
positioning of the tray within the mouth. Physical attraction of unlike molecules to each other
ix. The tray and impression material should be made is known as adhesion (GPT).
up of dimensionally stable materials. ● Saliva plays an important role in adhesion.
x. The external shape of the impression should be ● It wets the tissue surface of denture and the mu-
similar to the external form of complete denture. cosa forming a thin film between them which
Objectives of impression making helps hold the denture to the mucosa. In patients
Five objectives of impression making in complete den- with xerostomia, adhesion does not play a major
ture prosthodontics as stated by Carl O. Boucher in role.
1944 are as follows: ● Amount of adhesion present is proportional to the
Preservation of alveolar ridge denture base area.

Muller De Van’s (1952) statement: ‘The preservation of b. Cohesion
that which remains is of utmost importance and not the It is the physical attraction of like molecules for each
meticulous replacement of that which has been lost’. other (GPT).
This can be achieved by: ● Cohesive forces act within the thin film of saliva.
● Using techniques that reduce alveolar resorption, Watery serous saliva forms a thinner film and is
i.e. wider coverage so that force per unit area is less. more cohesive than thick mucous saliva.
● Placing more loads on stress-bearing areas and ● Cohesive forces increase with increase in denture-
less load on nonstress-bearing areas. bearing area.

Retention c. Interfacial surface tension
It is defined as that quality inherent in the prosthesis, which The tension or resistance to separation possessed by
resists the force of gravity, adhesiveness of foods, and the the film of liquid between the two well-adapted sur-
forces associated with the opening of the jaws (GPT). faces (GPT).
It is the ability of the denture to withstand displacement To obtain maximum interfacial surface tension:
against its path of insertion. ● Saliva should be thin and even.
Factors affecting retention are as follows: ● Perfect adaptation should be present between
A. Anatomical factors. the tissues and the denture base.

B. Physiological factors. ● The denture base should cover a large area.
C. Physical factors. ● There should be good adhesive and cohesive
D. Mechanical factors. forces, which aid to enhance interfacial surface

E. Muscular factors. tension.
● Plays a major role in retention of maxillary
A. Anatomical factors denture and is dependent on the presence of air

Anatomical factors which affect retention are as follows: at the margins of liquid and solid contact (liquid
● Size of the denture-bearing area: It increases with air interface).
increase in size of the denture-bearing area. ● If there is no liquid–air interface, then there will
2
● Maxillary denture-bearing area – 24 cm . be no surface tension. This phenomenon is seen in
2
● Mandible denture-bearing area – 14 cm . mandibular dentures, where there is excess saliva
● Hence, maxillary dentures have more retention along the denture borders with minimal interfa-
than mandibular dentures. cial surface tension and no retention. Stefan’s
● Quality of the denture-bearing area: The displace- formula to calculate interfacial surface tension:
ability of the tissues influences the retention of the F 5 (3/2 3 3.14 3 kr4/h3) 3 v, where:
denture. Tissues displaced during impression mak- F – Interfacial surface tension.
ing will lead to tissue rebound during denture use, k – Viscosity of the interposed liquid (saliva).
leading to loss of retention. r – Denture surface area.
B. Physiological factors h – Width of the space between the denture base
● Saliva retention depends upon viscosity of saliva. and the mucosa.
● Thick and ropy saliva accumulates between the tis- v – Velocity of the displacing force.
sue surface of the denture and the palate leading to F decreases with the increase in h.
loss of retention. Increase in r increases the F.
● Thin and watery saliva is ideal. A slow and steady increase in v will have least
● Ptyalism leads to gagging. resistance from interfacial surface tension
● Xerostomia produces soreness and irritation. than a rapid v.
d. Capillarity or capillary attraction ● Occlusal plane should be parallel to residual ridge

It is that quality or state, the surface tension of which and divide the interarch space equally.
causes elevation or depression of the surface of a Stability
liquid that is in contact with a solid (GPT). ‘The quality of a denture to be firm, steady or con-
Factors which improve capillary attraction and thus stant, to resist displacement by functional stresses
retention are as follows: and not to be subject to change of position when
● Closeness of adaptation of denture base to soft forces are applied’ (GPT).
tissue. It is the ability of the denture to withstand horizontal
● Greater surface of the denture-bearing area. forces.
● Thin film of saliva should be present. Factors controlling stability are as follows:
e. Atmospheric pressure and peripheral seal Vertical height of the residual ridge: It should be
Peripheral seal is the area of contact between the sufficient to obtain good stability.
peripheral borders of the denture and the resilient- Extremely resorbed ridges provide least stability.
limiting structures. Quality of soft tissue covering the ridge: For good
● It prevents air entry between the denture sur- stability, ridge should have a firm soft tissue base
face and the soft tissue maintaining a low pres- with adequate submucosa. Flabby tissues with
sure in space between the above two. excessive submucosa offer poor stability.
● To achieve good peripheral seal, the denture Quality of the impression
borders should rest on soft and resilient tissues i. It should be as accurate as possible.
which allow movement of mucosa along with ii. Impression surface should be smooth.
the denture base during function. iii. It should be devoid of voids and any rough sur-
● When displacing forces act on denture, a par- faces.
tial vacuum is produced between the denture iv. It should not warp on removal.
and the soft tissues, which aids in retention. v. It should be dimensionally stable and the cast
● This property is called the natural suction of a should be poured as soon as possible.
denture. Hence, atmospheric pressure is referred Occlusal plane
to as emergency retentive force or temporary ● It should be oriented parallel to the ridge.
restraining force. ● If it is inclined, then sliding forces will act on
● Retention produced by an atmospheric pres- denture and reduce its stability.

sure is directly proportional to the denture base ● It should divide the interarch space equally.
area. Arrangement of teeth and occlusion

D. Mechanical factors i. It plays an important role in the stability of the
Mechanical factors which control retention are as follows: denture. Balanced occlusion facilitates even distri-
● Undercuts bution of forces across the denture. Its absence
● Unilateral undercuts aid in retention. produces unbalanced, lever type forces on anyone
● Bilateral undercuts interfere with denture inser- side of the denture, leading to loss of stability.
tion and require surgical correction. ii. Teeth should be arranged in the neutral zone
● Retentive springs. which is defined as, ‘The potential space be-
● Magnetic forces: Intramucosal magnets aid in tween the lips and cheeks on one side and the
increasing retention of highly resorbed ridges. tongue on the other. Natural or artificial teeth in
● Denture adhesives: They are available as this zone are subject to equal and opposite forces
creams/gels/powders. They are coated on tissue from the surrounding musculature’ (GPT).
surface before wearing. Contour of the polished surfaces
● Suction chambers and suction discs: They are ● It should be harmonious with the oral structures
used in maxillary dentures to aid in retention by and not interfere with the action of oral muscu-
creating an area of negative pressure but avoided lature.
nowadays due to their potency of causing pala- Support
tal hyperplasia. The resistance to vertical forces of mastication, occlu-
E. Muscular factors sal forces and other forces applied in a direction to-
● Muscles exercise supplementary retentive force on wards the denture-bearing area (GPT).
the denture. ● For good support denture base should cover as
● There is a balance between the forces acting from the much denture-bearing area as possible which
buccal musculature and the tongue which is obtained helps to distribute forces over a wide area known
in the neutral zone and thus, the artificial teeth should as the snow-shoe effect. Thus, the force per unit
be arranged in neutral zone to achieve better retention. area is reduced.
● Confining the occlusal forces to stress-bearing ar- x. Referring for a second opinion and opinion
eas and reliving the nonstress-bearing areas will from other dental specialists (when required).
aid in improving support. xi. Making alginate impressions and preparing
Aesthetics mounted study models (when indicated).
It is the most vital objective. It is governed by the xii. Discussing the diagnosis, treatment planning
thickness of denture flanges. Thick flanges are pre- and prognosis with the patient.
ferred to give required mouth fullness in long-term xiii. Finalising the fees and obtaining the informed
edentulous patients. Impression should accurately consent.
reproduce the width and height of entire sulcus for
proper fabrication of flanges. Q.2. Diagnostic cast and its uses.
Q.4. Describe in brief the principles and objectives of max- Ans.

illary final impression for complete edentulous patients. Diagnostic cast
Ans. Diagnostic cast is a life-size reproduction of a part or
parts of oral cavity and/or facial structures for the pur-
[Same as LE Q.3] pose of study and treatment planning (GPT).
Ideal requirements of a diagnostic cast
i. It should be free of voids or projections.
SHORT ESSAYS: ii. Surface should be smooth, dense and free of sludge.
Q.1. Importance of preprosthetic evaluation of the eden- iii. It should cover all the areas, which provide den-
tulous area before making impression. ture support, e.g. it should extend 3–4 mm be-
yond the retromolar pad.
Ans.
iv. The walls of cast should be vertical or tapering
Preprosthetic evaluation importance outward, but never inward.
● To determine that no mental or physical condition v. The tongue space in a mandibular cast should be
exists which would contraindicate the wearing and smooth. The lingual peripheral seal (lingual
use of the denture itself. sulcus, lingual frenum and sublingual fold
● A review of past and current medical history with space) should also be intact.
particular attention to any condition that might in- vi. The cast should not show any traces of moisture.
crease the surgical risk. vii. The occlusal table should be parallel to the floor.
● Assessment of the nutritional status. Uses of diagnostic cast
● An intraoral examination and assessment of the i. To measure the depth and extent of the undercuts.
need for surgery, as well as ruling out nonsurgical ii. To determine the path of insertion of the denture.
alternatives. iii. To identify and plan the treatment for interfer-
● Evaluation of the TMJ and jaw relationship. ences like tori.
● Additional diagnostic procedures like radiographic iv. To perform mock surgeries for maxillofacial
studies, and blood and urine analyses. prosthesis.
● Dental model evaluation and mock surgery on the v. To determine the amount of preprosthetic sur-
diagnostic casts to get an idea about the actual surgery required.
gery results. vi. To evaluate the size and contour of the arch.
Following sequential manner for preprosthetic evalua- vii. To get an idea about retention and stability
tion should be carried out: offered by the tissues.
i. Recording the general information. viii. To determine the need for additional retentive
ii. Recoding the chief complaint and assessing features like over denture abutments and im-
patient’s expectations. plant abutments.
iii. Recording the relevant medical history.
iv. Recording current medication. Q.3. What are the objectives of complete denture prosth-
v. Recording the relevant dental history. odontics? Explain them.
vi. Performing the thorough visual and manual exami- Ans.
nation of the mouth and head and neck regions.
vii. Performing radiographic examination. Objectives of complete denture prosthodontics
viii. Referring for additional tests, if required, e.g. Five objectives of impression making in complete denture
blood, sugar and urine. prosthodontics as stated by Carl O. Boucher 1944 are as follows:
ix. Referring for medical consultation (when indi- i. Preservation of alveolar ridge: Muller De Van (1952)
cated). statement ‘the preservation of that which remains is of
utmost importance and not the meticulous replacement Inferior part of buccinator is attached to this area,
of that which has been lost’ can be achieved by but as the fibres run horizontally. It does not inter-
● Using techniques that reduce alveolar resorption, i.e. fere with denture.
wider coverage so that force per unit area is less. Histologically, mucosa is less keratinized and
● Placing more load on stress-bearing areas and less loosely attached.
load on nonstress-bearing areas. Secondary stress-bearing area: It forms the slopes of
ii. Retention: It is the ability of denture to withstand dis- the residual alveolar ridge, because they are com-
placement against its path of insertion. posed of thin plate of cortical bone.
iii. Stability: It is the ability of denture to resist horizontal
Q.3. Buccal shelf area.
forces.
iv. Support: It is the resistance to vertical forces of masti- Ans.
cation, occlusal forces and other forces applied in the Buccal shelf area
direction towards the denture-bearing area. It is the supporting structure of mandible.
v. Aesthetics: It is the most vital objective. It is governed by Boundaries
thickness of denture flanges. Thick flanges are preferred to Anteriorly: Buccal frenum.
give required mouth fullness in long-term edentulous pa- Posteriorly: Retromolar pad.
tients. Impression should accurately reproduce the width and Medially: Crest of the ridge.
the height of entire sulcus for proper fabrication of flanges. Laterally: External oblique line.
Inferior part of buccinator is attached to this area,
SHORT NOTES: but as the fibres run horizontally, it does not inter-
fere with denture.
Q.1. Preprosthetic surgery. Histology
Ans. Mucosa is less keratinized and loosely attached.
Function
Preprosthetic surgery It serves as the primary stress-bearing area, because
Surgical procedures are designed to facilitate fabrication of a it is at right angles to vertical occlusal loads and is
prosthesis or to improve the prognosis of prosthodontic care. covered with dense smooth cortical bone.
Various preprosthetic surgical procedures are as follows:
Q.4. Incisive papilla.
A. Procedures to improve bony foundation:
i. Retained dentition. Ans.
ii. Removal of pathologic bony conditions. Incisive papilla
iii. Techniques to deal with mandibular alveolar excess. ● A small tissue projection located immediately be-
iv. Techniques to deal with excessive alveolar bone hind and between the central incisors in dentulous
resorption. mouths.
a. Techniques to reduce alveolar atrophy. ● Location varies in the edentulous mouth. It may be
b. Techniques to correct alveolar atrophy. located on the crest of the ridge after resorption has
v. Techniques to compensate for alveolar atrophy. occurred.
B. Procedures to improve soft tissue foundation. ● It covers the incisive foramen through which the
C. Procedures to improve ridge relationships. nasopalatine nerves and vessels pass.
D. Implants. Significance: It serves as relief area.
● Relief is provided in the final impression to pre-
Q.2. Mandibular stress-bearing areas.
vent pressure on the emerging nasopalatine nerves
Ans. and vessels. Denture pressure on the papilla can
cause paraesthesia, pain, burning sensation and
Mandibular stress-bearing areas
other vague complaints.
● Primary stress bearing area: Also called buccal shelf
area, because it is at right angles to vertical occlusal Q.5. Muscles of the soft palate.
loads and is covered with dense smooth cortical bone.
Ans.
It is supporting structure of mandible.
Boundaries Muscles of the soft palate
Anteriorly: Buccal frenum. i. Tensor palati (tensor veli palatini): it is thin, triangu-
Posteriorly: Retromolar pad. lar muscle.
Medially: Crest of the ridge. Functions:
Laterally: External oblique line. a. Tightens the soft palate, chiefly the anterior part.
b. Opens the auditory tube to equalize air pressure Q.7. Muscles of mastication and facial expression.
between the middle ear and the nasopharynx.
ii. Levator palati (levator veli palatini): It is a cylindri- Ans.
cal muscle that lies deep to the tensor veli palatine. Muscles of mastication and facial expression
Functions Following are the muscles of mastication:
a. Elevates soft palate and closes the pharyngeal i. Masseter – quadrilateral covers lateral surface of ramus
isthmus. of mandible.
b. Opens the auditory tube, like the tensor veli ● Nerve supply – masseteric nerve, a branch of anterior
palatini. division of mandibular nerve.
iii. Musculus uvulae ● Action.
It is the longitudinal strip placed on one side of the ● It elevates mandible to close the mouth during
median plane, within the palatine aponeurosis, biting.
which pulls up the uvula. ii. Temporalis – fan-shaped muscle, which fills the tempo-
iv. Palatoglossus ral fossa.
It pulls up the root of the tongue, approximates the ● Nerve supply – two deep temporal branches of the
palatoglossal arches, and thus closes the oropharyn- anterior division of the mandibular nerve.
geal isthmus. ● Actions
v. Palatopharyngeous ● It elevates mandible.
It pulls up the wall of pharynx and shortens it during ● Posterior fibre retracts the protruded mandible.
swallowing. ● It helps in side to side grinding movement.
Q.6. Alveolingual sulcus. iii. Lateral pterygoid – short, conical, and has upper and
lower heads.
Ans. ● Nerve supply – a branch from anterior division of
the mandibular nerve.

Alveolingual sulcus ● Actions
● Alveolingual sulcus is also called as lingual vesti-
● It depresses the mandible to open the mouth with
bule-limiting structure of mandible. suprahyoid muscle.
● It extends from lingual frenum anteriorly to retromy-
● It helps in the protrusion of mandible.
lohyoid curtain posteriorly. ● It helps in side to side grinding movement.
● It is divided into three parts:
iv. Medial pterygoid – quadilateral, has a small superficial
i. Anterior part and large deep head.
● It extends from lingual frenum to premylohy-
● Nerve supply – nerve to medial pterygoid, branch of
oid fossa. the main trunk of the mandibular nerve.
● It is the shallowest portion of the lingual flange.
● Actions
ii. Middle part ● It elevates mandible.
● It extends from premylohyoid fossa to distal
● It helps in the protrusion of mandible.
end of mylohyoid ridge. ● It helps in side to side grinding movement.
● It slopes towards the tongue.
● It allows room for action of mylohyiod muscle. Q.8. Balanced occlusion.

● Increased flange height as it can be extended
Ans.
beyond the muscle attachment.
● It allows floor of mouth to raise without dis- Balanced occlusion
placing the denture. Balanced occlusion is defined as ‘the simultaneous con-
● It provides room for tongue rest on flange tacting of the maxillary and mandibular teeth on the
leading to retention. right and left and in the posterior and anterior occlusal
● It avoids impingement of sublingual gland areas in centric and eccentric positions, developed to
and submaxillary duct. lessen or limit tipping or rotating of the denture bases in
iii. Posterior region: Retromylohyoid fossa region relation to the supporting structures’ (GPT).
● It extends from the end of mylohyoid ridge to Characteristic requirements of balanced occlusion
retromylohyoid curtain. ● All the teeth of the working side (central incisor
● Posterior region slopes away from tongue and to second molar) should glide evenly against the
towards the ridge. opposing teeth.
● It guides the tongue on top of the lingual ● No single tooth should produce any interference
flange. or disocclusion of the other teeth.
● There should be contacts in the balancing side, Pterygomandibular raphe enters it from back inside
●
but they should not interfere with the smooth glid- corner.
ing movements of the working side. Significance
● There should be simultaneous contact during pro- ● It forms part of valve seal area.
trusion. ● It provides border seal.
Importance of balanced occlusion ● Extra pressure on the pad to be avoided to not to
It is one of the most important factors that affect injure the muscle fibres.
denture stability. Its absence will result in leverage of
denture during mandibular movement. Q.10. Anterior reference points.
Factors affecting balanced occlusion Ans.
● Inclination of the condylar path or condylar
guidance. Anterior reference points

● Incisal guidance. ● Anterior reference points are a terminology used in
● Orientation of the plane of occlusion or occlusal facebow transfer.

plane. ● It determines the level at which the casts are
● Cuspal angulation. mounted between the upper and lower members of

● Compensating curves. the articulator using facebow or it determines at
what level in the articulator, the occlusal plane is
Q.9. Retromolar pad. placed.
Some commonly used anterior reference points are as
Ans.
follows:
Retromolar pad I. Orbitale: It is located by Hanau facebow using
It is triangular pad of soft tissue found at the distal end orbital pointer.
of mandibular ridge. II. Orbitale minus 7 mm: It represents the Frankfort
It is covered with nonkeratinized epithelium. plane.
Contents III. Nasion: It is used with quick mount facebow
● Glandular tissue. (Whip mix).
● Temporalis tendon. IV. Ala of nose: It represents the camper’s plane.
● Buccinator fibres enter it from buccal side. V. 43 mm superior from the lower border of upper
● Superior pharyngeal constrictor enters it from lip. It is located by Denar facebow using Denar
lingual side. reference plane locator.
Topic 4
Primary Impression in Complete Dentures and Lab
Procedures Prior to Master Impression Making
LONG ESSAYS:
1. Give the importance of impression techniques used for different patient treatment planning and postinsertion
instructions to the patient.
2. Discuss the material and methods for recording a complete denture impression.
3. Explain how different groups of muscles causes dislodgement of maxillary and mandibular complete dentures
and how muscular power can be harnessed for further retention of complete denture.
4. Describe any one method of primary impression making for maxillary complete denture by stating step-by-step
precautions and causes of error in the impression. [Same as LE Q.1]
5. Define the term impression in complete dentures prosthodontics. Classify impression techniques and explain the
objectives and theories of impression making. [Same as LE Q.1]
6. What is mucostatic impression? Give in detail the mucostatic impression procedure with special reference to its
underlying principle. Describe its merits. [Same as LE Q.1]
7. Define impression. Discuss various theories of impression making and describe your method of impression
making. [Same as LE Q.1]
8. Define impression and discuss in detail about the most widely accepted technique of making impression in
complete denture prosthodontics. Describe the impression procedure you will follow for patient with upper
anterior movable flabby tissue. [Same as LE Q.1]
9. Various theories of impression making of edentulous arches. [Same as LE Q.1]
10. Selective pressure impression technique or selective compression theory. [Same as LE Q.1]
11. Controlled pressure theory of impression making. [Same as LE Q.1]
SHORT ESSAYS:
1 . Influence of saliva on retention and stability.
2. Impression technique for a flabby ridge. [Ref LE Q.1]
3. Classify methods of impression making in complete denture. [Ref LE Q.1]
4. Discuss various philosophies of impression making in complete denture. [Ref LE Q.1]
5. Impression compound.
6. Alginate impression materials.
7. Saliva and its role in complete dentures. [Same as SE Q.1]
8. Pressure theory of impression making. [Same as SE Q.3]
SHORT NOTES:
1 . What are the advantages of zinc oxide eugenol impression paste? State its composition.
2. What is functional impression and state the technique for making the same?
3. Selective pressure impression technique in patient with complete dentures. [Ref LE Q.1]
4. Syneresis and imbibition.
5. Disadvantages of condensation silicone.
6. Mucocompressive impression technique. [Same as SN Q.2]
7. Selective pressure impression. [Same as SN Q.3]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Give the importance of impression techniques used ● Placing more load on stress-bearing areas
for different patient treatment planning and postinser- and less load on nonstress-bearing areas.
tion instructions to the patient. ii. Retention: It is the ability of denture to withstand
displacement against its path of insertion.
Ans. iii. Stability: It is the ability of denture to resist
horizontal forces.
Impression iv. Support: It is the resistance to vertical forces of
A negative likeness or copy in reverse of the surface of mastication, occlusal forces and other forces applied
an object, an imprint of the teeth and adjacent structures in the direction towards the denture-bearing area.
for use in dentistry (GPT8). v. Aesthetics: It is the most vital objective. It is gov-
Objectives of impression making erned by thickness of denture flanges. Thick
Five objectives of impression making in complete den- flanges are preferred to give required mouth full-
ture prosthodontics as stated by Carl O. Boucher (1944) ness in long-term edentulous patients. Impression
are as follows: should accurately reproduce the width and height
i. Preservation of alveolar ridge: Muller De Van of entire sulcus for proper fabrication of flanges.
(1952) stated ‘the preservation of that which re-
[SE Q.3]
mains is of utmost importance and not the meticu-
lous replacement of that which has been lost’. {Classification of impression techniques
This can be achieved by A. Based on the theories of impression
● Using techniques that reduce alveolar re- ● Pressure theory.
sorption, i.e. wider coverage so that force ● Minimal pressure theory.
per unit area is less. ● Selective pressure theory.
B. Based on the position of the mouth while making the B. Minimal pressure theory
impression Synonyms: Mucostatic or nonpressure or passive technique.
● Open mouth. ● The minimal pressure technique was based on the
● Closed mouth. principle of mucostatics (Page, 1946).
C. Based on the method of manipulation for border moulding ● According to this principle, interfacial surface
● Hand manipulation. tension was the only significant way of retaining
● Functional movements.} complete dentures.
● Retention is achieved through accurate tissue adapta-
[SE Q.4] tion. Accordingly, the impression should cover only
{Theories of impression those areas of the denture foundation, where the mu-
The various theories are as follows: cosa is firmly attached.
● Thus, dentures made with this technique have
A. Pressure theory.
B. Minimal pressure theory. shorter flanges.
C. Selective pressure theory. According to Pascal’s law, if pressure is applied to
The selective pressure theory is the most widely followed. anyone part of a confined fluid, it is transmitted
equally to all parts. Page contended that since tis-
A. Pressure theory sues contain 80% or more of water and are con-
Synonyms: Mucocompressive or definite pressure. fined by the denture, they behave according to
It was proposed on the assumption that tissues re- Pascal’s law, thus assuming good rigidity.
corded under functional pressure (as during mastica- Advantages
tion) provided better support and retention for the ● High regard for tissue health and preservation.
denture and for this, a heavy-bodied material such as Disadvantages
impression compound is used. A preliminary impres- A. Most of the disadvantages stem from the use of
sion with compound is made. shorter flanges.
Technique introduced by Greene is as follows: B. The shorter flanges prevent the wider distribu-
● A custom tray is fabricated with its periphery tion of masticatory stresses.
short by 1/8 inch. C. With reduced coverage, the possibility of get-
● A second impression is made in this tray using ting greater retention, including the retaining
compound. potential of surrounding musculature is lost.
● Bite rims with uniform occlusal surfaces are D. The lack of border moulding reduces effective
then made. peripheral seal, thereby further reducing retention.
● Areas to be relieved (e.g. median palatal raphe) E. The lack of border seal also permits food to
are softened and the impression is again in- slip beneath the denture.
serted in the mouth and is held under biting F. The short denture borders are readily accessi-
pressure for 1 or 2 min. ble to the tongue which might provoke some
● The borders are moulded by asking the patient irritation.
to perform functional movements like whistling G. The shorter flanges may reduce support for the
and smiling. face which can affect aesthetics.
Advantages H. The shorter flange would mean less lateral
● Better retention and support during occlusal stability.
functions like mastication. I. Patients with poor residual ridges and reduced
Disadvantages areas of attached gingiva were difficult to treat.
● Excess pressure could lead to increased alveo- Technique
lar bone resorption eventually resulting in ● A compound impression is made.
loose dentures. ● A baseplate wax space is adapted on the result-
● Excess pressure was applied to the peripheral tis- ing cast according to the outline of the denture.
sues and the palate which was not well suited to ● A special tray is adapted over the wax spacer.
receive pressure resulting in transient ischaemia. ● The spacer is removed and an impression made
● Dentures fit well during mastication, but tend with a free-flowing material with as little pres-
to rebound when the tissue resume their nor- sure as possible.
mal resting state. ● Escape holes may be made for relief.
● The resorption eventually results in loose dentures. Many of Page’s contentions have now been
● Pressure on sharp spiny ridges or other bony questioned and his techniques based on this
areas often results in pain.} theory have fallen out of favour.
away and escape holes are made. A wash impres-

{SN Q.3}
sion is then made with the light-bodied material.
C. Selective pressure theory ● In technique given by Zafrulla Khan, a custom
Advocated by Boucher, this technique combines the tray is constructed with a window cut in the area
principles of both pressure and minimal pressure of the mobile tissues. Two impression materials
techniques. This theory is based on a thorough un- are used. The first material is used to record the
derstanding of the anatomy and physiology of basal areas covered by the tray. The mobile tissues vis-
seat and surrounding areas. ible through open window area are recorded with
Boucher divided the basal seat area into different free-flowing impression plaster or zinc oxide
zones, according to their eugenol.}
● Capacity to withstand masticatory loads with- Postinsertion instructions to the patient
out undergoing resorption (primary stress- i. Insertion and removal of prosthesis
bearing area). ● Patient is taught to insert and remove the den-
● Other areas were to be recorded at rest (sec- ture repeatedly.

ondary stress-bearing area). ● Prosthesis should be inserted along the path
● While other areas could be relieved (relief areas). of insertion.

● He also advocated maximum extension within ● If unilateral undercut present, then patient is
the comfort and functional limits of the sur- taught to insert the denture into undercut first,
rounding muscles and tissue. and then rotate the prosthesis into its final
Advantages position.
The technique considers the physiologic functions ● If the denture is very retentive and difficult to
of the tissues of the basal seat, and therefore remove, then patient is asked to blow with lips
appears more sound and appealing. closed to break the peripheral seal and remove
Disadvantages the denture.
A. Some feel that it is impossible to record areas ii. Prosthesis maintenance
with varying pressure. Denture should be cleaned using a denture brush
B. Since some areas are still recorded under func- and toothpaste/soap water (or any cleansing
tional load, the denture still faces the potential agent) as follows:
danger of rebounding and loosing retention. i. Chemical cleansers: Dilute solutions of
Impression techniques based on the selective pressure chlorhexidine, sodium perborate or nystatin
technique are most popular even today. can be used to store the dentures. Mineral
acids should not be used, as it corrodes the
metallic part.
Impression technique for upper anterior movable ii. Ultrasonic cleaners: It is a sonic cleaner in
flabby ridges which bubbles (which help to clear away
● The upper anterior movable flabby tissue presents the food particles) are bombarded against
a special problem. the denture.
iii. Prosthesis nightwear
[SE Q.2]
● Patient is advised not to wear the denture at
● {The hypermobile tissues should be recorded with- night and store it in water or any dilute me-
out distortion. dicinal solution.
Various techniques available to achieve this are as ● This is done to provide rest to mucosa to im-
follows: prove the blood supply and prevent mucosal
● A primary impression is made with alginate and a degeneration and bone resorption.
special tray is constructed with relief wax placed Nightwear is allowed in the following condi-
over the mobile tissues. Border moulding is car- tions:
ried out and the final impression is made after ● Bruxism patients where damage to oral
removing the wax spacer using a free-flowing tissues is more, if denture is not worn at
material. Escape holes are placed in the hypermo- night.
bile area of the tray. ● In cases of maxillary complete denture
● In one technique given by Hobkirk, the impres- and mandibular partial denture.
sion is made with heavy-bodied silicone in a iv. Periodic recall
border moulded special tray. The heavy-bodied ● Regular recall to check for proper denture
material overlying the hypermobile tissue is cut extension and occlusion.
● Patient is recalled after 24 h of insertion, to II. Alginate

correct occlusal disharmony and to check for Alginate has been used as both preliminary impression
immediate tissue reaction. material (when used in a stock tray), as well as final
● Then patient is called after 1 week to check impression material (when used in a custom tray). It
for tissue reaction and his/her comfort en- records good detail, but is affected by saliva, and so the
quiry done and problems corrected. mouth should be relatively dry. It is not very stable and
● Then patient is recalled after 3–6 months to so must be cast immediately. It is not correctable easily
determine tissue reaction and to see the but is easily remade. Since it is elastic, it is well suited
amount of residual ridge resorption. for ridges with severe undercuts.
● Postinsertion instructions should be reinforced Final impression materials
during recall appointments. The final impression material should be accurate as well
● In case of any tissue reactions like ulcers and as dimensionally stable.
soreness the patient is advised to stop wearing I. Alginate
the prosthesis and report immediately to the Alginate when used in conjunction with a custom
dentist. tray makes a final impression material. It does not
● Yearly recall visit to check the need for relin- adhere to the tray and must be retained with an
ing/rebasing. adhesive.
II. Rubber base
Q.2. Discuss the material and methods for recording a
Rubber-based materials record fine details and are
complete denture impression.
very stable. Being elastic, it is a perfect material for
Ans. recording undercuts. An adhesive is needed to hold
it to the tray. It is generally ‘water-phobic’ (water-
Complete denture impression hating) and so, the areas to be recorded must be
A thorough understanding of the material’s properties absolutely dry.
and manipulation is vital to the success of the impres- III. Zinc oxide eugenol
sion procedure. Zinc oxide eugenol paste is probably the most
Classification popular complete denture impression material and
Based on elasticity has been in use for a long time. It flows well and
● Rigid – like zinc oxide eugenol impression paste, records fine details. It is rigid and inelastic when
impression compound, and impression plaster. set and is therefore not particularly well suited
● Elastic – like alginate and elastomeric impression when severe undercuts are present. The mouth
materials. should be dry (but not desiccated) before the im-
Based on its prosthodontic use pression, as it is affected by water and thick saliva.
● Preliminary impression materials. Some patients complain of a burning sensation and
● Final impression materials. tissue irritation. This material adheres well to the
Preliminary impression materials tray and so tray adhesives are not required.
I. Modelling compound IV. Tissue conditioners
It is available in three forms: This material is used to condition the tissue as well
● Impression compound. as make what is known as ‘functional impressions’.
● Tray compound. The old denture itself is used as a final impression
● Stick compound. tray (see functional impression technique).
Impression compound is a good material for a pre- V. Impression plaster
liminary impression. It is easily correctable, can be Impression plaster was one of the earliest impression
border moulded, and is not influenced by saliva. It material used in dentistry. It was used for the minimal
can also be used as an impression tray, as it can be pressure technique, because it flows readily and re-
separated easily from the stock tray. It can also be cords fine details. It absorbs saliva and is therefore not
scraped easily (where relief is needed). Since it can- affected much by saliva. Because of its setting expan-
not record fine details, it is not suitable as a final sion, it is most accurate in thin sections and so is fa-
impression material. It is very viscous and can there- voured as a wash impression. It is not suitable for se-
fore compress or displace tissues. verely undercut ridges because of its rigidity. In the
Tray compound is used to make a custom tray di- old days, this problem was solved by breaking the
rectly in the mouth. impression and then reassembling it. Separating me-
Stick compounds are available in different colours dium is applied before the cast is poured. Currently, it
and are used to record the border seal areas (border is not as commonly used for impressions as before
moulding). because of the availability of better alternatives.
VI. Waxes located within the neutral zone. Placement of the teeth
Waxes which flow at mouth temperature are some- outside this zone, either buccally or lingually, can cause
times used for final impressions. They exert some the cheek or the tongue to dislodge the denture.
amount of pressure and too fine a detail cannot be ii. Shape of denture borders and denture flange: Denture
expected. A more common use for waxes is to cor- base should be shaped, such as:
rect deficiencies in final impressions made with a. To minimize interference with the functioning of
other materials such as plaster or eugenol. Another surrounding musculature (follow proper border
use is to make impressions for distal extension par- moulding technique).
tial dentures in the ‘altered cast technique’. Be- b. To utilize the surrounding musculature to provide a
cause, it is susceptible to thermal change, it must be positive seating
poured immediately. ● Buccal flanges are contoured to accommodate
the buccinators.
Q.3. Explain how different groups of muscles causes
● Lingual flange is designed to guide the tongue to
dislodgement of maxillary and mandibular complete
rest over the flange and permit any horizontal
dentures and how muscular power can be harnessed for
forces generated against the denture to be trans-
further retention of complete denture.
mitted as seating forces.
Ans. iii. Border moulding: It is also known as muscle trimming.
It keeps the denture border in harmony with the func-
The surrounding musculatures which effect denture reten- tional limits of the peripheral tissues, muscles and other
tion are as follows: structures.
Cheek muscles: The muscles of the cheek (buccinator)
Q.4. Describe any one method of primary impression
can cause dislodgment of the denture, if the teeth are placed
making for maxillary complete denture by stating step-
too far buccally, or if the flanges are overextended in the
by-step precautions and causes of error in the impression.
buccal sulcus, or if the denture base is not contoured well.
Lips: The lips can unseat a denture if the teeth are Ans.
placed too far forward. [Same as LE Q.1]
Modiolus: The modiolus or tendinous node is located at
the corner of the mouth and is formed by the intersection of Q.5. Define the term impression in complete dentures
several muscles of the cheeks and lips. The modiolus can prosthodontics. Classify impression techniques and ex-
cause unseating of the denture in the premolar region. plain the objectives and theories of impression making.
Tongue: The tongue is a very strong and active organ. If Ans.
the teeth are placed too far lingually, then it can crowd or
interfere with the activity of the tongue. The tongue can [Same as LE Q.1]
also be trained to improve seating of the denture. Q.6. What is mucostatic impression? Give in detail the
Floor of the mouth: The floor of the mouth is a rela- mucostatic impression procedure with special reference
tively mobile and unstable area. The act of swallowing to its underlying principle. Describe its merits.
raises and tenses the muscles of the floor of the mouth. The
activity of the muscles of the floor of the mouth can cause Ans.
instability of the mandibular denture. [Same as LE Q.1]
Soft palate: The soft palate moves considerably during
various functions. The soft palate can cause unseating of Q.7. Define impression. Discuss various theories of im-
the maxillary denture, if the posterior border is overexpression making and describe your method of impres-
tended or over post-dammed. sion making.
Masseter: The tensing of the masseter muscle (clench- Ans.
ing the teeth) can affect the distobuccal region of the upper
[Same as LE Q.1]
and lower dentures leading to instability.
Steps to be followed to harness the muscular power to Q.8. Define impression and discuss in detail about the
increase retention of denture: most widely accepted technique of making an impres-
i. Neutral zone: In order to understand the effect of the sion in complete denture prosthodontics. Describe the
surrounding musculature, one must understand the neu- impression procedure you will follow for a patient with
tral zone. It is defined as the potential space between the upper anterior movable flabby tissue.
lips and cheeks on one side and the tongue on the other;
Ans.
that area or position, where the forces between the
tongue and cheeks or lips are equal. The teeth should be [Same as LE Q.1]
Q.9. Various theories of impression making of edentu- Q.3. Classify methods of impression making in complete
lous arches. denture.
Ans. Ans.
Q.10. Selective pressure impression technique or selec- Q.4. Discuss various philosophies of impression making
tive compression theory. in complete denture.
Ans. Ans.
Q.11. Controlled pressure theory of impression making. Q.5. Impression compound.
Ans. Ans.
[Same as LE Q.1] Impression compound
● Impression compound is a good material for a pre-
SHORT ESSAYS: liminary impression.

● It is supplied in the form of sheets (brown in colour).
Q.1. Influence of saliva on retention and stability. Composition

● Natural/synthetic resin: 40% – for thermoplastic-
Ans. ity, flow and cohesion.
Saliva and its influence on retention and stability ● Waxes (bees/carnauba): 7% – thermoplasticity,
Saliva is an important factor in denture retention as well characterizes softening temperature and produces
as in the health of the tissues. The amount (rate of secre- smooth surface.
tion) and consistency of the saliva is noted. ● Stearic acid, shellac and gutta-percha: 3% – provides
Consistency can be as follows: plasticity and workability.

● Thin serous: This saliva is more favourable for ● Diatomaceous earth, French chalk and talc: 50% –
denture retention. filler, increases strength, reduces flow at mouth

● Thick mucus: The thick ropy consistency is dif- temperature and reduces plasticity.
ficult to work with and tends to displace the ● Rouge (iron oxide): It is used in trace amounts.
denture. Acts as a colour pigment to produce characteristic

● Mixed: Contains equal quantities of both kinds. red colour.
Amount Advantages
The salivary flow should neither be excessive nor ● It is easily correctable, can be border moulded,
less. The flow may be and is not influenced by saliva.

Normal: Ideal for denture retention. ● It can also be used as an impression tray, as it can
Excessive: Some patients are very sensitive. A be separated easily from the stock tray.
dentist conducting dental procedures on a patient ● It can also be scraped easily (where relief is
can stimulate copious amounts of salivary flow. needed).

Excessive salivary flow makes denture construc- Disadvantages
tion difficult and messy. ● It cannot record fine details and not suitable as a
Reduced: Reduced flow results in (dry mouth or final impression material.

xerostomia) retention of the denture. There is in- ● It is very viscous and can therefore, compress or
creased potential for soreness of the tissues. It can displace tissues.

also result in a coated tongue. Reduced flow is Q.6. Alginate impression materials.
seen with some drugs, certain syndromes and af-
ter radiation therapy. Salivary substitutes or oral Ans.
moisturizers may be prescribed.
Alginate impression materials
Q.2. Impression technique for a flabby ridge. ● Alginate is used both as preliminary impression mate-
rial (when used with stock tray) and a final impression

Ans.
material (when used with custom tray), because it pro-
[Ref LE Q.1] duces accurate and dimensionally stable impression.
● It is used in conjunction with a custom tray to make a Q.2. What is functional impression and state the technique
final impression material. It does not adhere to the tray for making the same?
and must be retained with an adhesive.
Ans.
● It is an irreversible hydrocolloid which sets by a chemi-
cal reaction. Pressure theory

It shows phenomena of: ● It is also known as mucocompressive or definite
● Syneresis: It is a process of losing water by the pressure theory.
impression when placed in dry atmosphere. ● It was introduced by Greene.
● Imbibition: It is a process of absorbing water by the ● It was proposed on the assumption that tissues re-
impression when placed in water. corded under functional pressure (as during mastica-
These effects can be minimized by: tion) provided better support and retention for the
● Keeping the impression in 100% relative humidity or denture and for this, a heavy-bodied material such as
in a damp cloth. impression compound is used. A preliminary impres-
● Pouring the cast immediately after taking the sion with compound is made.
impression. Advantages
● Better retention and support during occlusal func-
Q.7. Saliva and its role in complete dentures.
tions like mastication.
Ans. Disadvantages
● Excess pressure could lead to increased alveolar
[Same as SE Q.1]
bone resorption eventually resulting in loose
Q.8. Pressure theory of impression making. dentures.
● Excess pressure was applied to the peripheral
Ans. tissues and the palate which was not well suited
[Same as SE Q.3] to receive pressure resulted in transient isch-
aemia.
● Dentures fit well during mastication, but tend to
SHORT NOTES: rebound when the tissue resume their normal rest-
ing state.
Q.1. What are the advantages of zinc oxide eugenol ● The resorption eventually results in loose
impression paste? State its composition. dentures.
Ans. ● Pressure on sharp spiny ridges or other bony areas
often resulted in pain.

Zinc oxide eugenol
Zinc oxide eugenol is the most commonly used final Q.3. Selective pressure impression technique in patient
impression material. with complete dentures.
Advantages of zinc oxide eugenol paste as follows:
Ans.
● Dimensionally stable.
● Flows well and produce excellent surface details [Ref LE Q.1]

in the impression.
● Inexpensive and hygienic to use. Q.4. Syneresis and imbibition.
● Material adheres well to the tray and so tray adhe-
Ans.
sives are not required.
Composition Syneresis and imbibition
Base paste Hydrocolloids (agar and alginate) show phenomena of:
i. Zinc oxide – 87%. i. Syneresis: It is a process of losing water by the impres-
ii. Natural/synthetic oils – 13%. sion when placed in dry atmosphere.
Reactor paste ii. Imbibition: It is a process of absorbing water by the
i. Eugenol – 12%. impression when placed in water.
ii. Gum – 50%. iii. These effects can be minimized by:
iii. Kaolin talc – 20%. iv. Keeping the impression in 100% relative humidity or in
iv. Resinous balsam – 10%. a damp cloth.
v. Kaolin – 3%. v. Pouring the cast immediately after taking the
vi. Calcium or magnesium chloride – 5%. impression.
Q.5. Disadvantages of condensation silicone. Q.6. Mucocompressive impression technique.

Ans. Ans.
Disadvantages of condensation silicone [Same as SN Q.2]
● Hydrophobic, so requires a dry field of operation.
● Liquid component of the paste may be toxic. Q.7. Selective pressure impression.
● Dimensionally unstable.
Ans.
● More expensive.
● Putty-wash method is technique sensitive. [Same as SN Q.3]
Topic 5
Secondary Impression in Complete Dentures
and Lab Procedures Prior to Jaw Relation
LONG ESSAYS:
1. What is posterior palatal seal and give its significance? Describe one of the methods of projecting posterior
palatal seal in complete denture patients.
2. What is posterior palatal seal? Describe how it is obtained. [Same as LE Q.1]
3. Mention the importance of posterior palatal seal in complete denture? Describe in detail the anatomic location
and methods of recording the same. [Same as LE Q.1]
4. Discuss in detail posterior palatal seal. [Same as LE Q.1]
SHORT ESSAYS:
1 . Posterior palatal seal. [Ref LE Q.1]
2. Pascal’s law.
3. Border moulding in mandible.
4. Rubber base impression materials.
5. Define and explain posterior palatal seal with diagram. [Same as SE Q.1]
6. Write about the significance of posterior palatal seal with diagram. [Same as SE Q.1]
7. Write briefly about minimal pressure technique. [Same as SE Q.2]
SHORT NOTES:
1. Materials used for master impression.
2. Posterior palatal seal area.
3. Disinfecting the impression.
4. Border moulding. [Ref SE Q.3]
5. Fabrication of custom tray for completely edentulous arches.
6. Final impression material for complete dentures. [Same as SN Q.1]
7. Materials which can be used for wash impressions in final impression for complete dentures. [Same as SN Q.1]
8. Significance of posterior palatal seal. Enumerate techniques used to develop the same. [Same as SN Q.2]
9. Enumerate the functions of posterior palatal seal. [Same as SN Q.2]
10. Disinfection of impression. [Same as SN Q.3]
11. What is the purpose of border moulding? [Same as SN Q.4]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. What is posterior palatal seal and give its signifi- Location method
cance? Describe one of the methods of projecting poste- a. Valsalva manner: Here, both nostrils are held
rior palatal seal in complete denture patients. firmly when the patient gently blows through
Ans. the nose which places the soft palate down-
wards at its junction with hard palate.
[SE Q.1] b. Patient is asked to ‘ah’ with short vigorous bursts.
{Posterior palatal seal Posterior vibrating line
● It is an imaginary line at the junction of apo-
● The posterior palatal seal is the seal area at the poste-
rior border of a maxillary removable prosthesis (GPT). neurosis of tensor veli palatini and the muscu-
● It is the soft tissue area at or beyond the junction of
lar portion of soft palate.
● It represents the junction between slightly
hard and soft tissues on which pressure, within
physiological limits, can be applied by denture to aid movable part of soft palate and part of soft pal-
in its retention (GPT). ate that is markedly displaced during function.
● Also called postdam or postpalatal seal area.
Location method
● Patient is asked to say ‘ah’ in a normal, unex-
Functions/significance of posterior palatal seal area
a. It aids in denture retention. aggerated fashion.
b. Prevents food accumulation beneath the maxillary Methods to record posterior palatal seal
denture. A. Arbitrary techniques
c. Maintains contact with moving soft palate and thus i. Conventional technique by Winkler
reduces patient’s awareness and gag reflex. Recording stage: It is at the start of jaw relations.
d. Compensation for curing shrinkage. Method
● Firstly, hamular notch is located using T-burnisher/
e. Reduces tongue irritation.
f. When seal is placed in impression tray using com- mouth mirror and marked with indelible pencil.
● Posterior vibrating line is located by above
pound, then it:
● Prevents impression material form flowing down
method and marked with indelible pencil.
● The temporary denture base is pressed into
the throat.
● Helps in tray positioning.
place in mouth and then on the cast to transfer
● Gives idea about denture retention.
the markings and base is shortened accordingly.
● Then anterior vibrating line is determined by
Parts of posterior palatal seal
a. Posterior palatal seal. method described above and transferred to cast
b. Pterygomaxillary seal. as done previously.
● It is placed in pterygomaxillary notch or hamu-
Kingsley scraper is used to score the cast as follows:
lar notch and located just behind the maxillary a. Deepest area on either side of midline which
tuberosity. are at a distance of one third in front of poste-
● It is located using a T-burnisher/mouth mirror
rior vibrating line, i.e. 1–1.5 mm deep.
instrument that is moved posteriorly until a b. Scraping tapers to feather edge as it ap-
soft depression is felt immediately beyond the proaches the anterior vibrating line.
maxillary tuberosity. Seal is then checked in the mouth, if gap is
Boundaries of posterior palatal seal there between temporary denture base and soft
● Anteriorly, anterior vibrating line.
tissue, then cast can be scrapped more.
● Posteriorly, posterior vibrating line.
ii. Boucher’s technique
● Laterally, pterygomaxillary notch.
Recording stage: It is done during jaw relations.
Anterior vibrating line Method
● Posterior vibrating line is located and transferred
● It is an imaginary line located at the junction of
attached tissues overlying the hard palate and to cast and temporary denture base reduced to this
the movable tissues of the immediately adja- line and then a V-shaped groove (1–1.5 mm deep
cent soft palate. and 1.5 mm wide) is scrapped anterior to this line.
● If the above markings are too high, area of red-
Shape
● Cupid’s bow due to projection of posterior
ness will be seen within 24 h on tissues, in
nasal spine. which case it can be relieved.
Advantage ● 30° downward flexion of head is made and

Narrow bead-like seal is obtained by this method greenstick compound is applied to seal area and
which is more effective as compared to broad seal procedure repeated.
which causes greater tissue displacement. ● Angular depression resembling curved Gothic
B. Physiological techniques arch is seen in compound.}
i. Fluid wax technique
Recording stage: It is done after making the final Q.2. What is posterior palatal seal? Describe how it is
impression. obtained.
Method: It is by using zinc oxide eugenol or plaster Ans.
impression.
● Both vibrating lines are marked in mouth and [Same as LE Q.1]
transferred to impression surface using indeli-
Q.3. Mention the importance of posterior palatal seal in
ble pencil.
complete denture? Describe in detail the anatomic loca-
● Waxes which flow at mouth temperature are
tion and methods of recording the same.
used.
a. Korrecta wax no. 4 (orange). Ans.
b. Iowa wax (white). [Same as LE Q.1]
c. H-L physiological paste.
d. Adaptol (green). Q.4. Discuss in detail posterior palatal seal.
● Molten wax is painted between two lines, al- Ans.
lowed to cool and pressed gently into place for
[Same as LE Q.1]
4–6 min 30° downward flexion of head is done
and side to side rotation is made to bring the soft
palate downward and forward. SHORT ESSAYS:
Glossy appearance of wax – indicates good tis-
Q.1. Posterior palatal seal.
sue contact.
Dull appearance – indicates poor tissue contact. Ans.
Wax should terminate in feather edge near an-
[Ref LE Q.1]
terior vibrating line. Excess wax is trimmed off.
Advantages Q.2. Pascal’s law.
● Compression of tissues within physiological limits.
Ans.
● More retentive trial base.
Disadvantages Pascal’s law

● Time-consuming. ● According to Pascal’s law, if pressure is applied to
● Material handling is difficult. any one part of confined fluid, then it is transmitted
ii. Stick compound technique equally to all parts.
Recording stage: It is during border moulding of ● It is applied in minimal pressure technique for making
special tray before final impression is made. impression in complete denture prosthodontics given
Method: Stick compound and acrylic special tray is by Page (1946) based on principle of mucostatics.
used. Minimal pressure technique
● It is softened and applied on the tray between ● It is also called mucostatic/nonpressure/passive tech-
anterior and posterior vibrating line and pressed nique.
gently into mouth. Once material hardens, ex- ● According to principle of mucostatics, interfacial surface
cess material beyond anterior vibrating line is tension is the only way to retain complete denture which
trimmed off and tapered. is achieved through accurate tissue adaptation. Impres-
● Region is flamed lightly and process repeated. sion should cover areas of firmly attached mucosa only.
● Good contact indicated by dull appearance of ● Dentures made with this technique have shorter
compound. flanges.
iii. Extended palatal technique by Silverman in 1971. Advantages
● Denture border is extended 8.2 mm beyond the ● More tissue health and preservation.
anterior vibrating line. Disadvantages
Method a. Short flanges inhibit wider distribution of masti-
● Following border moulding, tray posterior bor- catory forces.
der is extended by adding black compound. b. Less retention due to less coverage area.
c. No border moulding, no peripheral seal and less his jaws against downward pressure from the opera-
retention. tor’s thumb in molar region.
d. Due to absence of border seal, food slips beneath e. Lingual flange: It is moulded by functional move-
the denture. ments of tongue. Patient training is important.
e. Short denture borders are readily available to f. Lingual frenum and sublingual flange (premolar to
tongue causing its irritation. premolar):
f. Less lateral stability. ● Patient is asked to protrude the tongue to deter-
g. Poor facial support due to shorter flanges and mine the height of flange anteriorly. Then, com-
hence, less aesthetic. pound is reheated and patient is asked to push his
Technique tongue forcefully against the front part of palate
● Compound impression is made and baseplate wax to develop thickness of flange.
adapted to cast according to denture outline. g. Mylohyoid portion of lingual flange (premolar to
● Special tray is made over wax spacer. molar region):
● Spacer is removed and impression made with ● Stick compound is placed between premylohyoid
free-flowing material with as little pressure as eminence and postmylohyoid eminence and patient
possible and escape holes are made for relief. is asked to protrude the tongue which determines
the flange length in this region.
Q.3. Border moulding in mandible.
● Tongue is made to contact left cheek to mould
Ans. right lingual flange and vice versa.

● Flange here, should slope towards the tongue to
{SN Q.4} allow mylohyoid muscle action which raises the

floor of mouth, and distolingual portion curves
Border moulding towards the ramus (when viewed through im-
● Border moulding is defined as the shaping of the
pression surface) to complete the characteristic
border areas of an impression material by func- S-curve.
tional or manual manipulation of the soft tissue h. Retromylohyoid portion:
adjacent to the borders to duplicate the contour It limits the distal most part of lingual flange which
and size of the vestibule. It determines the exten- rises towards the retromolar pad.
sion of a prosthesis by using tissue function or ● Patient is asked to open the mouth and pro-
manual manipulation of the tissues to shape the trude the tongue which activates the superior
border areas of an impression material (GPT8). constrictor.
Importance of border moulding ● Next, jaws are closed against resistance to
● It shapes the impression borders and allows the
operator’s thumb which activates the medial
muscles to function in harmony with denture in pterygoid muscle and limits the space in this
absence of which muscles can destabilize the den- region.
ture and also, it improves the border seal. ● Patient is asked to wipe the lower lip and con-
tact the opposite right and left buccal mucosa
Materials used for border moulding with tongue tip.
a. Modelling compound sticks come in colours grey
and green, and are most popular. Q.4. Rubber base impression materials.
b. Autopolymerizing acrylic resins. Ans.
c. Polyether impression paste.
d. Impression waxes. Rubber base impression materials
e. Periodontal pack. Rubber base is used as a final impression material.
Mandibular border moulding Advantages
a. Labial frenum and labial flange: The lower lip is a. Records fine details.
lifted outward, upward and inward. b. Very stable.
b. Buccal frenum: Cheek is lifted outward, upward, c. As it is elastic, it perfectly records undercuts.
inward and finally forward and backward. Disadvantages
c. Buccal flange (distal to frenum): Cheek is moved a. Acts as an adhesive required to hold the material
outward, upward and inward. to tray.
d. Masseteric notch: Recorded in distobuccal corner. b. It is a water-phobic material. So, areas to be
Compound is softened and patient is asked to close recorded should be absolutely dry.
Q.5. Define and explain posterior palatal seal with Posterior palatal seal area
diagram. ● It is the seal area at the posterior border of a maxil-
lary removable prosthesis (GPT).

Ans. ● It is the soft tissue area at or beyond the junction of
[Same as SE Q.1] hard and soft tissues on which pressure, within

physiological limits, can be applied by denture to aid
Q.6. Write about the significance of posterior palatal in its retention (GPT).
seal with diagram. ● Also called postdam or postpalatal seal area.
Functions/significance of posterior palatal seal area

Ans. ● Aids in denture retention.
● Prevents food accumulation beneath the maxillary

[Same as SE Q.1]
denture.
Q.7. Write briefly about minimal pressure technique. ● Maintains contact with moving soft palate and thus
reduces patient’s awareness and gag reflex.

Ans. ● Compensation for curing shrinkage.
● Reduces tongue irritation.

[Same as SE Q.2]
● When seal is placed in impression tray using com-
pound, it
SHORT NOTES: i. Prevents impression material form flowing down
the throat.
Q.1. Materials used for master impression.
ii. Helps in tray positioning.
Ans. iii. Gives idea about denture retention.
Methods to record posterior palatal seal
Materials used for master impression
a. Arbitrary techniques
Materials used for final impression should be accurate
i. Conventional technique by Winkler.
and dimensionally stable. Commonly used materials are as
ii. Boucher’s technique.
follows:
b. Physiological techniques
● Alginate: It should be retained mechanically to tray
i. Fluid wax technique.
using adhesive or making perforations in tray.
ii. Stick compound technique.
● Rubber base: It is elastic, records fine details and under-
iii. Extended palatal technique.
cuts, and is very stable. But, adhesive required to hold
the material to tray should be a water-phobic material. Q.3. Disinfecting the impression.
So, areas to be recorded should be absolutely dry.
● Zinc oxide eugenol: It is most popular, flows well, re- Ans.
cords fine details, adheres well to tray, but rigid and in- Disinfection of impression
elastic, not suitable for undercuts recording, material Both maxillary and mandibular impressions are rinsed
affected by water and saliva, so areas to be recorded in running water and disinfected using iodophor or 2%
should be absolutely dry. It causes burning sensation gluteraldehyde. Impression should be left undisturbed for
and tissue irritation in some patients. 10 min.
● Tissue conditioners: Old denture is used as final impres-
sion tray. Q.4. Border moulding.

● They are used to condition the tissue and make func-
Ans.
tional impression.
● Impression plaster: It was used earlier as an impression [Ref SE Q 3]
material, but not commonly used now.
Q.5. Fabrication of custom tray for completely edentu-
● Waxes: Flow at mouth temperature.
lous arches.
Used to correct deficiencies in final impression made
Ans.
with other materials and it does not itself recorded, as it
exerts pressure and fine details cannot be recorded. It is Custom tray for completely edentulous arches
susceptible to thermal change, so cast should be poured ● Custom tray is also called special tray or individual-
immediately. ized tray.
● It is used to make final impression.
Q.2. Posterior palatal seal area.
● It is fabricated on a primary cast made from primary
Ans. impression of the patient.
Materials used for its fabrication Q.8. Significance of posterior palatal seal. Enumerate
● Tray acrylic: It is the most stable and preferred mate- techniques used to develop the same.
rial. sprinkle on or dough technique
Ans.
● Vacuum formed baseplate.
● Shellac: There is high risk of warpage and low [Same as SN Q.2]

strength, so discontinued.
Q.9. Enumerate the functions of posterior palatal seal.
● Wax.
● Tray compound. Ans.

● Old denture.
[Same as SN Q.2]
Q.6. Final impression material for complete dentures.
Q.10. Disinfection of impression.
Ans.
Ans.
[Same as SN Q.1]
[Same as SN Q.3]
Q.7. Materials which can be used for wash impressions
Q.11. What is the purpose of border moulding?
in final impression for complete dentures.
Ans.
Ans.
[Same as SN Q.4]
[Same as SN Q.1]
Topic 6
Maxillomandibular Relations
LONG ESSAYS:
1 . What is orientation relation? Write in detail about recording of orientation relation in complete denture patient.
2. Classify jaw relation. Define centric relation. Explain its clinical significance. What are the methods of recording
the centric jaw relation?
3. Define physiological rest position of mandible. Give the importance of Silverman closest speaking space and
discuss the effects of increased and decreased vertical dimension in complete dentures.
4. What is a facebow? Discuss the importance of facebow transfer for an edentulous patient. [Same as LE Q.1]
5. What is facebow? Discuss the importance of same in complete dentures and partial removable prosthesis.
[Same as LE Q.1]
6. Describe and classify facebow? Mention the parts of facebow. Discuss the uses of facebow. [Same as LE Q.1]
7. Explain one in detail: (a) Note on eccentric jaw relation. (b) Add a note on difficulties encountered during
recording centric jaw relation. [Same as LE Q.2]
8. What are the different maxillomandibular relationships and discuss importance and different methods of
recording horizontal jaw relation. [Same as LE Q.2]
SHORT ESSAYS:
1 . Classification of jaw relations. [Ref LE Q.2]
2. Physiologic rest position of mandible and its significance. [Ref LE Q.3]
3. Write about orientation relation in complete denture.
4. Vertical jaw relationship. [Ref LE Q.3]
5. Facebow. [Ref LE Q.1 and LE Q.2]
6. Pre-extraction records for complete denture. [Ref LE Q.3]
7. Centric relation. [Ref LE Q.2]
8. Gothic arch tracing. [Ref LE Q.2]
9. Mention about training the patient to retrude mandible. [Ref LE Q.2]
1 0. Discuss the various jaw relation procedures in complete denture patients. [Same as SE Q.1]
11. Classify jaw relations. Discuss in detail the significance of jaw relations in complete denture construction. [Same as SE Q.1]
12. Define orientation relation. Write a note on its importance in complete denture. [Same as SE Q.3]
13. Orientation jaw relation. [Same as SE Q.3]
14. Plane of orientation. [Same as SE Q.3]
15. Methods of recording vertical jaw relations. [Same as SE Q.4]
16. Increased and decreased vertical dimension. [Same as SE Q.4]
17. Effect of incorrect vertical dimensions. [Same as SE Q.4]
18. Importance of pre-extraction records. [Same as SE Q.6]
19. Methods of recording centric jaw relation. [Same as SE Q.7]
20. Significance of recording centric relation. [Same as SE Q.7]
SHORT NOTES:
1. Describe the importance of marking the midline canine line and the high line during jaw relation.
2. Vertical jaw relation. [Ref LE Q.3]
3. State the consequences of increased vertical relation recording in complete denture. [Ref LE Q.3]
4. Freeway space. [Ref LE Q.3]
5. Enumerate the various methods of determining vertical relation of occlusion. [Ref LE Q.3]
6. Niswonger’s method of establishing vertical relation.
7. Define centric relation. Write in brief about different methods to record it.
8. Interocclusal clearance.
9. Physiological rest position of mandible. [Ref LE Q.3]
10. Closest speaking space. [Ref LE Q.3]
11. Hinge axis.
12. Perleche.
13. Beyron’s point.
14.
Freeway importance.
15.
Orientation jaw relation. [Ref SE Q.3]
16.
Importance of pre-extraction records.
17.
Needle’s chew-in technique. [Ref LE Q.2]
18.
Overjet and overbite.
19.
Occlusal rims for construction of complete dentures.
20.
Problems with reduced vertical dimension in complete dentures. [Same as SN Q.2]
21.
Increased vertical relation. [Same as SN Q.3]
22.
Enumerate characteristics of increased vertical relation in complete denture patient. [Same as SN Q.3]
23.
Effects of increased vertical dimension. [Same as SN Q.3]
24.
Interocclusal distance (IOD). [Same as SN Q.4]
25.
Centric jaw relation records. [Same as SN Q.7]
26.
Define centric relation. Write various methods for assisting the patient to retrude the mandible during centric
relation registration. [Same as SN Q.7]
27. Rest position of mandible. [Same as SN Q.9]
2 8. Significance of rest position of mandible. [Same as SN Q.9]
29. Silverman’s speaking space. [Same as SN Q.10]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. What is orientation relation? Write in detail about plane around an imaginary transverse axis passing
recording of orientation relation in complete denture through or near the condyles.
● Recording of orientation jaw relation is done using a
patient.
device called facebow.
Ans.
[SE Q.5]
Orientation relation and facebow
● It is the jaw relation when the mandible is kept in ● {Facebow is a caliper-like instrument used to record
posterior-most position. It can rotate in the sagittal the spatial relationship of the maxillary arch to some
anatomic reference point or points and then transfer scale is a rounded nylon earpiece which has a
this relationship to an articulator; it orients the dental central hole that connects to the auditory pin on
cast in the same relationship to the opening axis of the articulator.
the articulator. ● The external auditory meatus is located behind the
● The facebow is used to record the relationship of the actual hinge axis. The auditory pin is also located
jaws to the opening axis of the jaws and to orient the posterior to the opening axis of the articulator.
casts in this same relationship to the opening axis of ● In articulators that do not have an auditory
the articulator. pin, a condylar compensator is needed which

Indications for facebow use compensates for above by positioning the condy-
● When balanced occlusion is desired. lar inserts at a fixed distance behind the hinge
● When cusps form teeth are used. axis of the articulator.
● When interocclusal check records are used. Earpiece facebow has gained popularity because:
● For constructing accurate crowns and bridges. i. It is simple to use.
● In full mouth rehabilitation, when accurate occlusal ii. It does not require measurements or marks on
restorations are to be made. the face.
● When occlusal vertical dimension (OVD) is to be iii. It gives accuracy that is similar to other arbi-
changed during teeth setting. trary methods.
● For diagnostic mounting and treatment planning. Kinematic facebows
● In gnathological studies and treatment. ● They are also known as hingebow and adjustable axis
● For making occlusal corrections after denture facebow.

processing. ● They are used to locate and transfer the true hinge
Basic parts of a facebow axis.

The parts of the facebow are ● Complex instrument and requires the fabrication of
a. U-shaped frame. clutches, which are attached to lower jaws.

b. Condyle rods. ● They require more chair-side time and are rarely in-
c. Bite fork. dicated for routine prosthodontic procedures.

d. Orbital pointer (optional). ● They require the use of articulator with extendable
e. Locking clamps. condylar shafts, e.g. Hanau H2-X which must be

Classification of facebow extended to meet the stylus of facebow.
a. Arbitrary facebows Indications
i. Fascia type. ● For the cases where, high level of accuracy is re-
ii. Earpiece type. quired, e.g. for full mouth rehabilitation, occlusal
b. Kinematic facebows.} equilibration and gnathological studies.
Arbitrary facebows Plane of orientation
i. They are used as arbitrary or approximate points on ● Relationship of maxilla to skull and TMJ is different
the face as the posterior reference points. in most individuals.
ii. The condyle rods are positioned on these predeter- ● This can be easily transferred, if we relate maxilla to
mined points during the facebow transfer procedure. three points in the skull.
iii. These are most widely used type of facebow and are ● Two points located posterior to maxilla (posterior
sufficient for fabrication of most complete denture, reference points) and one anterior (anterior reference
fixed partial and removable partial denture prostheses. point).
A. Fascia type ● The spatial plane formed by joining the anterior and
● Utilizes approximate posterior reference points on posterior reference points is known as plane of orien-
the skin over the temporomandibular region. tation.
● These points are located by measuring from certain Anterior reference point
anatomical landmarks on the face. The fascia bow a. By using facebow, casts can be positioned at any
uses condylar rods instead of ear inserts. point between the upper and lower arms of the articu-
B. Earpiece type lator, because the facebow can rotate upward or
● First described by Dalbry in 1914. downward around the hinge axis of the articulator.
● This type of facebow uses the external auditory b. So, a standard is needed which can be used to mount
meatus as the arbitrary posterior reference point, most casts. Some operators prefer the midway point in
which is assumed to have a fixed relationship to the articulator, whereas, others prefer to orient it accord-
the hinge axis. ing to anatomical landmarks obtained from the patient.
● For this, a special earpiece is used instead of a c. Thus, the anterior point of reference determines at
condylar rod. Attached to the medial end of each what level in the articulator the occlusal plane is
placed or in other words, it determines the level at e. The position of the occlusal plane in the
which the casts are mounted. articulator is decided and the facebow is
Some commonly used anterior reference points: raised or lowered accordingly (using the
a. Nasion: Used with quick mount facebow (Whip elevating screw of the facebow). Many use
Mix). the midplane of the articulator as marked
b. Orbitale: Located by Hanau facebow with the on the incisal pin, whereas others adjust it
help of orbital pointer. according to the Frankfort plane (the orbital
c. Orbitale minus 7 mm: This plane represents pointer of the facebow is related to the or-
Frankfort plane. bitale indicator on the upper member of the
d. Ala of nose: This plane represents Camper’s plane. articulator).
e. 43 mm superior from lower border of upper lip: f. The upper cast is attached to upper record
Also called Denar reference plane base. The weight of the occlusal rim and cast is
f. Locator: Denar facebow uses this reference point. supported with the help of a cast support (also
Commonly used planes of orientation called mounting prop).
The commonly used planes during the facebow g. The notches (indices) in the base of the cast are
transfer are as follows: lightly lubricated. The upper cast is then se-
a. Axis–orbitale plane. cured to the upper arm of the articulator with
b. Frankfort plane. plaster (special low-setting expansion mount-
c. Camper’s plane. ing plaster recommended).
d. Axis–nasion plane. h. After the plaster sets, the facebow is disas-
Posterior reference point sembled. The articulator is placed upside
It is defined as a terminal hinge axis or opening axis of down. The lower occlusion rim is related to the
the jaw. It is usually taken as the posterior points. It may upper occlusion rim with the help of the centric
be determined approximately (arbitrarily) or absolutely relation record made earlier. The lower mount-
(kinematically). ing is completed with mounting plaster.
Arbitrary method The articulator is now ready for customizing,
● By measurement – as mentioned above. i.e. programming of the condylar and incisal
● By palpation – palpation of the TMJ area to locate the guidances.
hinge axis, as the patient opens and closes the mouth.
[SE Q.5]
Kinematic method
● Most accurate method of locating the hinge axis is {Advantages of the facebow
through the use of a kinematic facebow. a . It reduces errors in occlusion.
a. U-shaped frame is slipped over the bite fork ex- b. It permits more accurate programming of the articu-
tension. The locking clamps are then tightened lator.
gently at first and then firmly. This secures the bite c. It supports the cast, while mounting on the articulator.
fork to the rest of the facebow. d. The vertical dimension may be increased or de-
b. Orbitale pointer when present is positioned, so creased directly on the articulator without having to
that its tip points to the orbitale. All the locking make new centric relation records.}
nuts and clamps are secured.
Q.2. Classify jaw relation. Define centric relation.
c. Whole assembly is disengaged from the patient’s
Explain its clinical significance. What are the methods
face by loosening the condylar rods. The facebow
of recording the centric jaw relation?
assembly including the bite fork with attached
facebow is slipped off the patient’s face. Ans.
d. Whole assembly (including occlusal rim) is then
[SE Q.1]
positioned in the articulator. Condylar rods are
locked on to the hinge axis extensions of the con- {Jaw relation
dylar analogues on the articulator. In the earpiece ● Jaw relation is defined as any spatial relationship
type, the condylar rod is positioned behind the of the maxillae to the mandible; anyone of the
articulator hinge axis to compensate for the poste- infinite relations of the mandible to the maxillae
rior position of the auditory meatus (a small pin (GPT8).
known as auditory pin is present behind the hinge ● In the natural dentition, the presence of teeth makes
axis of the articulator on the condylar housing, it easy to determine the relationship of the jaws to
which slips into a hole in the ear insert). A condy- each other. In edentulous patients, the absence of
lar compensator may be used in articulators which teeth makes it necessary for the dentist to determine
do not have an auditory pin. and establish the relationship between the jaws.
Classification avascular portion of their respective disks with the

a. Orientation relations. complex in the anterior-superior position against the
b. Vertical relations (vertical dimension). shapes of the articular eminencies.
c. Horizontal relations. ● This position is independent of tooth contact. This
Importance position is clinically discernible when the mandible

● In edentulous mouth, above three relations to- is directed superiorly and anteriorly. It is restricted to
gether help determine the height of the jaws, a purely rotary movement about the transverse hori-
while mouth is opened, and the way they are re- zontal axis
lated to each other. Significance of centric relation
● In patients with natural teeth, the teeth determine a. Artificial teeth are best set to occlude evenly at
how the jaws are related to each. However, in centric relation
edentulous patients, the maxillomandibular rela- b. More definite than the vertical relation and is inde-
tions have to be established by the dentist.} pendent of the presence or absence of teeth.
c. It is recordable and reproducible over a period of time.
[SE Q.5]
d. Centric relation serves as a reference for establish-
{Facebow index ing an occlusion.
● It is a record of the orientation of the maxillary den- e. When centric relation and centric occlusion of
ture or teeth in relation to the articulator. It is an natural teeth do not coincide, the periodontal struc-
imprint of the teeth in plaster. tures around the teeth are endangered.
● When the denture is replaced into this index, it reori- f. When centric relation and centric occlusion of artifi-
ents the maxillary denture or teeth back into the cial teeth do not coincide, there is instability of the
original relation without having to make a new face- dentures and the patient may experience pain and
bow record. discomfort.
● It may be made before removing the maxillary cast g. Errors in mounting the casts on the articulator can
from the articulator prior to processing. The denture be detected, when the centric relation is used as the
can be remounted back on to the articulator with the horizontal reference position.
help of this index. h. An accurate centric relation is recorded properly
● A new facebow index can be made after final occlu- and it orients the lower cast to the opening axis of
sal correction and before delivery of the denture to the articulator and the mandible.
the patient. If at any future date, the dentures need to i. Accurately recorded centric relation when trans-
be returned to the articulator for corrections, the ferred to the articulator permits proper adjust-
facebow index would be useful for remounting.} ments of the condylar guidances for the control
Horizontal jaw relations of eccentric movements of the instrument.}
● Philipp Pfaff (1756) described a technique of ‘taking Difficulties in obtaining mandibular retrusion (centric
a bite’, also known as ‘mush’ or ‘biscuit’ or ‘squash’ relation)
bite. ● Centric relation is a learned position and obtaining
Classification correct centric relation involves training the patient
Horizontal jaw relations may be classified as: to retrude the mandible. Many patients find this
i. Centric relations. difficult as edentulous patients tend to protrude the
ii. Eccentric relations. mandible.
a. Protrusive relation. a. Biologic difficulties
b. Lateral relations i. Due to lack of coordination between muscles.
● Left lateral. ii. In the edentulous state, some patients assume a
● Right lateral. more prognathic position for convenience.
iii. Old denture wearers assume habitual eccentric
[SE Q.7]
positions due to wear of teeth or due to a previ-
i. Centric relation ous wrong centric relation.
● {After establishing vertical relation, centric rela-
iv. Senility or other neuromuscular diseases.
tion is recorded. b. Psychological difficulties
● It is a bone-to-bone relation and is classed as a When a patient fails to follow instructions, the den-
horizontal relation, because variations from it oc- tist may get frustrated, leading to more anxiety in
cur in the horizontal plane. the patient. It is extremely important that the dentist
● It is defined as the maxillomandibular relationship, does not display his disappointment or frustration to
in which the condyles articulate with the thinnest the patient.
c. Mechanical difficulties b. Uneven contacts may cause clenching in ner-

These difficulties are due to ill-fitting bases or due to vous patients.
some interference between the bases. Ill-fitting bases
tend to shift around making observations difficult. [SE Q.10]
{Methods used for recording centric jaw relations
[SE Q.9] i. Tactile or interocclusal check records.
{Methods of assisting the patient to retrude the mandible ii. Functional (chew-in) methods
The patient may be instructed to a. Needle–House method.
a. Let the jaw relax, pull it back and close slowly on the b. Patterson’s method.
back teeth. c. Meyer’s method.
b. Push the upper jaw out and close the back teeth. iii. Graphic methods (excursive method)
c. Protrude and retrude the mandible repeatedly, while a. Intraoral tracing.
patient holds a finger lightly against the chin. b. Extraoral tracing.
d. Boos stretch-relax exercises – open wide and relax, iv. Terminal hinge axis method.
move the jaws to the left and relax, right and relax, v. Other methods
forward and relax. This helps the patient to coordi- a. Strips of celluloid placed between the rims.
nate movements and follow the dentist’s instructions. b. Heating the surface of one of the rim.
e. Roll the tongue backwards towards posterior border c. Deep heating or pooling method.
of upper denture and close the rims until they meet. d. Soft wax is placed over the occlusal surfaces of man-
f. Swallow and close. The disadvantage is that a patient dibular posterior teeth.
can swallow in slight eccentric positions also. e. Soft cones of wax placed on the lower denture bases.
g. Tapping rims together rapidly and repeatedly.
i. Interocclusal check records
h. Tilting the head backwards tends to pull the mandi-
● Also known as bite registration, interocclusal record.
ble backwards, because of tension on the infrahyoid
● They are most widely used methods of recording
muscles.
centric relation.
i. Massaging or palpation of the temporalis and mas-
Uses
seter muscles to relax them.
a. To record centric relation.
j. In the terminal hinge position, closing the mandible tenses
b. To record eccentric relations, e.g. protrusive, left
the temporalis muscle which can be felt by the dentist.
and right lateral relations.
k. The dentist can also assist and guide in retruding us-
c. To verify centric relation on the articulator.
ing fingers placed on the sides of the lower rims.}
Method
Recording centric relation or bite registration
Before recording centric relation, the bases are
After sufficient training of the patient to retrude the
checked for interferences.
mandible to centric relation, it must be recorded. This is
● Training the patient
known as a centric relation record. This record is neces-
a. The patient is trained to retrude the mandible
sary to transfer it to an articulator.
into centric relation using one of the various
There are two schools of thought regarding pressure
methods described above.
used while recording centric relation.
b. A line is scribed in the wax from the upper to the
A. Minimal closing pressure.
lower occlusion rim in the canine-premolar region.
B. Heavy closing pressure.
c. A mark is also made along the midline of the up-
A. Minimal closing pressure per and lower rims, which will serve as reference
● Advocated to reduce tissue displacement. Thus, marks during patient training and later while cre-
the opposing denture teeth will touch uniformly ating an index. These lines should coincide repeat-
and simultaneously at first contact. edly when the patient closes in centric relation.
B. Heavy closing pressure ● Indexing the rim
● The objective is to produce the same displace- a. ‘Notches’ are created in the upper occlusal rim on
ment of soft tissues that occurs when the patient either side in the mid-posterior region.
masticates. b. A small section of wax is removed from the lower
Advantage rim to create space for the registration material
● Occlusal forces are evenly distributed over the (corresponding to the notches in the upper rim).
residual ridges under heavy loads. c. The indices should be sharp and well defined.
Disadvantages d. Some operators prefer to create notches in the
a. If the soft tissues have uneven thickness, then lower rim while placing the registration material
the teeth contact unevenly at first contact. in the maxillary rim.
● Recording centric relation

carborundum paste. Compensating curves are gener-
a. Once the patient is well trained and the dentist is
ated in this.
confident, the record is made. The notches are lu-
. Meyer’s method: This method uses soft wax to estab-
d
bricated with petroleum jelly. A recording material
lish a generated path. A plaster index is made of the
like quick-setting plaster or bite registration wax is
wax path and this is used to set the teeth.
placed in the relief space in the opposite rim.
b. The patient is instructed to close in centric relation.
The reference lines are used to visually verify cor-
[SE Q.8]
rect closure. The jaws are held stationary, till the
material sets or hardens. iii. {Excursive methods – Gothic arch tracing:
c. Other bite registration materials may also be used. Arrow point tracer or height tracer.
d. Once the maxillary cast is mounted on the articu- Uses
lator, this record can then be used to mount the a. To verify or confirm centric relation obtained by
mandibular cast. other methods.
e. The index maintains a record of the relation be- b. It is also used to obtain protrusive and lateral re-
tween the upper and lower occlusion rims. Even cords.
if the two rims are separated, they can be reas- The tracings obtained resemble a Gothic arch or an
sembled back in the exact same relation with the arrow point.
help of the index. Attaching the tracing devices: Prior to using, a tracing
● Trimming the record device, and the occlusion rims are mounted on an ar-
The registration wax is hardened in chilled water. A ticulator using a tentative centric relation record (using
heated instrument may be used to trim the excess. The an interocclusal check record). The tracing devices are
rims are replaced in the mouth to verify the accuracy attached to the occlusion rims while they are on the
of the registration. articulator.
An interocclusal check record can be made Types
a. Between upper and lower occlusion rims. a. Intraoral (arrow points posteriorly).
b. Between upper and lower artificial or natural b. Extraoral (arrow points anteriorly).
teeth. Tracing assembly: The tracing assembly consists of
c. Between a central-bearing plate and pin. a tracing table and a stylus. The stylus traces the
Bite registration materials Gothic arch on to the tracing table.
a. Quick setting plaster. Extraoral tracer – the tracing assembly is located
b. Bite registration (ZOE) paste. outside the mouth.
c. Bite registration wax. Intraoral tracer – it is located inside the mouth.
d. Bite registration silicone. Central bearing device: It consists of a small
Requirements of bite registration materials fixed ball and a plate. They are located inside
a. Should be dimensionally accurate after setting. the mouth between the upper and lower occlu-
b. Should be fluid in consistency to avoid pressure sion rims. They help to maintain the vertical
during recording. relation while the patient performs the mandibu-
c. Adequate working time. lar movements.
d. Short setting time to reduce discomfort to patient Terminal hinge axis: It is determined using kine-
and distortion due to movement. matic facebow. As the mandible rotates around the
ii. Functional method of recording centric relation hinge axis and occludes with the wax rims, it comes
automatically in centric relation.}
{SN Q.17} iv. Other methods
a. Strips of celluloid: After adjusting the rim, a strip of
a. Needle–House method: Four metal styli fixed in the
celluloid is placed between the rims and pulled. If it
compound maxillary rim carve four diamond-shaped
pulls out easily, then it indicates uneven contact, and
tracings in the mandibular rim as the mandible is moved
the rim is readjusted.
through various excursive movements.
Disadvantage: Unequal pressure error may still be
b. The records can be transferred only to a Needle–
present.
House articulator.
b. Deep heating or ‘pooling’ of the posterior portions
c. Patterson’s method: A trench is made in a wax man-
of the mandibular rim leaving the anterior portion
dibular rim and filled with a mixture of plaster and
cold (to maintain OVD).
c. Softened wax is placed on the mandibular posterior preserved and used to programme the adjust-
teeth and maxillary teeth are closed into it. able articulator.
Advantage: Smaller surface contact instead of a 3. Functional procedures are similar to those de-
large flat wax surface. scribed earlier.
Disadvantage: Record has to be made at an in- b. Lateral jaw relations
creased vertical relation to avoid contact of teeth. The mandible can also be moved to the left or right
d. Swallowing technique using soft cones of wax es- sides. The relations of the mandible to the maxilla
tablish vertical as well as centric relation. when it is moved to the left or right of centric rela-
Disadvantage: Results are not consistent.} tion are known as lateral jaw relations.
v. Eccentric relations When the mandible is moved to one side, a separa-
An eccentric maxillomandibular relation is any other tion may be observed between the occlusion rims
horizontal relationship of the mandible to the maxilla on the opposite side which is the result of the
other than centric position. downward displacement of condyle (balancing
The eccentric relation records are used to programme side) as it travels downward and medially along the
the articulator to simulate the patient’s jaw movements. medial slope of the mandibular fossa (also known
The important eccentric relations are as Bennett movement).
Protrusive and lateral (left and right) Applications
Importance ● To programme the articulator (to programme
These are necessary to programme an adjustable the lateral condylar guidance which together
articulator to simulate the patient’s jaw move- with the incisal guidance guides the lateral
ments which are helpful in constructing a bal- movement of the articulator).
anced denture occlusion and restorations which However, this can be done only in an articu-
are in harmony with the functional movements of lator that accepts lateral relation records.
the mandible. The Hanau semi-adjustable articulators do
The eccentric positions are recorded by: not accept lateral relation records. Instead, a
a. Functional methods. formula is used to derive the lateral condylar
b. Excursive (graphic) methods. settings.
c. Direct check records. Recording lateral relations
a. Protrusive relation ● Lateral jaw relations can be recorded using
Mandible can be protruded to a position anterior to functional techniques, graphic techniques or

that of centric relation which is known as the pro- direct check records. In addition, Hanau’s for-
truded jaw relation. mula can be used.
In this position, a wedge-shaped opening is ob- 1. Graphic method: With the help of the Gothic
served in the posterior section between the upper arch tracing, two separate records are made,
and the lower occlusion rims known as Chris- one in the left lateral position and one in the
tensen’s phenomenon. right lateral position.
Applications 2. Lateral check records: These are made simi-
● To programme the articulator (to programme lar to the protrusive record except that the
the horizontal condylar guidance which to- mandible is held in the lateral position, while
gether with the incisal guidance guides the the record is being made. Left and right lat-
protrusive movement of the articulator). eral records are made.
Protrusive records are made by
Hanau’s formula: Around 1930, Hanau recommended a
1. Direct protrusive check record: After suitable train-
formula to derive the lateral inclination as follows:
ing, the patient is asked to protrude by 5–6 mm and
L 5 H 1 12/8
close. The position is recorded using the interoc-
Where, L 5 Lateral condylar inclination (in degrees)
clusal check record method and a suitable record-
H 5 Horizontal condylar inclination (in degrees)
ing material. The protrusive check record is made
This formula is used only with the Hanau articulator.
at a slightly increased vertical dimension.
2. Graphic method: Using the Gothic arch trac- Q.3. Define physiological rest position of mandible. Give
ing, the patient is asked to protrude the man- the importance of Silverman closest speaking space and
dible and close at a point 5–6 mm forward of discuss the effects of increased and decreased vertical
the apex of the arrow point (centric). This posi- dimension in complete dentures.
tion is then recorded using quick setting plaster
or a suitable recording medium. The record is Ans.
Vertical relations
In natural teeth, it is 1–8 mm.
It is used determine the amount of separation between
In complete dentures, it is 2–4 mm at premolar
the two jaws and needs to be established correctly for
region tolerated well by most patients
the proper comfort, health and function of the mouth.
Importance
An adequate interocclusal rest space is necessary
{SN Q.2}
for the comfort of the patient, health of the tissues
Definition and proper functioning of the dentures.)
It is defined as the distance between two selected
anatomic or marked points (usually one on the tip of OVD 5 RVD – 2–4 mm
the nose and the other upon the chin), one on a fixed Thus, OVD 5 RVD – IOD or
and one on a movable member (GPT8). Other vertical relations such as when the mouth is
Types half open or wide open are of no significance in
1. The rest vertical dimension (RVD) or vertical the construction of dentures.
relation of rest.
2. The OVD or vertical relation of occlusion. (SE Q.4 and SN Q.5)
3. The difference between RVD and OVD also
known as ‘interocclusal dimension’ (IOD) or {(Methods of determining vertical relation
‘rest space’ or ‘freeway space’. A. Mechanical methods
4. Other vertical relations. 1. Ridge relations
● Distance from incisive papilla.
(SE Q.2 and SN Q.9) ● Parallelism of the ridges.
2. Measurement of former dentures.

{(Physiologic rest position 3. Pre-extraction records
Physiologic rest position occurs somewhere downward ● Profile radiographs.
and slightly forward from centric relation. In this posi- ● Profile photographs.
tion, the jaw opening and closing muscles are in tonic ● Articulated casts.
balance. ● Lead wire silhouettes.
Factors affecting are as follows: ● Resin facemasks.
● Tonicity of jaw muscles. ● Facial measurements.
● Position of head (it modifies the effect of gravity).)} B. Physiologic methods
1. Physiologic rest position tests
RVD ● Parting the lips after swallowing.
It is defined as the distance between two selected ● Niswonger’s method.
points (one of which is on the middle of the face 2. Phonetics
or nose and the other of which is on the lower face ● Using the M sound.
or chin) measured when the mandible is in the ● Using h, s and j sounds.
physiologic rest position. ● Silverman’s closest speaking space.
OVD ● Facial expression.
It is defined as the distance measured between 3. Facial expression and aesthetics as guides.
two points when the occluding members are in 4. Swallowing threshold.
contact (GPT8). 5. Tactile sense
The OVD in dentulous individuals is established ● Lytle’s method (neuromuscular perception).
by the occlusal stops provided by the teeth. It is ● Boos bimeter (power point).
affected by tooth loss, wear, caries etc. ● Patient’s tactile sense as a guide.
The OVD in edentulous patients is established with 6. Electromyography.)}
the help of occlusal rims. It is usually determined
by first finding out the physiologic rest position
(RVD) and then reducing to 2–4 mm (IOD).) A. Mechanical methods
1. Ridge relations
{SN Q.4} a. Incisive papilla distance: The distance of the
incisal papilla from incisal edge of mandibular
(Interocclusal rest space (IOD) incisors is about 4 mm. It is 6 mm away from edge
It is also known as freeway space or IOD. of central incisors.
It is the difference between the rest vertical relation Disadvantage: Useful only in treating single com-
and the occlusal vertical relation. plete dentures.
b. Parallelism of ridges: Sears suggested that correct Sorensen’s profile guide: It is one of the devices for
vertical relation is at a point where the jaws are paral- recording facial measurement.}
lel, with a 5° opening in the posterior region. . Physiological methods (postextraction methods)
B
Disadvantages
● Not reliable in cases of marked resorption.
[SE Q.2]
● When teeth are lost at irregular intervals, 1. {Physiologic rest position tests
the residual ridges are not parallel. Swallow and relax: The patient is asked to swallow and
i. Measurement of former dentures relax. The lips are parted gently after instructing the
The former dentures can be measured between the bor- patient to hold the jaws still. There should be 2–4 mm
ders of the maxillary and mandibular dentures with a of space between the rims in the premolar region.
Boley gauge (after compensating for occlusal wear). Niswonger’s method (1934): Two markings are made,
one on the upper lip below the nasal septum, and the
[SE Q.6]
other on the chin. The patient is told to swallow and re-
ii. Pre-extraction records lax. The distance between the marks is measured. The
Sometimes it is possible to see a patient before he or occlusal rims are adjusted until the distance between the
she loses his/her natural teeth. In such a case any of the marks is 2–4 mm less during occlusion.
following methods can be used to record the distance. Disadvantage: The marks move with the skin.}
a. Profile radiographs are made with teeth in occlusion. 2. Phonetics as guide
These are compared with those made with occlusion a . The dentist asks the patient to speak certain
rims in position. words and then makes observations of the rela-
Disadvantages tionship of the occlusion rims to each other and
1. Image may be distorted. to the lips.
2. Time-consuming. b. Using ‘m’ sound: The patient repeats the letter ‘m’.
3. Radiation hazards. When the lip touches, all jaw movements are stopped.
b. Profile photographs are compared before and after The distance between the two reference points are
treatment. measured. The occlusion rims are then adjusted, so that
Disadvantage: Profile angles can change with they are 2–4 mm short of this position when they are
changes in the patient’s posture. occluded.
c. Articulated casts measurements are made between c. The ch, s and j sounds: When correctly placed, these
stable landmarks with the teeth in occlusion, e.g. sounds bring the upper and lower incisors close to-
between the upper and lower freni. gether. The lower central incisors come forward
d. Lead wire silhouettes (not commonly used cur- nearly directly below the upper centrals almost
rently). Lead wires are adapted to the patients (pro- touching them. At the right vertical height, there
file) before extraction. The outline is transferred to a should be a 1 mm space between the upper and lower
cardboard and cut out. After extraction, the cut out occlusion rims. If the rims contact, wax should be
is placed against the patient’s profile to check verti- removed to reduce the vertical height of the rims. If
cal relation. the space is more than 1 mm, then the wax is added
e. Acrylic facemask (Swenson’s technique) is made be- to increase the vertical height.
fore extraction using a facial impression and cast. This d. Using 33: When repeating this word there should be
method is not practical. enough space for the tip of the tongue to protrude
f. Facial measurements between the anterior teeth.
Dakometer: The instrument is positioned on the e. Using f or v sounds: The maxillary incisal edge
bridge of the nose with compound. The chin piece is should lightly contact the lower lip at the vermillion
screwed till it touches the front of the chin. A spring border when the patient produces a ‘V’ or ‘F’ sound.
pressure gauge controls pressure. An incisor attach- If the patient contacts the lower lip well into the oral
ment records the position of the central incisors. portion, the maxillary incisal edge may be too short.
Records are noted and the compound nosepiece pre- If the lower lip is contacted with such force causing
served for reassembly after extraction. it to fold when producing an ‘F’ or ‘V’, the maxillary
Willis-gauge: One arm contacts the base of the nose rim may be too long.
and the other arm is moved along the side until it Silverman’s closest speaking space
touches the base of the chin. It is different from freeway space.
Disadvantage: Is not accurate as there may be varia- The freeway space establishes vertical dimension
tions in applying pressure. when the muscles are at rest.
mouth should be equal to the distance between the

{SN Q.10}
lower border of the septum of the nose and the lower
The closest speaking space establishes vertical relation border of the chin.
when the jaws are in the function of speech. Thus, one is 1. Swallowing threshold
‘static’ and the other is ‘dynamic’. When a person swallows, the teeth come together
Pound and Murrells technique: Using ‘f’, ‘v’ and ‘s’ with very light contact.
sounds and speaking wax, the positions of the upper and Method
lower anterior teeth are established. Cones of soft wax having excessive height are
placed on the lower base. Salivation is stimu-
3. Aesthetics as guide lated (e.g. using candy) and the patient is in-
Facial aesthetics: An experienced dentist evaluates fa- structed to swallow. The repeated swallowing
cial expression. In the normal relaxed position, the lips reduces the height of the wax to the OVD.
are even anteroposteriorly and in slight contact. The Disadvantage
nares and the skin around the eyes and chin are relaxed. The results obtained are not consistent and are
If the face appears strained, the vertical height may be affected by the length of time the swallowing
too much. If the corners of the mouth droop, making the motion is performed.
chin appear too close to the nose, then vertical dimen- 2. Tactile or neuromuscular perception methods
sion may be too less. Patient’s tactile sense: The patient is asked if the
Disadvantage: Not practical method. It requires skill rims appear to touch too soon, or if the jaw closes
and is expensive equipment. too much or if it feels just right.
Disadvantage
(SE Q.4 and SN Q.20) Some patients are not always able to judge cor-
rectly. Not effective in senile patients or men-
{(Effects of decreased vertical dimension tally compromised patients.
a . Decreased chewing efficiency. a. Boos bimeter: Boos (1940) stated that max-
b. Cheek biting – flabby cheek tissues get trapped. imum biting force occurs at OVD. A device
c. Appearance: The chin appears close to nose, lips that measures the biting force is attached to
lose their fullness and vermilion border is reduced to the mandibular record base and a metal
a line, wrinkles are deepened. Face appears flabby. plate (central bearing point) to the maxil-
d. Angular cheilitis: A deep crease forms at the corner lary. A screw is turned to adjust vertical
of the mouth. Constant wetness due to saliva leads relation. The maximum power point is de-
to infection and soreness. termined on the spring gauge.
e. TMJ pain, clicking sounds, headaches etc. b. Lytle’s method (neuromuscular perception):
f. Costen’s syndrome (now disputed) is due to pro- Using a central bearing plate and pin, vertical
longed over closure. relation is increased beyond physiologic rest
g. Limited tongue space.) position (the pin is made too long). The pin
is lowered by a half turn at a time until the
patient signifies over closure. The procedure
{SN Q.3} is then reversed until the patient signifies that
it is just right.
Effects of increased vertical dimension: c. Electromyography: Rest position can be
Excessive vertical height (inadequate freeway space) determined by recording the minimal activ-
can cause certain problems: ity of muscles of mastication.
● Discomfort and annoyance to the patient.
● Trauma to the underlying mucosa.

Q.4. What is a facebow? Discuss the importance of face-
● Rapid resorption of alveolar bone.
bow transfer for an edentulous patient.
● Clicking of teeth. Ans.
● Rapid wear of acrylic teeth.
● Strained face appearance (elongated face).

[Same as LE Q.1]
● Difficulty in closing lips. Q.5. What is facebow? Discuss the importance of same
● Difficulty in swallowing.)} in complete dentures and partial removable prosthesis.
Ans.
Willis method (facial proportions): The distance be-
tween the outer canthus of the eye and the corner of the [Same as LE Q.1]
Q.6. Describe and classify facebow? Mention the parts Commonly used planes of orientation
of facebow. Discuss the uses of facebow. ● Axis–orbitale plane.
● Frankfort plane.
Ans.
● Camper’s plane.
[Same as LE Q.1] ● Axis–nasion plane.
Anterior reference points

Q.7. Explain one in detail: (a) Note on eccentric jaw By using facebow, casts can be positioned at any point
relation. (b) Add a note on difficulties encountered dur- between the upper and lower arms of the articulator,
ing recording centric jaw relation. because the facebow can rotate upward or downward
Ans. around the hinge axis of the articulator.
So, a standard is needed which can be used to mount
[Same as LE Q.2] most casts. Some operators prefer the midway point in
Q.8. What are the different maxillomandibular relation- the articulator, whereas, others prefer to orient it accord-
ships and discuss the importance and different methods ing to anatomical landmarks obtained from the patient.
of recording horizontal jaw relation. Thus, the anterior point of reference determines at what
level in the articulator, the occlusal plane is placed or in
Ans. other words, it determines the level at which the casts
[Same as LE Q.2] are mounted.
Commonly used anterior reference points
A. Nasion: Used with Quick Mount facebow (Whip
SHORT ESSAYS: Mix).
Q.1. Classification of jaw relations. B. Orbitale: Located by Hanau facebow with the
help of orbital pointer.
Ans. C. Orbitale minus 7 mm: This plane represents
[Ref LE Q.2] Frankfort plane.
D. Ala of nose: This plane represents Camper’s plane.
Q.2. Physiologic rest position of mandible and its E. 43 mm superior from lower border of upper lip:
significance. (Denar reference plane)
Ans. F. Locator: Denar facebow uses this reference point.
Posterior reference points
[Ref LE Q.3] Terminal hinge axis or opening axis of the jaw is usually
Q.3. Write about orientation relation in complete denture. taken as the posterior points. It may be determined ap-
proximately (arbitrarily) or absolutely (kinematically).
Ans. Arbitrary method
● By measurement – as mentioned above.
{SN Q.15} ● By palpation – palpation of the TMJ area to locate the

hinge axis, as the patient opens and closes the mouth.
Orientation relation Kinematic method
Orientation relation is defined as the jaw relation It is the most accurate method of locating the hinge
when the mandible is kept in the posterior-most axis i through the use of a kinematic facebow.
position. It can rotate in the sagittal plane around Commonly used posterior reference points
an imaginary transverse axis passing through or a. 13 mm from posterior margin of tragus to
near the condyles. canthus.
Recording of orientation jaw relation is done using a b. 13 mm in front of anterior margin of meatus.
device called facebow. c. 13 mm from foot of tragus to canthus.
Plane of orientation d. 10 mm anterior to centre of external auditory
● Relationship of maxilla to skull and TMJ is differ-
meatus and 7 mm below Frankfort plane.
ent in most individuals. e. Ear axis.
● This can be easily transferred if we relate maxilla
Importance
to three points in the skull. a. In edentulous mouth, above three relations to-
● Two points located posterior to maxilla (posterior
gether help to determine the height of the dentures
reference points) and one anterior (anterior refer- and the way they are related to each other.
ence point). b. In patients with natural teeth, the teeth determine
● The spatial plane formed by joining the anterior
how the jaws are related to each. However, in
and posterior reference points is known as plane edentulous patients, the maxillomandibular rela-
of orientation. tions have to be established by the dentist.
Q.4. Vertical jaw relationship. Q.16. Increased and decreased vertical dimension.
Ans. Ans.
Q.5. Facebow. Q.17. Effect of incorrect vertical dimensions.
Ans. Ans.
[Ref LE Q.1 and LE Q.2] [Same as SE Q.4]
Q.6. Pre-extraction records for complete denture. Q.18. Importance of pre-extraction records.
Ans. Ans.
Q.7. Centric relation. Q.19. Methods of recording centric jaw relation.
Ans. Ans.
Q.8. Gothic arch tracing. Q.20. Significance of recording centric relation.
Ans. Ans.
Q.9. Mention about training the patient to retrude mandible. SHORT NOTES:
Ans. Q.1. Describe the importance of marking the midline
[Ref LE Q.2] canine line and the high line during jaw relation.
Q.10. Discuss the various jaw relation procedures in Ans.
complete denture patients. ● Midline is marked for bilateral symmetry.
Ans. ● Canine line determines the space for setting the anterior
teeth that is central, lateral incisors and canine.
[Ref LE Q.2] ● High line refers to upper lip line, while smiling about 2 mm of
Q.11. Classify jaw relations. Discuss in detail the signifi- incisal edge of upper teeth should be exposed. At rest, upper
cance of jaw relations in complete denture construction. lip border should cover 1–2 mm of incisal edge of lower teeth.
● These lines aid in making jaw relation record and are
Ans.
marked prior to jaw relation.
[Same as SE Q.1]
Q.2. Vertical jaw relation.
Q.12. Define orientation relation. Write a note on its Ans.
importance in complete denture.
[Ref LE Q.3]
Ans.
Q.3. State the consequences of increased vertical relation
[Same as SE Q.3]
recording in complete denture.
Q.13. Orientation jaw relation. Ans.
Ans. [Ref LE Q.3]
[Same as SE Q.3] Q.4. Freeway space.
Q. 14. Plane of orientation. Ans.
Ans. [Ref LE Q.3]
[Same as SE Q.3] Q.5. Enumerate the various methods of determining
Q.15. Methods of recording vertical jaw relations. vertical relation of occlusion.
Ans. Ans.

Q.6. Niswonger’s method of establishing vertical relation. j. The dentist can also assist and guide in retruding
using fingers placed on the sides of the lower rims.
Ans.
Niswonger’s method (1934): In this method, two markings Q.8. Interocclusal clearance.
are made, one on the upper lip below the nasal septum, and Ans.
the other on the chin. The patient is told to swallow and
relax. The distance between the marks is measured. The Interocclusal rest space (IOD) is also known as Freeway
occlusal rims are adjusted, until the distance between the space or IOD.
marks is 2–4 mm less during occlusion. It is the difference between the rest vertical relation and
Disadvantage: The marks move with the skin. the occlusal vertical relation.
In natural teeth, this distance is 1–8 mm.
Q.7. Define centric relation. Write in brief about differ- In complete dentures, it is 2–4 mm at premolar region
ent methods to record it. tolerated well by most patients.
Importance
Ans. An adequate interocclusal rest space is necessary for
Centric relation the comfort of the patient, health of the tissues and
Centric relation is defined as the maxillomandibular for proper functioning of the dentures.
relationship in which the condyles articulate with the Q.9. Physiological rest position of mandible.
thinnest avascular portion of their respective disks with
the complex in the anterosuperior position against the Ans.
shapes of the articular eminencies. This position is inde-
[Ref LE Q.3]
pendent of tooth contact. This position is clinically dis-
cernible, when the mandible is directed superiorly and Q.10. Closest speaking space.
anteriorly. It is restricted to a purely rotary movement
about the transverse horizontal axis Ans.
Classification of methods used for recording centric
[Ref LE Q.3]
relation
a. Tactile or interocclusal check records. Q.11. Hinge axis.
b. Functional (chew-in) methods.
c. Graphic methods (excursive method). Ans.
d. Terminal hinge axis method. Hinge axis
e. Other methods. ● Hinge axis is also known as transverse horizontal axis.
Methods of assisting the patient to retrude the mandible ● It is an imaginary line around which the mandible
The patient may be instructed to may rotate within the sagittal plane.
a. Let the jaw relax, pull it back and close slowly on ● It runs horizontally from the right side on the man-
the back teeth. dible to the left.
b. Push the upper jaw out and close the back teeth. ● Rotation around this axis is seen during protrusive
c. Protrude and retrude the mandible repeatedly, movements.
while patient holds a finger lightly against the chin. ● This transverse axis varies during different phases of
d. Boos stretch-relax exercises: Open wide and relax, protrusive movement.
move the jaws to the left and relax, right and relax and ● Initial mouth opening passes through the head of
forward and relax. This helps the patient to coordinate the condyle.
movements and follow the dentist’s instructions. ● Later stage of mouth opening passes through man-
e. Roll the tongue backwards towards posterior border dibular foramen.
of upper denture and close the rims until they meet. ● It is determined by kinematic facebow accurately.
f. Swallow and close: The disadvantage is that a pa-
tient can swallow in slight eccentric positions also. Q.12. Perleche.
g. Tapping rims together rapidly and repeatedly.
Ans.
h. Tilting the head backwards tends to pull the man-
dible backwards, because of tension on the infra- ● Also known as angular cheilitis.
hyoid muscles. ● It is a deep crease formed at the corner of the mouth.
i. Massaging or palpation of the temporalis and mas- Constant wetness due to saliva leads to infection and
seter muscles to relax them. In the terminal hinge soreness.
position, closing the mandible tenses the tempora- ● Corners of mouth are moist and drooping.
lis muscle which can be felt by the dentist. ● Fungal infection is seen at the folds.
● This condition is seen cases of decreased vertical di- e. Acrylic facemasks (Swenson’s technique): It is not a
mension and also in cases of vitamin deficiency or sec- practical method. Before extraction, it is made using
ondary to fungal (Candida) infection in the mouth. facial impression and cast.
f. Facial measurements:
Q.13. Beyron’s point?
i. Dakometer: This instrument is positioned on the
Ans. bridge of the nose with impression compound and
chin piece is screwed, until it touches the chin front.
Beyron’s point
A spring pressure gauge controls pressure. An inci-
● A posterior reference point – arbitrary terminal hinge
sor attachment records position of central incisors.
axis/opening axis of the jaw taken while determining
Records are noted and compound nosepiece pre-
the plane of orientation.
served for reassembly after extraction.
● It is located 13 mm from posterior margin of tragus
ii. Willis gauge: One arm contacts the base of the nose
to canthus.
and the other arm is moved along the side, until it
● It gives 98% accuracy.
touches the base of the chin. It is not an accurate
● It was given by Beyron.
method.
Q.14. Freeway importance. iii. Sorensen’s profile guide: It is one of the devices for
recording facial measurement.
Ans.
Q.17. Needle’s chew-in technique.
Freeway is also known as interocclusal rest space (IOD)
It is the difference between the rest vertical relation and Ans.
the occlusal vertical relation. [Ref LE Q.2]
In natural teeth, this distance is 1–8 mm.
In complete dentures, it is 2–4 mm at premolar region Q.18. Overjet and overbite.
tolerated well by most patients. Ans.
Importance
Overjet
An adequate interocclusal rest space is necessary for the
It is the horizontal overlap of the maxillary and man-
comfort of the patient, health of the tissues, and for
dibular anterior teeth. In normal class 1 relationship, the
proper functioning of the dentures.
mandibular incisors are located 2–4 mm behind the
Q.15. Orientation jaw relation. maxillary incisors.
Overbite
Ans.
It is the vertical overlap between maxillary and man-
[Ref SE Q.3] dibular anterior teeth. Adequate overbite is required
for aesthetics.
Q.16. Importance of pre-extraction records.
If excessive, then it can resist anterior movement of
Ans. denture, causing dislodgement.
Normal value is 2–4 mm.
Importance of pre-extraction records
They provide valuable information about the patient denti- Q.19. Occlusal rims for construction of complete dentures.
tion and facial profile before extraction.
Ans.
a. Profile radiographs: These are made with teeth in occlu-
sion and compared with those made with occlusal rims Occlusal rim
in position, but has following disadvantages: It is also known as record rim or bite rim.
i. Distorted image. Definition
ii. Time-consuming. Occlusal rims are occluding surfaces fabricated on
iii. Radiation hazards. interim or final denture bases for the purpose of mak-
b. Profile photographs: The can be compared before and ing maxillomandibular relationship records and for
after treatment, but profile angles can change with arranging teeth.
change in patient’s posture. Uses
c. Articulated casts: With teeth in occlusion, measure- a. To determine lip support and facial aesthetics.
ments are made between stable landmarks, i.e. between b. To determine arch form and plane of occlusion.
upper and lower frena. c. To establish the teeth size and position.
d. Lead wire silhouettes: These are adapted to patients d. To establish the contour of polished surface.
before extraction and outline is transferred to cardboard e. For tentative establishment, i.e. for recording and
as a cut out. After extraction, this cut out is placed transfer of jaw relations.
against patient’s profile to check vertical relation. It is f. To know the patient’s response to denture-like form.
not commonly used now. g. For arrangement of artificial teeth.
Q.20. Problems with reduced vertical dimension in com- Q.25. Centric jaw relation records.
plete dentures.
Ans.
Ans.
[Same as SN Q.7]
[Same as SN Q.3]
Q.26. Define centric relation. Write various methods for
Q.21. Increased vertical relation. assisting the patient to retrude the mandible during
centric relation registration.
Ans.
Ans.
[Same as SN Q.3]
[Same as SN Q.7]
Q.22. Enumerate characteristics of increased vertical
relation in complete denture patient. Q.27. Rest position of mandible.
Ans. Ans.
Q.23. Effects of increased vertical dimension. Q.28. Significance of rest position of mandible.
Ans. Ans.
Q.24. Interocclusal distance (IOD). Q.29. Silverman’s speaking space.
Ans. Ans.
Topic 7
Lab Procedures Prior to Try-In
LONG ESSAYS:
1. What is balanced occlusion? What are the laws of articulation of developing balanced occlusion in complete
denture prosthesis?
2. What is an articulator? Classify articulator and write uses and requirements of an articulator.
3. Write in detail the procedures involved in the selection of anterior teeth in complete denture patient.
4. Discuss the importance of try-in stage in complete denture prosthodontics.
5. Discuss the role of arrangement of artificial teeth in complete denture prosthesis.
6. What is balanced articulation? Mention its importance/rationale. Describe the factors responsible for balanced
articulation in complete dentures. [Same as LE Q.1]
7. Define balanced occlusion. Enumerate the advantages of a balanced occlusion. Describe any two factors that
affect a protrusive balance. [Same as LE Q.1]
8. What is balanced occlusion and how do you establish it, while fabricating a complete denture? [Same as LE Q.1]
9. Define articulator. Discuss the advantages, disadvantages and classification of articulators. [Same as LE Q.2]
10. What is an articulator? Give the classification, functions and requirements of an articulator. [Same as LE Q.2]
11. Define articulators. Give classification, uses of articulator and discuss in detail about a semi-adjustable articulator.
[Same as LE Q.2]
12. What are the factors for the selection of anterior teeth for a complete denture patient? [Same as LE Q.3]
1 3. Define denture aesthetics and discuss the various factors influencing denture aesthetics. [Same as LE Q.3]
14. Discuss the physical and biological factors involved in selection of teeth for complete denture construction in
edentulous patient. [Same as LE Q.3]
15. Discuss the principles of arrangement of artificial teeth in complete denture prosthesis. [Same as LE Q.3]
16. Selection of anterior and posterior teeth in complete denture. [Same as LE Q.3]
17. Dentogenic concept. [Same as LE Q.3]
18. Shade selection. [Same as LE Q.3]
19. Discuss the principle in arrangements of artificial teeth in complete denture prosthodontics. [Same as LE Q.5]
SHORT ESSAYS:
1. Rationale of balanced occlusion. [Ref LE Q.1]
2. Try-in procedure. [Ref LE Q.4]
3. Anterior teeth selection for complete denture. [Ref LE Q.3]
4. Types of posterior teeth. [Ref LE Q.3]
5. Principles of teeth arrangement for complete edentulous patient. [Ref LE Q.5]
6. Define articulator and discuss its advantages and disadvantages. [Ref LE Q.2]
7. Condylar and incisal guidance. [Ref LE Q.1]
8. Nonanatomic teeth. [Ref LE Q.3]
9. Compensating curves. [Ref LE Q.1]
10. Bennett’s movement and Bennett angle.
11. Define and classify articulators.
12. Laws of balanced occlusion. [Same as SE Q.1]
13. Enumerate the factors affecting balanced occlusion. [Same as SE Q.1]
14. Dentogenic concept. [Same as SE Q.3]
15. Shade selection. [Same as SE Q.3]
16. Discuss selection of posterior teeth for complete denture. [Same as SE Q.4]
17. Mention the uses and requirements of an articulator. [Same as SE Q.6]
SHORT NOTES:
1. Define articulator. [Ref LE Q.2]
2. Discuss in short, neutral zone.
3. Porcelain denture teeth. Its indications and contraindications.
4. Differences between natural and artificial dentition.
5. Describe the various dimensions of colour. [Ref LE Q.3]
6. SPA factor in complete denture.
7. Canine-guided occlusion.
8. Importance of try-in in complete denture.
9. Selection of teeth for geriatric patient.
10. Indications of nonanatomic teeth in complete denture.
11. Compensatory curve importance.
12. Squint test.
13. Balanced occlusion.
14. Cuspless teeth. [Ref LE Q.3]
15. Neutrocentric occlusion.
16. Group function occlusion.
17. Lingualized occlusion.
18. Christenson’s phenomenon.
19. Advantages and disadvantages of porcelain teeth.
20. Write the methods of selecting the colour shade of artificial teeth. [Same as SN Q.5]
21. Dentogenic concept and dynesthetics: sex, personality, age or SPA factor. [Same as SN Q.6]
22. Selection of anterior teeth. [Same as SN Q.9]
23. What are the criteria for selection of anterior teeth for complete denture patient? [Same as SN Q.9]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. What is balanced occlusion? What are the laws of ● This factor cannot be modified. All the other four
articulation of developing balanced occlusion in com- factors of occlusion should be modified to compen-
plete denture prosthesis? sate the effects of this factor.
● In patients with steep condylar guidance, the incisal
Ans. guidance should be decreased to reduce the amount
[SE Q.1] of jaw separation produced during protrusion and
vice versa. But, it should be remembered that the
{Balanced occlusion incisal guidance cannot be made very steep, because
‘The simultaneous contacting of the maxillary and man- it has its own ill effects.
dibular teeth on the right and the left and in the posterior Incisal guidance
and the anterior occlusal areas in centric and eccentric It is defined as ‘the influence of the contacting surfaces
positions, developed to lessen or limit tipping or rotat- of the mandibular and the maxillary anterior teeth on
ing of the denture bases in relation to the supporting mandibular movements’ (GPT).
structures’. ● It is the second factor of occlusion.
Importance/rationale ● It is determined by the dentist and customized for
● It is one of the most important factors that affect patient during anterior try-in.
denture stability. ● It acts as a controlling path for the movement of
● Absence of it will result in leverage of the denture casts in an articulator.
during mandibular movement. ● It should be set depending upon the desired over-
● More important during parafunctional movements to jet and overbite planned for the patient. If the
maintain denture stability. overjet is increased, then the inclination of the
Factors responsible for balanced articulation in com- incisal guidance is decreased. If the overbite is
plete dentures or laws of articulation of developing increased, then the incisal inclination increases.
balanced occlusion are as follows: ● The incisal guidance has more influence on the
a. Condylar guidance. posterior teeth than the condylar guidance, because
b. Incisal guidance. the action of the incisal inclination is closer to the
c. Compensating curves. teeth than the action of the condylar guidance.
d. Relative cusp height. ● During protrusive movements, the incisal edge of
e. Plane of orientation of the occlusal plane.} the mandibular anterior teeth move in a downward
and forward path corresponding to the palatal
[SE Q.7] surfaces of the upper incisors. This is known as
{Condylar guidance the protrusive incisal path or incisal guidance.
● First factor of occlusion. The angle formed by this protrusive path to the
● Only factor which can be recorded from the patient. horizontal plane is called as the protrusive incisal
● Registered using protrusive registration. The patient path of inclination or the incisal guide angle.
is asked to protrude with the occlusal rims. ● It influences the shape of the posterior teeth. If the
● Interocclusal record material is injected between the incisal guidance is steep, then steep cusps or a
occlusal rims in this position. The occlusal rims with steep occlusal plane or a steep compensatory
interocclusal record are transferred to the articulator. curve is needed to produce balanced occlusion
Since the occlusal rims are in a protrusive relation, ● In a complete denture, the incisal guide angle
the upper member of the articulator is moved back to should be as flat (more acute) as possible.
accommodate them. ● The incisal guidance cannot be altered beyond
● Interocclusal record is carefully removed and the up- limits. The location and angulation of the incisors
per member is allowed to slide forward to its original are governed by various factors like aesthetics,
position. The condylar guidance should be adjusted function and phonetics.}
or rotated till the upper member slides freely into [SE Q.9]
position. It is transferred to the articulator as the
condylar guidance. {Compensating curve
● Increase in the condylar guidance increases the jaw
It is ‘the anteroposterior and lateral curvatures in the
separation during protrusion. alignment of the occluding surfaces and incisal edges of
artificial teeth which are used to develop balanced occlu- inner inclines of the maxillary buccal cusp. In the
sion’ (GPT). balancing side, the mandibular buccal cusps should
● It is an important factor for establishing balanced contact the inner inclines of the maxillary palatal
occlusion and determined by the inclination of the cusp. This relationship forms a balance, only if the
posterior teeth and their vertical relationship to the teeth are set following the Monson’s curve, and
occlusal plane. then there will be lateral balance of occlusion.
● The posterior teeth should be arranged such that their Compensating curve for anti-Monson or Wilson’s curve
occlusal surfaces form a curve which should be in It is ‘A curve of occlusion which is convex upwards’
harmony with the movements of the mandible guided (GPT).
posteriorly by the condylar path. ● This curve runs opposite to the direction of the
● A steep condylar path requires a steep compensatory Monson’s curve.

curve to produce balanced occlusion otherwise there ● It is followed when the first premolars are ar-
will be loss of balancing molar contacts during ranged, so that they do not produce any interfer-
protrusion. ence to lateral movements.
There are two types of compensating curves, namely: Reverse curve
i. Anteroposterior compensating curves. It is ‘A curve of occlusion which in transverse cross-sec-
ii. Lateral compensating curves. tion conforms to a line which is convex upward’ (GPT).
Curve of Spee, Wilson’s curve and Monson’s curve are ● It improves the stability of the denture.
associated with natural dentition. In complete dentures, ● It is explained in relation to mandibular posterior
compensating curves similar to these curves should be teeth.

incorporated to produce balanced occlusion. ● The reverse curve was modified by Max. Pleasure
to form the pleasure curve.

i. Anteroposterior compensating curves Pleasure curve
These are compensatory curves running in an antero- It is ‘A curve of occlusion which in transverse cross-
posterior direction. They compensate for the curve of section conforms to a line which is convex upward
Spee seen in natural dentition. except for the last molars’ (GPT).
Compensating curve for curve of Spee ● It was proposed by Max. Pleasure to balance the
● Curve of Spee is defined as, ‘Anatomic curvature of occlusion and increase the stability of the denture.
the occlusal alignment of teeth beginning at the tip ● Here, the first molar is horizontal and the second
of the lower canine and following the buccal cusps premolar is buccally tilted.
of the natural premolars and molars, and continuing ● The second molar independently follows the an-
to the anterior border of the ramus as described by teroposterior compensating curve and is lingually
Graf von Spee’(GPT). tilted.
● It is an imaginary curve joining the buccal cusps ● This curve runs from the palatal cusp of the first
of the mandibular posterior teeth starting from the premolar to the distobuccal cusp of the second
canine passing through the head of the condyle. molar.
● It is seen in the natural dentition and should be ● The second molar gives occlusal balance and the
reproduced in a CD. second premolar gives lever balance.}

● The significance of this curve is that when the pa-
tient moves his mandible forward, the posterior a. Relative cusp height
teeth set on this curve will continue to remain in Cuspal angulation
contact. If the teeth are not arranged according to It is ‘The angle made by the average slope of a cusp
this curve, there will be disocclusion during protru- with the cusp plane measured mesiodistally or buc-
sion of the mandible (Christensen’s phenomenon). colingually’ (GPT).
ii. Lateral compensating curves ● The mesiodistal cusps which lock the occlusion
These curves run transversely from one side of the arch and repositioning of teeth do not occur due to set-
to the other. The following curves fall in this category: tling of denture base.
Compensating curve for Monson’s curve ● To prevent the above, the mesiodistal cusps are
It is ‘The curve of occlusion in which each cusp and reduced during occlusal reshaping. In the absence
incisal edge touches or conforms to a segment of a of mesiodistal cusps, the buccolingual cusps are
sphere of 8 inches in diameter with its centre in the considered as a factor for balanced occlusion.
region of the glabella’ (GPT). ● Shallow overbite cases: The cuspal angle should
This curve runs across the palatal and buccal cusps be reduced to balance the incisal guidance, so that
of the maxillary molars. the jaw separation will be less. Teeth with steep
● During lateral movement, the mandibular lingual cusps will produce occlusal interference in these
cusps on the working side should slide along the cases.
● Deep bite (steep incisal guidance): The jaw sepa- [SE Q.6]
ration is more during protrusion. Teeth with high
cuspal inclines are required in these cases to pro-
{Uses of an articulator
● To diagnose the state of occlusion in both the natural
duce posterior contact during protrusion.
and artificial dentitions.
Protrusive balanced occlusion
To plan dental procedures based on the relationship
● It is present when mandible moves in a forward
between opposing natural and artificial teeth, e.g. in
direction and the occlusal contacts are smooth and
evaluation of the possibility of balanced occlusion.
simultaneous anteriorly and posteriorly.
● To aid in the fabrication of restorations and prosth-
● There should be at least three points of contact in
odontic replacements.
the occlusal plane. Two located posteriorly and
● To correct and modify completed restorations.
one located in the anterior region. This is absent
● To arrange artificial teeth.
in natural dentition.
Requirements of an articulator
Factors that govern protrusive balance are
Minimal requirements
● The inclination of the condylar path recorded on
● It should hold casts in the correct horizontal relation-
the patient represents the path travelled by the
ship.
condyle in protrusion, which is modified by the
● The incisal guide table should be customizable and
combined action of all the tissues in the temporo-
allow modification.
mandibular joint (TMJ) and the ridges covered by
● It should hold casts in the correct vertical relation-
the recording bases.
ship.
● Angle of the incisal guidance chosen for the
● The cast should be easily removable and reattachable.
patient.
● It should provide a positive anterior vertical stop
● Angle of the plane of occlusion.
(incisal pin).
● The compensating curves chosen for orientation
● It should accept facebow transfer record using an
with the condylar path and the incisal guidance.
anterior reference point.
● Cuspal height and inclination of the posterior
● It should open and close in a hinge movement.
teeth.
● It should be made of noncorrosive and rigid materi-
. Plane of occlusion or occlusal plane
b
als that resist wear and tear.
It is ‘An imaginary surface which is related anatomi-
● It should not be bulky or heavy.
cally to the cranium and which theoretically touches the
● There should be adequate space present between the
incisal edges of the incisors and the tips of the occluding
upper and lower members.
surfaces of the posterior teeth. It is not a plane in the
● The moving parts should move freely without any
true sense of the word, but represents the mean curva-
friction.
ture of the surface’ (GPT).
● The nonmoving parts should be of a rigid articula-
● It is established anteriorly by the height of the lower
tor’s construction.
canine, which nearly coincides with the commissure
Additional requirements
of the mouth.
● The condylar guides should allow protrusive and
● It is established posteriorly by the height of the retro-
lateral jaw motion.
molar pad. It is usually parallel to the ala-tragus line or
● The condylar guide should be adjustable in a hori-
Camper’s line.
zontal direction.
● It can be slightly altered. Tilting the plane of occlu-
● The articulator should be adjustable to accept and
sion beyond 10° is not advisable.
alter the Bennett movement.
Q.2. What is an articulator? Classify articulator and Advantages of articulators
write uses and requirements of an articulator. ● Properly mounted casts allow the operator to visual-
ize the patient’s occlusion, especially from the lin-

Ans.
gual view.
(SE Q.6 and SN Q.1) ● Patient cooperation is not a factor when using an ar-
ticulator once the appropriate interocclusal records

{(Articulator are obtained from the patient.
Articulator is ‘A mechanical device which represents ● The refinement of complete denture occlusion in the
the TMJs and the jaw members to which maxillary mouth is extremely difficult, because of shifting den-
and mandibular casts may be attached to simulate ture bases and resiliency of the supporting tissues.
jaw movements’ (GPT).)} This difficulty is eliminated when articulators are
used.
● Reduced chair time and patient’s appointment time. relationships that occur in different persons is
● The patient’s saliva, tongue and cheeks are not fac- provided.
tors when using an articulator. b. Based on the type of record used for their adjust-
Disadvantages of articulators ment
● Metal articulators show errors in tooling (manufacture)/ Based on the type of record accepted by the articula-
errors resulting from metal fatigue. tor, they are classified as:
● The articulator may not exactly simulate the intrabor- i. Interocclusal record adjustment
der and functional movements of the mandible. ● Most articulators are adjusted by some kind of
● Errors in jaw relation procedures are reproduced as interocclusal records.

errors in denture occlusion. Articulators do not have ● These records are made up of base plate wax,
any provision to correct these errors.} plaster of Paris, and zinc oxide eugenol paste
Classification of articulators or cold-cure acrylic resin.
The most popular methods of classifying are ii. Graphic record adjustment
a. Based on the theories of occlusion. ● It consists of records of the extreme border
b. Based on the type of interocclusal record used. positions of mandibular movements.

c. Based on the ability to simulate jaw movements. ● These articulators are capable of accurately
d. Based on the adjustability of the articulator. reproducing the border movements of the
mandible.
a. Based on the theories of occlusion ● The facebow and jaw-writing apparatus
i. Bonwill theory of articulator (pantograph) can be attached to transfer the

● It was designed by W.G.A. Bonwill. records.
● According to the Bonwill’s theory of occlusion, ● Hinge axis location for adjusting articulators:
teeth move in relation to each other as guided by A transographic record can be used to record
the condylar and the incisal guidance. the accurate location of the hinge axis in an
● It is also known as the theory of equilateral trian- articulator.
gle. The distance between the condyles is equal to c. Based on the ability to simulate jaw movements
the distance between the condyle and the mid- This is the most widely used classification.
point of the mandibular incisors (incisal point). At the International Prosthodontic Workshop on
● An equilateral triangle is formed between the complete denture occlusion at the University of
two condyles and the incisal point and the di- Michigan in 1972, the articulators were classified
mension of the equilateral triangle is 4 inches. based on the instrument’s capability, intent, record-
● This articulator allows lateral movement and ing procedure and record acceptance.
permits the movement of the mechanism Class I
(joint) only in the horizontal plane. ● Simple articulators capable of accepting a sin-
ii. Conical theory of articulators (proposed by gle static registration.

R.E. Hall) ● Only vertical motion is possible.
● It was proposed that the lower teeth move over ● These articulators are used in the cases where
the surfaces of the upper teeth as over the surface a tentative jaw relation is done, e.g. Slab ar-
of a cone, generating an angle of 45o with the ticulator and Barn door articulator.
central axis of the cone tipped 45° to the occlusal Class II
plane, e.g. the Hall automatic articulator is de- ● They permit horizontal and vertical move-
signed by R.E. Hall. ments, but do not orient the movement to TMJ
iii. Spherical theory articulators with a facebow.
● It was proposed that lower teeth move over the ● Type A: Limited eccentric motion is possible
surface of upper teeth as over a surface of based on the average values, e.g. mean-value
sphere with a diameter of 8 inches. articulator.
● The centre of the sphere was located in the ● Type B: Limited eccentric motion is possible
region of glabella. The surface of the sphere based on theories of arbitrary motion, e.g.
passed through the glenoid fossa and along Monson’s articulator and Hall’s articulator.
with the articulating eminences, e.g. the ar- ● Type C: Limited eccentric motion is possible
ticulator devised by G.S. Monson. based on engraving records obtained from the
Disadvantages of articulators based on theory of occlu- patient, e.g. House’s articulator.
sion are Class III
● These articulators are based on theoretical concepts ● These articulators permit horizontal and verti-
and no provision for variations from the theoretical cal movements.

● They do accept facebow transfer, but this facil- ● Advantages: Facebow transfer. Occlusal plane
ity is limited. and relationships of opposing casts are preserved
● They cannot allow total customization of con- when articulator is opened or closed.
dylar pathways. Nonarcon articulators
● These instruments simulate condylar pathways ● These have condylar elements attached to up-
by using average or mechanical equivalents for per member and condylar guidance to lower
the whole or part of the condylar motion. member.
● Type A: It accepts static protrusive registration ● Reverse of TMJ, e.g. Hanau H Series, Dentatus
and use equivalents for other types of motion, e.g. and Gysi.
Hanau H, Hanau II and Bergstorm articulator. Fully adjustable articulators
● Type B: It accepts static lateral protrusive registra- ● These are capable of being adjusted to follow
tion and use equivalents for other type of motion, the mandibular movement in all directions.
e.g. Panadent, trubite and Teledyne Hanau univer- ● These have numerous adjustable readings,
sity series. which can be customized for each patient.
Class IV ● These do not have the condylar guidance. In-
● These articulators accept three-dimensional stead, they have receptacles in which acrylic
dynamic registrations. dough can be contoured to form a customized
● They are capable of accurately reproducing the condylar and incisal guidance.
condylar pathways for each patient. ● These are complex and are not commonly used,
● They allow point-orientation of the casts using e.g. Stuart instrument gnathoscope, simulator by
a facebow transfer. E. Granger.
● Type A: The condylar path is determined by the
engraving registrations produced by the pa- Q.3. Write in detail the procedures involved in the selec-
tient. This path cannot be modified, e.g. TMJ tion of anterior teeth in complete denture patient.
articulator. Ans.
● Type B: They are similar to type A, but they al-
low angulations and customization of the con- [SE Q.3]

dylar path, e.g. Stuart instrument gnathoscope.
d. Based on the adjustability of the articulator {Anterior teeth selection
It is classified as: ● Anterior teeth play an important role in aesthetics of a
● Nonadjustable. patient. They are not subjected to heavy occlusal load
● Semi-adjustable. like the posteriors. Hence, aesthetics is given more im-
● Fully adjustable. portance during anterior teeth selection.
Nonadjustable articulators ● The following factors are also considered during the
● They can open and close in a fixed horizontal selection of anterior teeth:
axis. A. Size of the teeth.
● They have a fixed condylar path along which B. Form of the teeth.
the condylar ball can be moved to simulate C. Colour/shade of the teeth.
lateral and protrusive jaw movement. A. Size of the anterior teeth
● The incisal guide pins ride on an inclined plate
● The tooth size should be appropriate to the size of the
in a fixed inclination. face and sex of the patient. The following methods are
Semi-adjustable articulators used as a guide to select the size of the teeth:
● They have adjustable horizontal condylar
i. Methods using pre-extraction records.
paths, adjustable lateral condylar paths, adjust- ii. Methods using anthropological measurements of the
able incisal guide tables and adjustable inter- patient.
condylar distances. iii. Methods using anatomical landmarks.
● Degree and ease of these adjustments differ.
iv. Methods using theoretical concepts.
Two types of semi-adjustable articulators are v. Other factors.}
Arcon articulators
● The term was derived by Bergstorm from the i. Methods using pre-extraction records
words articulator and condyle, e.g. Hanau Uni- ● Like diagnostic casts, photographs and radiographs, the
versity series and Whip Mix articulators. teeth of close relatives and preserved extracted teeth
● Condylar element attached to lower member can be used to determine the size of the artificial teeth.
and condylar guidance to upper member of ● Diagnostic casts
articulator. i. They are prepared before the extraction of the

● Resemble TMJ. teeth.
ii. They provide an idea about the size and shape of is the distance measured between the hairline and
the teeth. the tip of the chin.
iii. The actual size and shape required can be deter- Width of the maxillary central incisor 5 Bizygo-
mined, but the shade of the teeth cannot be deter- matic width/16
mined using this method. Width of the maxillary central incisor 5 Length of
● Pre-extraction photographs: The lateral, ante- the face/20
rior and anterolateral views of the patient should ● Based on the size of the face: This is a tentative
be taken before extraction. These photographs measurement in which the size of the teeth is deter-
must show at least the incisal edges of the ante- mined by the size of the face. For example, large
rior teeth. This method is useful to determine teeth are selected for patients with a large face.
the exact width and outline of the teeth. ● H. Pound’s formula: Pound derived two formulae to
● Pre-extraction radiographs: They are usually ob- determine the width and length of the central incisor
tained from the patient’s previous dentist. Radio- using the bizygomatic width and the length of the
graphic errors are a major limitation to this face, respectively.
method. The occluso-gingival height and the out- Width of the maxillary central incisor 5 Bizygo-
line of the teeth can be recorded. But the contour matic width/16
and size cannot be accurately determined, as the Length of the maxillary central incisor 5 Length of
radiograph is a two-dimensional image. the face/16
● Teeth of close relatives: This method is usu- ● Based on the width of the nose: The width of the
ally followed only if the other records are not nose is measured with a vernier calliper. This mea-
available. The size and contour of the patient’s surement is transferred to the occlusal rim. The
son or daughter’s tooth is taken as reference. width of the nose is equal to the combined width of
● Preserved extracted teeth: This is the best the anterior teeth.
method to determine the size of the anterior iii. Methods using anatomical landmarks
tooth. The exact details about the size and Various anatomical landmarks like the size of the maxillary
contour can be recorded from this method. arch and location of the canine eminences, buccal frenal
ii. Methods using anthropological measurements of the attachments, corners of the mouth, and ala of the nose can
patient be used to determine the size of the artificial teeth.
● These are postextraction records made directly from ● Size of the maxillary arch: The distance between the
the edentulous patient which measure certain ana- incisive papilla and the hamular notch on one side is
tomical dimensions and derive the size of the teeth added with the distance between two hamular
using certain formulae. notches. This gives the combined width of all the
● Anthropometric cephalic index: The transverse cir- anterior and posterior teeth of the maxillary arch.
cumference of the head is measured using a measuring ● Location of canine eminences: A canine eminence is
tape at the level of the forehead. The width of the up- formed in the region between the canine and the first
per central incisor can be derived from this measure- premolar after extraction of teeth.
ment. Sears called this formula as the anthropometric ● The distance between the two canine eminences is
cephalic index. measured along the residual ridge. This measured

Width of upper central incisor 5 Circumference of value gives the combined width of the anterior teeth.
the head/13 ● Location of the buccal frenal attachments: The at-
● The bizygomatic width can be used to determine the tachments of the buccal frenum are marked on the
width of the central incisor and also the combined residual ridge. The distance between the two mark-
width of the anteriors. The bizygomatic width is the ings recorded along the residual ridge gives the
distance measured between the malar prominences combined width of the maxillary anteriors.
on either side. This measurement is also used in ● Location of the corners of the mouth: The corner of
Berry’s Biometric index and in H. Pound’s formulae. the mouth marks the distal end of the canine. The
Total width of upper anteriors 5 Bizygomatic corners of the mouth are recorded on the occlusal rim
width/3.36 and the distance is measured between these markings.
Total width of lower anteriors 5 4/5 the width of The anterior teeth are set within these markings.
upper anteriors ● Location of the ala of the nose: The patient is asked
● Berry’s biometric index: Berry’s biometric index is to sit upright and look straight. A line passing
used to derive the width of the central incisor using through the midpoint between the eyebrows and the
the bizygomatic width and/or the length of the face. lateral end of the ala of the nose extended onto the
The formula using the length of the face cannot be occlusal rim gives the combined width of the ante-
used for edentulous patients. The length of the face rior teeth.
iv. Methods using theoretical concepts Phlegmatic type: Phlegm dominance (phlegm is a
● Winkler’s concept: According to Winkler, the teeth watery fluid elaborated from brain).
should be selected based on three different views, Choleric type: Yellow bile dominance (from
namely physiological, psychological and biomechanical. liver).
Psychological Melancholic type: Black bile dominance (from
● Positive self-evaluation patient shows a broad smile. spleen).
● Negative self-evaluation shows a tight-lipped Association of certain mental, functional and
small smile. physical characteristics created the tempera-
● The Camper’s line is the psychological plane of ment theory. People of each group exhibit a
orientation. certain type of teeth.
● It is raised in happy people and is tilted downward l Concept of harmony by J.W. White in 1872
in depressed. According to him, the size and colour of the teeth
Biomechanical should be in harmony with the size of the head
● The teeth should be placed such that they fulfil the and colour of the eye, respectively.
biomechanics of the denture. v. Other factors
● It is not necessary to set the teeth on, outside, or Other factors that influence the size of teeth are
inside the ridge. ● Size of the face.
● Instead they should be set in the neutral zone (the ● Interarch spacing.
zone of balance between the buccal and lingual ● Distance between the distal ends of the maxillary
musculature). cuspid.
Physiological–biological ● Length of the lips.
The facial musculature contributes to the aesthetics ● Size and relation of the arches.
of a patient.
[SE Q.3]
Increased thickness of denture base in labial and buc-
cal sulci produces a puffy appearance. Facial wrinkles B. {Form of the anterior teeth
fade when the vertical dimension is increased accord- It can be determined using the following factors:
ingly. The dentist should evaluate the perioral tissues i. Shape of the patient’s face or facial form
and arrange the teeth. The teeth selected should be in harmony with the
● Typical form theory by Leon Williams (1917) facial form. Ovoid teeth are preferred for patients
This theory helps determine the size and form of the with an oval face, etc.
anterior teeth. According to him, the shape of the ii. Patient’s profile
teeth should be the inverse of the shape of the face. ● The patient may have a convex, straight or a con-
That is, if the face tapers downwards, the teeth should cave profile.
taper upward. ● The labial form of the anterior teeth should be
According to Leon Williams, facial forms fall into similar to the facial profile of the patient.
below four categories: For example, the labial form should be straight
Square for patients with a straight profile and convex for
Ovoid a patient with a convex profile.
Tapering iii. Dentogenic concept and dynesthetics (sex, personal-
Combination. ity, age or SPA factor)
● Temperamental theory by Dr Sparzheim ● Described by Frush and Fisher, this concept
This theory is based on the concept of Hip- states that sex, personality and age of the patient
pocrates. determine the form of the anterior teeth.
It is one of the oldest theories proposed around Sex: The form or shape of the teeth differs in
2400 years ago. males and females as follows:
Hippocrates stated that the body comprised of i. In females, the incisal angles are more rounded
four juices of humour, namely, blood, phlegm, and the teeth have a lesser angulation.
yellow bile and black bile. Imbalance of these ii. In males, the incisal angles are rounded to a
juices is the basis for the various ailments and dif- lesser degree and the teeth are more angular.
ferences in man. Age: It is important in teeth selection because of
Man can be classified based on the dominance of the physiological and functional changes that
humour as follows: occur in the oral tissues. The patient can be
Sanguineous type: Blood dominance. young, middle-aged or old-aged.
The following changes are observed with an advance in ● In people with light skin colour, teeth with lighter
age of the patient: shades should be chosen and vice versa.
● Due to decrease in muscle tone, sagging of the ● Saturation or chroma
cheeks and the lower lips occur. To prevent cheek ● It is the amount of colour per unit area of an ob-
biting due to sagging, the horizontal overlap of ject or intensity of the colour. Objects with highly
the posterior teeth can be increased. saturated colours lack depth.
● Interocclusal distance reduces with age. Hence, ● Translucency
mandibular teeth are more visible than the maxil- ● Property of the object to partially allow passage of
lary teeth. light through it.

● Old people usually have abraded teeth with worn ● Enamel has high brilliance and translucency;
out contacts. Hence, placement of contoured hence, artificial teeth should also show the same
teeth may look artificial. properties for a natural appearance.)}
● Old patients have gingival recession. It can be
reproduced in the dentures to provide a natural [SE Q.3]

appearance. {The hue and brilliance of a tooth is influenced or de-
● Old people show a blunt smile line and patho- termined by the following factors:
logic migration of teeth. Age
● The colour of the teeth also changes with age. ● Young people have lighter teeth where the co-
In old people, the enamel is abraded and the lour of the pulp is shown through the translu-
dentine which carries a yellow tinge is more cent enamel.
visible. ● Old people show dark and opaque teeth due to
Personality: The dentist should select and arrange the the deposition of secondary dentine and conse-
teeth, so that it improves the patient’s personality. The quent reduction in size of the pulp chamber.
patient can be either vigorous or delicate. ● Teeth shine more, in old people, as they get
i. More squarish and large teeth – vigorous people. polished due to regular wear of the teeth.
ii. Anteriors in a flat plane for executives and teeth ● Teeth of older people obtain a brownish tinge,
should be relatively smaller and more symmetri- because exposed dentine tends to stain.
cally arranged. The incisal edge of the central ● Preserved extracted teeth are not used to select
incisors is parallel to the lips and the laterals are the colour of the teeth, because they become
above the occlusal plane in males. But, the inci- discoloured (as they are nonvital).
sal edges of the central and lateral incisors fol- Habits
low curve of the lower lip in females. The distal ● Smokers, alcoholics and pan chewers have
surface of the centrals is rotated posteriorly for discoloured teeth due to stains.
females. ● In such people, porcelain teeth are preferred,
C. Colour/shade of the anterior teeth} because they are not porous and do not allow
percolation.
(SE Q.3 and SN Q.5) Complexion
● Colour of the teeth chosen should be in har-
{(A single colour can be described under four parameters: mony with the complexion of the patient.
● Hue. ● Colour of the face is more important, because
● Brilliance or value. the teeth fall into the framework of the face.
● Saturation or chroma. Colour of the eyes
● Translucency. Colour of the iris is considered unreliable, because
● Hue the eyes are too small and far away from the teeth
● A specific colour produced by a specific wave- to significantly influence the choice of colour.
length of light. Colour of the patient’s hair
● It should be in harmony with the patient’s skin It is very unreliable, because of factors like cos-
colour or else it will produce an artificial look for metics. Also, hair colour changes with age.
the denture. Steps in the selection of contour for anterior teeth:
● Brilliance or value ● For single tooth replacement, adjacent teeth are
● Lightness or darkness of the object. taken as guide.
● Dilution of colour with either black or white to pro- ● For an edentulous patient, factors like skin colour,
duce lighter or darker shades respectively. hair colour and eye colour are considered.
The following reference points on the face can be used of the arch does not exceed the distance between
to select the colour of the tooth: the canine and the retromolar pad.
l Side of the nose: This point helps to determine the ● Posterior teeth should not be placed over steep
basic hue, brilliance and saturation. anteroposterior ridge slope, as this would lead to
● Under the lips with only the incisal edge exposed: forward displacement of the denture.
This reference point gives an idea of how the teeth ● Similarly, the teeth should not be placed over dis-
will look when the patient is relaxed. placeable tissues like the retromolar pad as it will
● Under the lips with the mouth wide open and only cause tipping of the denture during the function.
the cervical third covered: This gives an idea of ● In the cases with inadequate mesiodistal length,
how the teeth will look when the patient is smiling. the premolar can be omitted.
Hanau’s quint ii. Form of the posterior teeth
Squint test ● Posterior teeth are available in different forms.
● It is used to check and compare the colour of the ● Factors that control the selection of the form of a
teeth with the colour of the face. tooth are:

● The dentist should partially close his eyes to re- Condylar inclination: Teeth with a high cuspal
duce light and compare artificial teeth of different height are required for patients with steep condy-
shades with the colour of the face. lar guidance. This is because the jaw separation
● The colour of the teeth that fades first from view will increase for patients with acute condylar
is least conspicuous (contrasting) to the colour of guidance during protrusion.
the face.} Height of the residual ridge: Shallow cusped teeth
go better with shallow ridges.
[SE Q.4] Patient’s age: Teeth with shallow cusps are pre-
ferred in older people.
{Posterior teeth selection: Ridge relationship: Monoplane teeth are preferred
It is classified under two divisions, namely:
for cases with posterior crossbite or severe class II
i. Size of the teeth.
relationship.
ii. Form of the teeth.
Hanau’s quint.
i. Size of the posterior teeth Morphologically teeth can be classified as:
The following factors are considered while selecting the i. Cusp teeth
size of the teeth: a. Anatomic teeth.
Buccolingual width b. Semi-anatomic or modified cusp or low cusp
● It should be decreased for artificial teeth, so that teeth.
the buccal and the lingual surfaces slope out from ii. Cuspless teeth.
the occlusal surface to provide a proper path of iii. Special forms.
escapement of food during mastication.
● It should be such that the forces from the tongue i. Cusp teeth
neutralize the forces of the cheek. They have cusps and fossae-like natural teeth. They
● If the buccolingual width increases, the forces act- are of two types, namely anatomic and semi-
ing on the denture will also increase, leading to anatomic. Cusp teeth can be used in the following
increase in the rate of ridge resorption. occlusal schemes:
● Broader teeth encroach into the tongue space ● Bilateral balanced occlusion in centric and ec-
leading to instability of the denture. Also, the centric relations.

teeth should not encroach into the buccal corridor ● Balance in centric only.
space to avoid cheek biting. ● Nonintercusping cusp (modified occlusion).
Occlusogingival height and mesiodistal length a. Anatomic teeth

● They are determined by the available interarch ● These teeth resemble normal newly erupted
distance. teeth.
● The occlusal plane should be located at the mid- ● They provide best aesthetics and are most
point of interocclusal distance. commonly used type of artificial teeth.

● Large teeth selected for cases with inadequate ● Cusps resemble normal dentition with an an-
interocclusal distance appear artificial and require gle of 33°. Anatomic teeth with 30° cuspal
modification before arrangement. angulation are also available and are called
● Measures like altering the thickness of the denture Pilkington-Turner teeth.}
base can also be done to accommodate large teeth. Advantages of anatomic teeth
● Each tooth should be selected such that the ● They closely resemble natural teeth. They are
combined length of all posterior teeth on that side highly aesthetic.

● Proper contours for crushing and triturating. c. Flat plane balance in centric only.
● Presence of adequate sluiceways. d. Reverse-pitch (anti-Monson) curve.)}
● There is greater chewing efficiency. Excessive
[SE Q.4 and Q.8]
chewing pressure is minimized.
● More vertical chewing stroke. {Advantages of cuspless occlusal schemes
● Cuspal inclines provide a depth to obtain ec- More stable lower denture during mastication.
●
centric balance. More vertical chewing stroke.
●
● They provide a greater resistance to rotation ● More shear in chewing stroke.
of dentures. ● More tongue room.
● They provide a comfortable position to return Disadvantages of cuspless occlusal schemes
to, when cusps are making contact in fossae. ● Less stable upper denture.
Disadvantages of anatomic teeth ● No balance during excursive guides – pleasure curve
● More difficult and time-consuming to obtain needs to be added.}
balanced occlusion.
(SE Q.4, Q.8 and SN Q.14)
● Settling (stabilization of occlusion) results in
more damaging interferences. {(Advantages of zero degree teeth

● Possibilities of more lateral stress in function. Easy to set up.
●
● Settling also causes the vertical dimension at Less lateral stress.
●
occlusion to decrease and the mandible to ● Least anteroposterior interferences after set-
move forward. tling.
● Settling will lead to residual ridge. ● Best for patients with poor neuromuscular control
and poor ridge relationships.

[SE Q.4] ● Reduced buccolingual width.
{b. Semi-anatomic teeth ● Sharp grooves and sluiceways compensate for
● It also known as modified-cusp or low-cusp teeth. cusps in getting equal chewing efficiency.
● They may have 20° or 10° cuspal angulation. Disadvantages of zero degree teeth
● Ten-degree semi-anatomic teeth are known as func- ● Difficult to obtain balanced occlusion in excursive
tional or anatoline teeth. movements.

They are used in cases with mild discrepancies in jaw rela- ● Less chewing efficiency for fibrous and tough
tion. They are more flexible to arrange than anatomic food.

teeth, but they are not as flexible as nonanatomic teeth.} ● Poor aesthetics.
Advantages of semi-anatomic teeth ● When set on flat plane, a space develops posteri-
● They are easier to arrange and obtain balanced orly when excursions occur called Christenson’s
occlusion. phenomena causing excessive pressure and re-
● They can provide freedom, if settling occurs. sorption in the anterior region.)}
● Reduction of lateral stresses.
[SE Q.4]
● They provide all the advantages of cusp teeth.
Disadvantages of semi-anatomic teeth {iii. Special tooth forms

● Less aesthetic (buccal cusps are shorter). Include French’s posteriors, cutter bars, masticators,
● Less chewing efficiency (controversial: some VO posteriors, Sosin-bladed teeth, etc.}
claim greater). Advantages
● They provide moderate to excellent function.
(SE Q.4, Q.8 and SN Q.14) Disadvantages
● Poor aesthetics.
{(ii. Cuspless teeth
● They require meticulous execution and skill.
● They are also known as 0°, flat or monoplane teeth.
● They are more expensive.
They have no cuspal angulation hence are very
● They are poorly designed and have only ‘gim-
flexible to set.
● It is easy to set nonanatomic teeth in balanced
mick’ value.
occlusion. Q.4. Discuss the importance of try-in stage in complete
● Cuspless teeth can be used for the following denture prosthodontics.
occlusal schemes:
a. Bilateral balance with a compensating curve. Ans.
b. Three-point balance with a balancing ramp. Try-in stage in complete denture prosthodontics
[SE Q.2] Intraoral

● Retromolar pad area – height of mandibular
{The try-in stage is a preliminary insertion of remov- plane is usually placed at level of junction be-
able denture wax-up or a partial denture casting or a tween anterior two-third and posterior one-
finished restoration to determine the fit, aesthetics and third of retromolar pad area.
maxillomandibular relations (GPT). ● Tongue: Normally it rests on lingual part of
Procedure for try-in mandibular anteriors.
It involves verification of all the procedures carried out in ● Linea alba buccalis.
fabrication of complete denture as follows: Extraoral
a. Primary evaluation ● Mandibular occlusal plane is kept at the level
● Check for adaptation: Base plate adaption is checked of corners of the mouth.
on an articulator extraorally first and then intraorally g. Evaluation of vertical height
in the patient. ● Physiological rest position verification:
● Occlusion evaluation: Complete intercuspation of ● Patient is seated erect on dental chair, so that the
denture teeth should be present in centric relation. ala-tragal line is parallel to the floor and two
● Evaluation of vertical height: Both at rest and occlu- points are marked on patient’s face – one on tip of
sion verified. the nose and other one at chin tip.
● Evaluation of polished surfaces: Should be smooth and ● Patient is instructed to relax and swallow and
void-free to avoid discomfort and food entrapment. distance between above-marked points is recorded
b. Preliminary evaluation in articulator and measured. This is physiological rest position.
● Evaluation of impression surface: Checked for adap- ● Next, trial dentures are placed in patient’s mouth
tation and it should be free of projections. and height measured at occlusion which should be
● Evaluation of polished surface: Free of any void and 2–4 mm less than above.
be in harmony with tissue contour. ● Tactile sense method.
● Evaluation of occlusal surface: Should be free of wax ● Phonetics.
and gingival margins should be carved out properly. ● Silverman’s closest speaking space.
c. Evaluation of mouth h. Evaluation of centric relation
● Denture coverage is verified and denture border ex- Intraoral
tension is seen, so that it does not extend over the Patient is asked to keep the tongue at the junction of
nonsupporting structures. hard and soft palate and close the mouth, till the teeth
d. Evaluation of preliminary trial denture (maxillary and attain maximum intercuspation.
mandibular in mouth) ● Swallowing technique.
● Evaluation of denture extension. ● Head position.
● Evaluation of retention, stability, support and aes- Extraoral
thetics. Extraoral evaluation is done using kinematic facebow.
e. Evaluation of cheek support i. Aesthetic arrangement of anterior teeth
● The incisal third of anterior teeth should be visible Following factors are checked:
when upper lip is at rest (low lip line). ● Harmony of arch form and residual ridge form.
● The middle third should also be visible while smiling ● Harmony of opposing inclines of labial and lin-
(high lip line). gual surfaces.
● Thickness of labial and buccal flanges of denture ● Harmony of teeth and profile.
determines the labial and the buccal fullness of face. ● Harmony of incisal edge of maxillary anteriors
f. Occlusal plane evaluation with smiling line of lower lip.
Occlusal verification of maxillary trail denture j. Eccentric relation evaluation
Intraoral ● Protrusive and lateral relations are verified by mandibular
● Parotid papilla – maxillary occlusal plane movements and if any occlusal interferences are present,
should be one-fourth inch below it. then they should be eradicated by selective grinding.
● Linea alba buccalis. k. Incorporation of posterior palatal seal area
Extraoral ● Patient is asked to keep the mouth open and say ‘ah’.
● Interpupillary line: The anterior part of maxil- ● Line is drawn in mouth across the palate extending
lary occlusal plane should be parallel to it and from one hamular notch to other.
2 mm below the upper lip line or smile line. ● The denture should extend till this line that is PPS.
● Camper’s line or ala-tragal line: Posterior part of ● Checked by placing the mouth mirror at distal end
the maxillary occlusal plane should be parallel to of denture. There should be no gap between the
it when the patient is in upright sitting position. tissues and denture, when patients say ‘ah’.
Occlusal verification of mandibular trail denture ● Checking of phonetics.}
Maxillary canine ● The mesiopalatal cusp alone should touch the occlu-
● The long axis of the tooth is parallel to the vertical sal plane. This arrangement gives rise to the lateral
axis when viewed from the front. A mild mesial tilt curves.
is supposed to improve its aesthetics. Maxillary second molar
● The long axis of the tooth is parallel to the vertical It is arranged similar to a first molar except in a higher level.
axis when viewed from the side. ● The long axis of the tooth is tilted buccally when
● The cuspal tip of the canine touches the plane of viewed from the front.
occlusion. ● The long axis of the tooth is tilted distally when
● The cervical third of the canine should be more viewed from the side.
prominent than the cuspal third. ● The mesiopalatal cusp should be the nearest cusp
to the occlusal plane.

Q.5. Discuss the role of arrangement of artificial teeth in Mandibular central incisor
complete denture prosthesis. ● The long axis of the tooth is parallel to the vertical
Ans. axis when viewed from the front.

● The long axis of the tooth slopes slightly labially
An artificial tooth is set by softening the wax in that portion when viewed from the side.
of the occlusal rim and positioning the tooth on it. ● The incisal edge of the tooth should be 2 mm above
Principles of tooth arrangement the plane of occlusion.
Each tooth is attached/luted/sealed to the occlusal rim Mandibular lateral incisor
based on the following principles: ● The long axis of the tooth is parallel to the vertical
Maxillary lateral incisor axis when viewed from the front.
● The long axis of the tooth is tilted towards the mid- ● The incisal edge of the tooth should be 2 mm above
line when viewed from the front. the plane of occlusion.
● The long axis of the tooth is sloping labially when Mandibular canine
viewed from the side. The inclination of the slope is ● The long axis of the tooth is very slightly tilted lin-
greater than that of the central incisor. gually when viewed from the front.
● The incisal edge is 2 mm above the level of the oc- ● The long axis of the tooth slopes slightly mesially
clusal plane and the edge is tilted towards the midline. when viewed from the side.
Maxillary first premolar ● The canine tip is slightly more than 2 mm above the
Maxillary central incisor occlusal plane.
● The long axis of the tooth is parallel to the vertical Mandibular second premolar
axis when viewed from the front. ● The long axis of the tooth slopes slightly lingually
● The long axis of the tooth is sloping labially when when viewed from the front.
viewed from the side. ● The long axis of the tooth is parallel to the vertical
● The incisal edge of the tooth evenly contacts the axis when viewed from the side.
occlusal plane. ● The long axis of the tooth slopes slightly labially
● The long axis of the tooth is parallel to the vertical when viewed from the side, but not so steeply as the
axis when viewed from the front. central incisor.
● The long axis is parallel to the vertical axis when ● Both the cusps are 2 mm above the level of the
viewed from the side. occlusal plane.
● The buccal cusp touches the occlusal plane and Mandibular first molar
the palatal cusp is positioned about 0.5 mm above ● The long axis of the tooth slopes slightly lingually
the occlusal plane. when viewed from the front.
Maxillary second premolar ● The long axis of the tooth is tilted mesially when
● The long axis of the tooth is parallel to the vertical viewed from the side.
axis when viewed from the front. ● All the cusps are above the level of the occlusal plane
● The long axis of the tooth is parallel to the vertical with the mesial and lingual cusps being lower than
axis when viewed from the side also. the distal and buccal cusps.
● Both the buccal and the palatal cusps should touch Mandibular first premolar
the occlusal plane. ● The long axis of the tooth slopes slightly lingually
Maxillary first molar when viewed from the front.
● The long axis of the tooth is tilted buccally when ● The long axis of the tooth is parallel to the vertical
viewed from the front. axis when viewed from the side.
● The long axis of the tooth is tilted distally when ● The lingual cusp is below the occlusal plane and the
viewed from the side. buccal cusp should be 2 mm above the occlusal plane.
Mandibular second molar 3. Overjet and overbite

● The long axis of the tooth slopes slightly lingually ● Overjet denotes the distance between the upper
when viewed from the front. and lower incisors measured in the horizontal
● The long axis of the tooth is tilted mesially when plane. It should be at least 2 mm in a normal indi-
viewed from the side. vidual. Overjet is increased in cases with class II
● All the cusps are above the level of the first molar malocclusion and decreased in cases with class III
with the mesial and the lingual cusps being lower malocclusion.
than the distal and the buccal cusps. ● Overbite denotes the vertical overlap of the maxillary
and mandibular anteriors. It is usually 0.5 mm in a

[SE Q.5]
normal individual. Increase in overjet or overbite can
{Other guidelines for arrangement of teeth alter the incisal guidance of the occlusion.
The arrangement of teeth should satisfy the following 4. Compensating curves: The compensating curve for
concepts: curve of Spee, Wilson’s curve and the Monson’s curve
1. Key of occlusion: It denotes the relationship of the upper are normally incorporated to obtain a balanced occlu-
and the lower teeth during function. sion. Arranging the teeth according to the previously
a. Canine key of occlusion: According to this principle, mentioned setting principles will automatically incorpo-
usually the distal arm of the lower canine should rate the compensating curves.
align with the mesial arm of the upper canine. The 5. Neutral zone: Teeth should be arranged in the neutral
artificial teeth should be arranged according to this zone where the forces of the buccal musculature are
rule. compensated by the lingual musculature.
b. Molar key of occlusion: According to this principle, ● If the teeth are arranged buccally, the buccinator will
the mesiobuccal cusp of the maxillary permanent destabilize the denture.

molars should coincide with the mesiobuccal groove ● Similarly, if the teeth are arranged lingually, there
(also called buccal groove) of the mandibular perma- will be reduction of the tongue space and the tongue
nent molars. will destabilize the denture.
● This is class I molar relationship. Artificial teeth 6. Tooth to ridge relation: The following factors should be
should be set according to this principle. Even if considered:
there is an abnormal jaw relation, the molar rela- ● The mandibular posterior teeth should be arranged
tionship is always maintained, as it is the most on the ridge for more stability.
efficient relationship. ● The mandibular anteriors should be inclined such
2. Arch form: The maxillary arch is usually ‘U’-shaped that the incisive forces are transferred to the crest of
and the mandibular arch is ‘V’- shaped. But it is not the ridge.
mandatory for anyone to follow a fixed arch form. ● Generally, all posterior teeth should have their long
Whatever is the shape of the arch, the symmetry should axis coinciding with the long axis of the residual
never be lost. ridge.
The maxillary arch should have a smooth curve formed 7. Characterization of dentures
by the incisal edge of the anteriors. The canine will ● Artificial teeth have ideal morphology. This fre-
mark the turn of the arch and is the most prominent quently imparts an artificial appearance to the den-
tooth among the anteriors. ture, because, it is almost impossible for anyone to
Regarding the posteriors, there are two concepts followed: have a perfect set of teeth in the perfect arrangement
a. Aligned occlusal groove concept: The central grooves especially in old age.
of all the maxillary posteriors should lie on the ● Hence, the dentist can add his personal touch and
straight line joining the tip or distal arm of the canine produce small imperfections, which make the teeth
anteriorly and the midpoint of the occlusal rim look natural. These imperfections should not com-
posteriorly. promise the functions of the denture.
b. Aligned buccal ridge concept: According to this con- ● Methods of characterization include mild chipping,
cept, the line formed by the central grooves should occlusal wear facets and small restorations on the
pass lingual to the canine, and the buccal ridges of teeth, staining to depict the endemic conditions,
the maxillary canine, maxillary first premolar, maxil- mild rotations and alteration in anterior teeth
lary second premolar and the mesiobuccal line angle arrangement.
of the maxillary first molar should lie in a straight ● Though these characterizations produce a striking
line. According to this concept, the arch makes a resemblance to natural teeth, patient prefers to have
slight medial curvature at the first molar region. white, unaltered artificial looking teeth.}
Q.6. What is balanced articulation? Mention its importance/ Q.15. Discuss the principles of arrangement of artificial
rationale. Describe the factors responsible for balanced ar- teeth in complete denture prosthesis.
ticulation in complete dentures.
Ans.
Ans.
[Same as LE Q.3]
[Same as LE Q.1]
Q.16. Selection of anterior and posterior teeth in com-
Q.7. Define balanced occlusion. Enumerate the advan- plete denture.
tages of a balanced occlusion. Describe any two factors
that affect a protrusive balance. Ans.
Ans. [Same as LE Q.3]

[Same as LE Q.1] Q.17. Dentogenic concept.
Q.8. What is balanced occlusion and how do you estab- Ans.
lish it, while fabricating a complete denture?
[Same as LE Q.3]
Ans.
Q.18. Shade selection.
[Same as LE Q.1]
Ans.
Q.9. Define articulator. Discuss the advantages, disad-
vantages and classification of articulators. [Same as LE Q.3]
Ans. Q.19. Discuss the principle in arrangements of artificial

teeth in complete denture prosthodontics.
[Same as LE Q.2]
Ans.
Q.10. What is an articulator? Give the classification,
functions and requirements of an articulator. [Same as LE Q.5]
Ans.
[Same as LE Q.2]
SHORT ESSAYS:
Q.1. Rationale of balanced occlusion.
Q.11. Define articulators. Give classification, uses of
articulator and discuss in detail about a semi-adjustable Ans.
articulator.
[Ref LE Q.1]
Ans.
Q.2. Try-in procedure.
[Same as LE Q.2]
Ans.
Q.12. What are the factors for the selection of anterior
teeth for a complete denture patient? [Ref LE Q.4]
Ans. Q.3. Anterior teeth selection for complete denture.

Q.13. Define denture aesthetics and discuss the various [Ref LE Q.3]
factors influencing denture aesthetics.
Q.4. Types of posterior teeth.
Ans.
Ans.
[Same as LE Q.3]
[Ref LE Q.3]
Q.14. Discuss the physical and biological factors involved
in selection of teeth for complete denture construction in Q.5. Principles of teeth arrangement for complete eden-
edentulous patient. tulous patient.
Ans. Ans.
Q.6. Define articulator and discuss its advantages and Q.11. Define and classify articulators.
disadvantages.
Ans.
Ans.
Definition
[Ref LE Q.2] Articulator is defined as ‘A mechanical device which
represents the temporomandibular joints and the jaw
Q.7. Condylar and incisal guidance.
members to which maxillary and mandibular casts may
Ans. be attached to simulate jaw movements’ (GPT8).
Classification of articulators
[Ref LE Q.1]
The most popular methods of classifying are
Q.8. Nonanatomic teeth. A. Based on the theories of occlusion
i. Bonwill theory articulator.
Ans.
ii. Conical theory articulators (proposed by R.E.
[Ref LE Q.3] Hall).
iii. Spherical theory articulators.
Q.9. Compensating curves.
B. Based on the type of record used for their adjust-
Ans. ment
i. Interocclusal record adjustment.
[Ref LE Q.1]
ii. Graphic record adjustment.
Q.10. Bennett’s movement and Bennett angle. C. Based on the ability to simulate jaw movements
Class I: Simple articulators capable of accepting a
Ans.
single static registration, e.g. Slab articulator and
Bennett’s movement or mandibular lateral translation Barndoor articulator.
It is also known as Bennett’s shift, direct lateral side Class II: Permits horizontal and vertical movements,
shift, side shift or laterotrusion, described by Dr Norman but they do not orient the movement to TMJ with a
Godfrey Bennett in 1908. facebow.
It is described as follows: ● Type A: Limited eccentric motion is possible
● When the mandible is moved to one side, there based on the average values, e.g. mean-value
occurs an outward bodily shift of the working side articulator.
condyle (also known as rotating condyle). ● Type B: Limited eccentric motion is possible
● This lateral or outward side shift of the condyle on based on theories of arbitrary motion, e.g. Mon-
one side corresponds with a medial or inward son’s articulator and Hall articulator.
movement of the condyle on the other side (also ● Type C: Limited eccentric motion is possible
known as orbiting condyle). based on engraving records obtained from the

● As the mandible is moved further to the side, after patient, e.g. House’s articulator.
the initial immediate medial movement or simul- Class III: These articulators permit horizontal and
taneously with it, there occurs a progressive vertical movements.
downward and forward movement of the orbiting They do accept facebow transfer, but this facility
(balancing side) condyle. is limited.
Significance ● Type A: It accepts static protrusive registration
● Bennett’s movement is incorporated in many ar- and uses equivalents for other types of motion,
ticulator designs and is significant while restoring e.g. Hanau H, Hanau II and Bergstorm articulator.
the occlusion in dentulous individuals. ● Type B: It accepts static lateral protrusive regis-
● According to GYSI, it averages around 1.5 mm per tration and uses equivalents for other type of
side, but in rare instances can measure up to 4 mm. motion, e.g. Panadent, trubite and Teledyne
● The attributes of Bennett’s movement determines Hanau university series.
cusp height and morphology. Class IV: These articulators accept three-dimensional
Bennett angle dynamic registrations.
It is formed between the path of nonworking condyle They are capable of accurately reproducing the
and the sagittal plane. condylar pathways for each patient.
It is about 15° according to GYSI. ● Type A: The condylar path is determined by
It is given by the following formula: the engraving registrations produced by the
Bennett angle (L) 5 H/8 1 12, where H 5 horizon- patient. This path cannot be modified, e.g.
tal condylar inclination. TMJ articulator.
● Type B: They are similar to type A, but they al- Q.3. Porcelain denture teeth. Its indications and contra-
low angulations and customization of the con- indications.
dylar path, e.g. Stuart instrument gnathoscope.
Ans.
D. Based on the adjustability of the articulator
● Nonadjustable. Porcelain denture teeth
● Semi-adjustable. Porcelain denture teeth are one of the artificial teeth
● Fully adjustable. which do not bond chemically to the denture base, but
are mechanically retained to it with the help of pins or
Q.12. Laws of balanced occlusion.
channels within the teeth in which acrylic enters and
Ans. locks the teeth mechanically to the denture base.
[Same as SE Q.1] Indications
● Inter-ridge space is sufficient.
Q.13. Enumerate the factors affecting balanced occlusion. ● Well-formed ridges.
● When superior aesthetics is required.

Ans.
Contraindications
[Same as SE Q.1] ● Poor mandibular ridges.
● When opposing natural teeth are present, as it can

Q.14. Dentogenic concept.
cause their chipping and wear.
Ans. ● When opposed by gold crowns and bridges, as it
[Same as SE Q.3] causes their significant wear.

Q.15. Shade selection. Q.4. Differences between natural and artificial dentition.
Ans. Ans.
[Same as SE Q.3] Differences between natural and artificial dentition is
as follows:
Q.16. Discuss selection of posterior teeth for complete
denture.
Natural dentition Artificial dentition
Ans.
Functions independently and Functions as group and occlu-
[Same as SE Q.4] each individual tooth dis- sal loads are not individually
perses the occlusal load. managed.
Q.17. Mention the uses and requirements of an articulator.
Malocclusion does not pose a Malocclusion poses immediate
Ans. problem for long time. drastic problems.
[Same as SE Q.6] Nonvertical forces are well Nonvertical forces damage the
tolerated. supporting tissues.
Incising does not affect the Incising will lift the posterior
SHORT NOTES: posterior teeth. part of denture.
Q.1. Define articulator. Second molar is the favoured Heavy mastication over sec-
area for heavy mastication for ond molar can tilt or shift the
Ans. better leverage and power. denture base.
[Ref LE Q.2] Bilateral balance is not important Bilateral balance is mandatory
and considered as hindrance. to produce stability of denture.
Q.2. Discuss in short, neutral zone.
Proprioceptive impulses give No feedback present and den-
Ans. feedback to avoid occlusal ture rests in centric relation
prematurities, which helps and any prematurities in this
Neutral zone the patient to have a habitual relation can cause shifting of
● In neutral zone, the forces of the buccal musculature occlusion away from centric denture base.
are compensated by the lingual musculature. relation.
● Teeth should be arranged in the neutral zone.
● If the teeth are arranged buccally, the buccinator will
destabilize the denture. Q.5. Describe the various dimensions of colour.

● Similarly, if the teeth are arranged lingually, there
Ans.
will be reduction of the tongue space and the tongue
will destabilize the denture. [Ref LE Q.3]
Q.6. SPA factor in complete denture. Q.7. Canine-guided occlusion.

Ans. Ans.
Dentogenic concept and dynesthetics: sex, personality, ● Canine-guided occlusion also known as canine-protected
age or SPA factor. articulation or anterior-protected articulation.
Sex ● A form of mutually protected articulation in which the
● The incisal edge of the central incisors is parallel to vertical and horizontal overlap of the canine teeth disen-
the lips and the laterals are above the occlusal plane in gage the posterior teeth in the excursive movements of
males. But the incisal edges of the central and lateral the mandible (GPT8).
incisors follow the curve of the lower lip in females.
● The distal surface of the centrals is rotated poste-
Q.8. Importance of try-in in complete denture.
riorly for females. Ans.
● The mesial surface of the lateral incisors is rotated
anteriorly in relation to the centrals in females. Try-in in complete denture

● In males, the mesial end of the laterals is hidden
It is a preliminary insertion of removable denture wax-up or
by the centrals. This makes the canine very prom- a partial denture casting or a finished restoration to determine
inent in males. the fit, aesthetics, and maxillomandibular relations (GPT).
● Only the mesial thirds of the canines are visible in
Procedure
females because they are rotated anteriorly, a. Primary evaluation.
whereas even the middle two-thirds of the canines b. Preliminary evaluation in articulator.
are visible in males. c. Evaluation of mouth.
● The cervical regions are prominent in males than
d. Evaluation of preliminary trial denture (maxillary
in females. and mandibular in mouth).
● Females on smiling expose more anterior teeth.
e. Evaluation of cheek support.
Hence, the premolars should be arranged based on f. Occlusal plane evaluation.
aesthetics for females. g. Evaluation of vertical height.
Personality h. Evaluation of centric relation.
● The dentist should select and arrange the teeth, so
i. Eccentric relation evaluation.
that it improves the patient’s personality. The pa- j. Incorporation of posterior palatal seal area.
tient can be either vigorous or delicate. Q.9. Selection of teeth for geriatric patient.
● More squarish, large teeth – vigorous people. Anteri-
ors in a flat plane for executives and teeth should be Ans.

relatively smaller and more symmetrically arranged. Anterior teeth selection for geriatric patient
Age ● Aesthetics and phonetics are important.
● It is important in teeth selection, because of the
● Pre-extraction guides available are
physiological and functional changes that occur in i. Photographs.
the oral tissues. ii. Diagnostic casts.
● The patient can be young, middle-aged or old-aged.
iii. Radiographs.
The following changes are observed with an advance iv. Observation of teeth of close relative.
in age of the patient: v. Extracted teeth of patient.
● Due to decrease in muscle tone, sagging of the
● Criteria of selection of anterior teeth:
cheeks and the lower lips occur. To prevent i. Size of the tooth.
cheek biting (due to sagging), the horizontal ii. Form of the tooth.
overlap of the posterior teeth can be increased. iii. Colour of the tooth.
● Interocclusal distance reduces with age. Hence,
iv. Material of the tooth.
mandibular teeth are more visible than the
maxillary teeth. Q.10. Indications of nonanatomic teeth in complete denture.
● Old people usually have abraded teeth with
Ans.
worn out contacts. Hence, placement of con-
toured teeth may look artificial. ● Nonanatomic teeth are also known as 0°, flat or mono-
● Old patients have gingival recession. It can be plane teeth.
reproduced in the dentures to provide a natural ● They have no cuspal angulation, hence are very flexible to
appearance. set. It is easy to set nonanatomic teeth in balanced occlusion.

● The colour of the teeth also changes with age. In Cuspless teeth can be used for the following occlusal schemes:
old people, the enamel is abraded and the den- ● Bilateral balance with a compensating curve.
tine which carries a yellow tinge is more visible. ● Three-point balance with a balancing ramp.
● Flat plane balance in centric only. Absence of it will result in leverage of the denture
●
● Reverse-pitch (anti-Monson) curve. during mandibular movement.

● It is more important during parafunctional move-
Q.11. Compensatory curve importance.
ments to maintain denture stability.
Ans. Laws of articulation of developing balanced occlusion
Five factors which govern balanced articulation are as
Compensating curve
follows:
It is defined as ‘The anteroposterior and lateral curva-
i. Condylar guidance.
tures in the alignment of the occluding surfaces and in-
ii. Incisal guidance.
cisal edges of artificial teeth which are used to develop
iii. Compensating curves.
balanced occlusion’ (GPT).
iv. Relative cusp height.
● It is the important factor for establishing balanced
v. Plane of orientation of the occlusal plane.
occlusion and it can be determined by the inclina-
tion of the posterior teeth and their vertical rela- Q.14. Cuspless teeth.
tionship to the occlusal plane.
Ans.
● The posterior teeth should be arranged such that
their occlusal surfaces form a curve which should [Ref LE Q.3]

be in harmony with the movements of the man-
dible guided posteriorly by the condylar path. Q.15. Neutrocentric occlusion.
● A steep condylar path requires a steep compensa- Ans.
tory curve to produce balanced occlusion other-
wise there will be loss of balancing molar con- Neutrocentric concept of occlusion states that plane of occlu-
tacts during protrusion. sion should be flat and parallel to the residual alveolar ridge.
There are two types of compensating curves, namely: This concept is similar to the monoplane occlusion used
i. Anteroposterior curves. to set nonanatomic teeth.
ii. Lateral curves. The term neutrocentric denotes an occlusion that elimi-
nates the anteroposterior and buccolingual inclines in order
Curve of Spee, Wilson’s curve and Monson’s curve are as- to direct the forces to the posterior teeth.
sociated with natural dentition. In complete dentures, com-
pensating curves similar to these curves should be incorpo- Q.16. Group function occlusion.
rated to produce balanced occlusion. Ans.
Q.12. Squint test. Group function occlusion refers to multiple contact rela-
Ans. tions between the maxillary and mandibular teeth in lateral
movements on the working side, whereby simultaneous
Squint testis used to check and compare the colour of the contact of several teeth acts as a group to distribute occlusal
teeth with the colour of the face. forces (GPT8).
The dentist should partially close his eyes to reduce light
and compare artificial teeth of different shades with the Q.17. Lingualized occlusion.
colour of the face. The colour of the teeth that fades first Ans.
from view is least conspicuous (contrasting) to the colour
Lingualized occlusion
of the face.
● Lingualized occlusion was first proposed by Alfred
Q.13. Balanced occlusion. Gysi (1927).

● It involves the use of a large upper palatal cusp
Ans.
against a wide lower central fossa. Here, the buccal
Balanced occlusion cusps of the upper and lower teeth do not contact
Balanced occlusion is the ‘The simultaneous contacting each other. It has superior chewing efficiency.
of the maxillary and mandibular teeth on the right and ● Payne used 30° anatomical teeth which are reshaped to
the left and in the posterior and anterior occlusal areas obtain lingual occlusion. This scheme had complete
in centric and eccentric positions, developed to lessen or intercuspation without any deflective occlusal contacts.
limit tipping or rotating of the denture bases in relation Myerson’s lingualized integration
to the supporting structures’ (GPT). Myerson proposed specialized tooth moulds for arrang-
Importance/rationale ing teeth in lingualized occlusion. These are as follows:
● It is one of the most important factors that affect ● Two different moulds for the maxillary posteriors –
denture stability. control contact (CC) mould for patients with

variations in centric position and maximum con- Do not wear easily.

●
tact (MC) mould for patients who can reproduce Maintain vertical dimension and mastication effi-
●
accurate centric position. The remaining teeth are ciency for long periods.
common for both these moulds. ● They can be reused through rebasing.
● These teeth provide maximal intercuspation, good Disadvantages

cuspal height to perform occlusal reshaping and a ● Clicking sound on impact.
natural and a pleasing appearance. ● Difficult to grind and adjust.
● The ‘MC’ mould maxillary posteriors have taller ● Requires adequate inter-ridge distance.
cusps with a more anatomical appearance and ● Abrades or chips opposing natural teeth and gold
also offers a more ‘exacting occlusion’ compared crowns.

to the ‘CC’ mould. ● Do not form chemical bond to denture base.
● Do not self-adjust.
Q.18. Christenson’s phenomenon.
● Being brittle, may fracture or chip.
Ans.
Q.20. Write the methods of selecting the colour shade of
Christenson’s phenomenon artificial teeth.
● This phenomenon is given by Christensen.
● The protrusive movement is not a simple straight Ans.

forward movement of the mandible. [Same as SN Q.5]
● As the mandible moves forward, the occlusion rims
separately in the posterior region even as it remains Q.21. Dentogenic concept and dynesthetics: sex, person-
in contact anteriorly. ality, age or SPA factor.
● Thus during protrusion, a wedge-shaped opening is
formed in the posterior part of the occlusion rims. Ans.

This is termed as Christensen’s phenomenon.
● The posterior separation is due to the downward
[Same as SN Q.6]
displacement of the condyles, as it travels along the
articular slope. Q.22. Selection of anterior teeth.
● By recording this gap and transferring the record, the
Ans.
articulator can be programmed to simulate some of
the patient’s mandibular movements.
[Same as SN Q.9]
Q.19. Advantages and disadvantages of porcelain teeth.
Ans. Q.23. What are the criteria for selection of anterior
teeth for complete denture patient?
Porcelain teeth
Advantages Ans.
● Superior aesthetic as compared to acrylic teeth.
● Do not stain and discolour easily. [Same as SN Q.9]
Topic 8
Lab Procedures Prior to Insertion
and Complete Denture Insertion
LONG ESSAYS:
1 . Discuss in brief the various postinsertion problems in an edentulous patient using complete dentures.
2. Discuss in detail about the insertion instructions and aftercare of the complete dentures.
3. Write an essay on sequelae of complete denture wearing.
4. Classify denture stomatitis and write its causative factors.
5. Tissue conditioners.
6. What are the various postinsertion problems and their management? [Same as LE Q.1]
7. Discuss in brief the postinsertion management in complete denture prosthodontics. [Same as LE Q.1]
8. What are the postinsertion problems in complete dentures? Discuss the methods of rectifying the same.
[Same as LE Q.1]
9. Give your method of fitting complete denture prosthesis and instruction and aftercare to patients. [Same as LE Q.2]
1 0. What is the importance of patient education? What insertion instructions you will give to a patient receiving
complete denture prosthesis? [Same as LE Q.2]
11. Conditioning of abused and irritated tissues. [Same as LE Q.5]
SHORT ESSAYS:
1. Importance of finishing and polishing of complete denture.
2. Write about the instructions given to complete denture patient at the time of denture delivery. [Ref LE Q.2]
3. Problems associated with complete denture use and methods for rectifying the same. [Ref LE Q.1]
4. Denture stomatitis. [Ref LE Q.3]
5. Compare the residual ridge resorption in maxillary and mandibular ridges. [Ref LE Q.3]
6. Denture cleansing agents.
7. Denture resins.
8. Importance of patient education.
9. Describe the steps in complete denture delivery.
10. Burning mouth syndrome. [Ref LE Q.3]
11. Postinsertion problems in complete denture patient. [Same as SE Q.3]
12. Ridge resorption. [Same as SE Q.5]
13. Mechanism of action of denture cleansers. [Same as SE Q.6]
14. Importance of counselling for a complete denture wearer. [Same as SE Q.8]
SHORT NOTES:
1. Perleche.
2. Epulis fissuratum. [Ref LE Q.3]
3. Postinsertion problems of complete denture.
4. Denture adhesives.
5. Need for periodic recall of complete denture patients.
6. Denture stomatitis. [Ref LE Q.4]
7. Denture cleansing agents.
8. Diet in complete denture.
9. Gag reflex. [Ref LE Q.3]
10. Articulating paper.
11. Residual ridge resorption. [Ref LE Q.3]
12. Injection moulding technique.
13. Bilabial sounds.
14. Denture irritation hyperplasia. [Same as SN Q.2]
15. Denture hyperplasia. [Same as SN Q.2]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Discuss in brief the various postinsertion problems [SE Q.3]
in an edentulous patient using complete dentures.
{Postinsertion problems can be divided into three broad
Ans. categories:
a. Decrease in denture retention.
Postinsertion problems in complete dentures b. Decrease in denture stability.
c. Decrease in denture support.
Management of postinsertion problems iv. Neuromuscular control

Following are the various postinsertion problems and their ● Forces generated during mastication are suffi-
management: cient to destabilize the denture.

a. Decrease in denture retention Correction
i. Lack of seal ● Temporary use of denture adhesives may help
Causes the patient to learn necessary skills.

● Border underextension in depth and width. . Decrease in denture stability
b
● Underextension of posterior border. i. Overextension of denture borders in depth and
● Residual ridge resorption. width.
● Inelasticity of cheeks – ageing, scleroderma Correction: Use pressure indicating paste and cor-
and submucous fibrosis. rect the borders.
Correction ii. Poor fit of supporting tissues (recoil of displaced
● Addition of tracing compound to the required tissues lifts dentures).
extension and processing it with acrylic resin. Correction: Reline/rebase using minimal pressure
● Relining of denture. technique.
● Slight reduction in the depth and width of iii. Denture not in optimal space (denture borders are
border. not in neutral zone).
ii. Air beneath the impression surface of denture/lack Correction: Reshape overextended regions, so that it
of seal does not interfere with muscular movement.
Causes iv. Occlusion: Uneven initial contact can cause dis-
i. Poor fit of the supporting tissues due to placement.
● Deficient impression. Correction: Adjust occlusion by selective grinding
● Damaged cast. either in the mouth or in the articulator after re-
● Warped denture. mount procedure.
● Overadjustment of impression surface. c. Decrease in denture support
ii. Resorption of the residual ridge. i. Lack of ridge support: Due to progressive RRR.
iii. Change in the fluid content of supporting Correction: Optimal denture border extension in
tissues due to depth and width and extend the lingual flange.
● Lack of recovery of tissues from the pres- ii. Fibrous displaceable tissue: Due to which, during
sure of old dentures. mastication, the denture tends to sink in.
● Effect of medication, e.g. diuretics. Correction: Rebase/reline and optimize occlusal
● Effect of change in posture of patient with balance.
high volume of tissue fluid. iii. Bony prominences covered with thin mucosa, e.g.
iv. Undercut residual ridges, e.g. bimaxillary prominent maxillary midline suture, tori and poste-
tuberosities. rior nasal spine.
v. Excessive relief over areas of reduced tis- Correction: Relive the denture in these areas.
sue displaceability. iv. Nonresilient soft tissue: Which do not adapt the tis-
Correction sue surface of denture.
● Relining and rebasing of denture with mini- Correction: Rebase/reline and optimal border exten-
mum pressure technique. sion can be produced using low viscosity impres-
● Addition of tissue conditioners restores reten- sion material.}
tive forces.
● Ensure old dentures are not worn for at least
Q.2. Discuss in detail about the insertion instructions
72 h prior to making impression. and aftercare of the complete dentures.
● Add softened tracing compound and extend it
Ans.
up to the depth of undercut area and replace it
with acrylic. When giving fabricated complete denture, the following are
iii. Xerostomia checked to ensure proper fit of denture:
● Reduced ability to form along the borders and the i. Evaluation of processing.
polished surfaces of the dentures. ii. Evaluation of polished surfaces.
Correction iii. Evaluation of tissue fit and comfort.
● Supplement with artificial saliva and modify iv. Evaluation of retention, stability and support.
dentures to maximize retentive forces and v. Evaluation of jaw relation.
minimize displacing forces. vi. Evaluation of occlusion.
vii. Evaluation of aesthetics. ● Patient is recalled after 24 h of insertion to correct

viii. Evaluation of speech function. occlusal disharmony and to check for immediate
tissue reaction.
Importance of postinsertion instructions:
● Next, patient is called after 1 week to check for
● It is crucial part of denture insertion and delivery.
tissue reaction and his/her comfort enquiry done
● If proper instructions are not followed, then there is
and problems corrected.
great harm to supporting tissues resulting in failure of
● Next, patient is recalled after 3–6 months to deter-
denture itself even if how well it is fabricated.
mine tissue reaction and see the amount of RRR.
● Instruction is either given verbally or by using visual
● Postinsertion instructions should be reinforced
aids and model demonstrations.
during recall appointments.
● Also printed instructions on paper can be provided, so
● In the case of any tissue reactions like ulcers and
that patient can refer to that at home.
soreness, the patient is advised to stop wearing the
[SE Q.2] prosthesis and report immediately to the dentist.
● Yearly recall visit to check the need for relining/
{Postinsertion instructions to the patient rebasing.}
A. Insertion and removal of prosthesis
● Patient is taught to insert and remove the denture
Q.3. Write an essay on sequelae of complete denture
repeatedly. wearing.
● Prosthesis should be inserted along the path of
Ans.
insertion.
● If unilateral undercut is present, then patient is Sequelae of wearing complete dentures
taught to insert the denture into undercut first, and The dentures can produce severe side effects, which if
then rotate the prosthesis into its final position. left unchecked, will produce:
● If the denture is very retentive and difficult to re- ● Destabilization of occlusion.
move, then patient is asked to blow with lips ● Loss of retention.
closed, to break the peripheral seal and remove the ● Decreased masticatory efficiency.
denture. ● Poor aesthetics.
B. Prosthesis maintenance ● Increased ridge resorption.
Denture should be cleaned using a denture brush ● Tissue injury.
and tooth paste/soap water (or any cleansing agent) These problems will progress making patient ‘pros-
as follows: thetically maladaptive’ and cannot wear dentures any more.
i. Chemical cleansers: Dilute solutions of chlorhex- The interaction of prosthesis and oral environment has
idine, sodium perborate or nystatin can be used to several aspects. The surface properties of the prosthesis
store the dentures. Mineral acids should not be may affect plaque formation. Surface irregularities and
used, as it corrodes the metallic part. microporosities can enhance microbial colonization.
ii. Ultrasonic cleaner: It is a sonic cleaner in which Plaque formation is also influenced by:
bubbles (which help to clear away the food par- ● Design of prosthesis.
ticles) are bombarded against the denture. ● Health of adjacent mucosa.
C. Prosthesis nightwear ● Composition of saliva.
● Patient is advised not to wear the denture at ● Salivary secretion rate.
night and store it in water or any dilute medicinal ● Oral hygiene.
solution. ● Denture wearing habits.
● This is done to provide rest to mucosa to improve Thus, prosthesis may promote infection of the underly-
the blood supply and prevent mucosal degenera- ing mucosa; there may be caries, and periodontal diseases
tion and bone resorption. of the over denture abutments, periimplantitis (inflamma-
Nightwear is allowed in following conditions: tion of the periimplantal membrane), and chemical degra-
● Bruxism patients: In these patients, the dam- dation or corrosion of prosthesis.
age to oral tissues is more, if denture is not All these disorders produced are accelerated in the oral
worn at night. tissues due to the presence of a denture and are grouped as
● Cases of maxillary complete denture and sequelae of wearing complete dentures.
mandibular partial denture. Sequelae of complete denture wear are divided into di-
D. Periodic recall rect and indirect types depending on the effect of the pros-
● Regular recall to check for proper denture exten- thesis on the tissues.
sion and occlusion. a. Direct sequelae of wearing complete dentures
[SE Q.4] Local factors

● Dentures
{1. Denture stomatitis ● Environmental changes due to dentures.
● Pathological reaction of the palatal portion of the ● Trauma.
denture-bearing mucosa. ● Denture usage, nightwear.
● It is commonly known as ‘denture-induced stoma- ● Denture cleanliness.
titis’, ‘denture sore mouth’, ‘denture stomatitis’, ● Xerostomia
‘inflammatory papillary hyperplasia’ or ‘chronic ● Sjogren syndrome.
atrophic candidiasis’. ● Irradiation.
● It is seen in 50% of the complete denture wearers. ● Drug therapy.
Classification by Newton ● High carbohydrate diet: Increases plaque accumu-
● Type I: Localized simple infection with pinpoint lation.
hyperaemia. ● Use of broad-spectrum antibiotics: They destroy
● Type II (erythematous type): Generalized simple normal symbiotic colonies leading to the forma-
type presenting a more diffuse erythema involv- tion of pathological colonies.
ing a part or the entire denture covered mucosa. ● Smoking tobacco: Affects oral hygiene and also
● Type III (granular type): It involves the central produces other effects.
part of the hard palate and alveolar ridge. Often Management and preventive measures
seen in association with type I and II. Supportive measures
Type I is usually trauma-induced, types II and III ● Institution of efficient oral and denture hygiene
are associated with microbial plaque accumulation. habits. Correction of denture wearing habits.
Candida-associated denture stomatitis (CADS) is The patient is advised to store the dentures in
often seen along with angular cheilitis or glossitis. 0.2%–2% chlorhexidine during night.
Diagnosis ● The patient should be instructed to remove the
CADS is confirmed by: denture after meals and scrub before reinsert-
● The presence of mycelia or the pseudohyphae ing it. The mucosa in contact with the denture
in a direct smear. should be hygienically maintained and mas-
● The isolation of more than 50 candidial colo- saged with a soft toothbrush.
nies from the lesions. ● Patient is advised not to use the dentures at night
● The Candida usually resides on the fitting or leave it exposed to air. Rough areas in the tis-
surface of the denture. sue surface of the denture should be smoothened
Aetiology or relined using a soft-tissue conditioner.
● Direct factor that produces denture stomatitis is ● Polishing of the external surface of the dentures
the presence of the denture in the oral cavity. should be done routinely in order to facilitate
● It is usually seen in patients who wear their den- denture cleansing.
tures both day and night. Drug therapy
● Trauma from the denture in addition to plaque ● Local therapy with Nystatin, Amphotericin B,
accumulation can stimulate the turnover of palatal Miconazole and Clotrimazole are usually pre-
epithelial cells, thereby reducing the degree of ferred to systemic therapy.
keratinization and barrier function. ● Antifungal drugs that remove Candida albi-
● ‘CADS’ is also correlated with angular cheilitis. cans are given mainly,
The infection may start beneath the maxillary ● After the clinical diagnosis has been con-
denture and later spread to the angle of the mouth. firmed by mycological examination.
Predisposing factors ● In patients with associated burning sensa-
These factors do not directly produce denture stoma- tion in the mucosa.
titis, but they favour the progress or initiation of the ● In patients where the infection has spread
lesion. to other sites of the oral cavity and the
Systemic factors pharynx.
i. Old age. ● In patients at increased risk of systemic my-
ii. Diabetes mellitus. cotic infections due to systemic diseases.
iii. Nutritional deficiency: Iron, folate, vitamin B2, etc. ● To reduce the risk of relapse, the following
iv. Malignancy: Acute leukaemia, agranulocytosis, etc. precautions are followed:
v. Immune defects: Due to the use of corticoste- ● Antifungal treatment should continue for
roids and other immune suppressants. 4 weeks.
● When lozenges are prescribed, patient

● The lesions usually subside after surgical excision
should be instructed to retain the dentures
of the tissues and correction of the dentures. Re-
during its use.
currence is rare. These lesions produce marked
Surgical management
discomfort under pressure and microbial irritation.
● Elimination of deep crypts in type III denture
They may produce severe lymphadenopathy mim-
stomatitis by cryosurgery.}
icking a neoplasm.
2 . Flabby ridge
● Due to replacement of bone by fibrous tissue, the re-
sidual ridge becomes extremely mobile and resilient 5. Oral cancer in denture wearers
● It is most commonly seen in anterior maxilla oppos- ● It usually manifests as nonhealing ulcers or as in-
ing natural mandibular anterior teeth due to the fected aberrant hyperplastic tissues.
presence of excessive load on the ridge and unstable ● Carcinomas in the floor of the mouth have very poor
occlusal conditions. prognosis.

Histopathology ● Predisposing factors include heavy use of alcohol, to-
● Marked fibrosis, inflammation and resorption bacco smoking/chewing, illiteracy and poverty etc.
of underlying bone. ● Patients should be recalled every 6 months for a
Treatment comprehensive oral examination. If denture sore

As they provide poor denture support, they should spots do not heal after correcting the dentures, then
be surgically removed. If there is extreme ridge malignancy should be suspected. Large lesions of
atrophy, then complete removal of the flabby denture irritation hyperplasia should be referred to
ridge will eliminate the vestibule. In such cases, the pathologist.
flabby tissue is preserved, so that the resilient
[SE Q.10]
ridge may help to provide some retention to the
denture. {6. BMS
3. Traumatic ulcers ● It is characterized by burning sensation in the struc-
They are commonly known as ‘sore spots’. tures in contact with dentures without any visible
● They usually develop within 1–2 days after place- changes in the mucosa.
ment of new dentures. ● In burning mouth sensation, mucosa is often in-
● They are characterized by small, painful lesions flamed due to mechanical irritation, infection or an
covered with a grey necrotic membrane and sur- allergic reaction whereas in BMS, the mucosa is
rounded by an inflammatory halo with firm, ele- clinically healthy.
vated borders. Epidemiology
Aetiology ● It is common in postmenopausal women above
● Direct cause for this lesion includes overextended 50 years of age.

denture flanges (and/or) unbalanced occlusion. ● The general complaint includes burning sensa-
● Predisposing factors like use of immune- tion of the supporting structures of the denture
compromised drugs suppress the resistance of and the tongue.
mucosa to the mechanical irritation. ● The syndrome is aggravated by fatigue, tension
Treatment and intake of hot foods. The intensity of pain and

Normally, after denture correction ulcers heal burning sensation is reduced during eating,
within few days. sleeping, mental distraction etc.
If no treatment is done, then it progresses to den- Clinical features
ture irritational hyperplasia. ● This condition does not have any overt clinical
signs or symptoms.
{SN Q.2} ● Pain starts in the morning and aggravates during
the day.
4. Denture irritation hyperplasia (Epulis fissuratum) ● Burning sensation is usually accompanied with
● Hyperplastic reaction of the mucosa occurring
dry mouth and persistent altered taste sensation.
along the borders of the denture. ● Other associated symptoms include headache,
● Lesions result from trauma due to unstable den-
insomnia, decreased libido and irritability or
tures with thin denture flanges. depression.
● Symptoms: Mild with single or numerous lesions
Aetiology
showing flaps of hyperplastic connective tissue. Local factors
Deep ulcerations, fissuring and inflammation may ● Mechanical irritation caused by ill-fitting
occur at the depth of the sulcus. dentures.
● Prolonged period of masticatory muscle activity. (SE Q.5 and SN Q.11)

● Constant parafunctional movements of the
{(8. RRR
tongue.
● It is most common and important sequelae of
● Constant excessive friction on the mucosa.
wearing complete denture.
● Candidal infections and allergic reactions can
● There is continuous loss of bone after tooth ex-
produce symptoms similar to burning mouth
traction and after placement of complete denture.
sensation (BMS).
● RRR is more common in women due to osteopo-
● Myofascial pain.
rotic changes in bone.
Systemic factors
● It is alveolar remodelling, which occurs due to
● Vitamin and iron deficiency.
change in the functional stimulus of bone tissue.
● Xerostomia.
● Ridge resorption is a chronic progressive change
● Menopause.
in the bone structure, which results in severe im-
● Diabetes
pairment in the fit and function of the prosthesis.
● Medication.
● It is more important in areas with thick cortical
Psychogenic factors
bone, i.e. the buccal parts of the maxilla and lin-
● Anxiety.
gual parts of the mandible that serve as load-
● Depression.
bearing regions.)}
Treatment
EMS patients are more psychologically affected. [SE Q.5]
They consider that their psychiatric disorders are due
to poor dentures. These patients may need counsel-
{Aetiopathogenesis
l Wherever there is pressure, bone resorbs due to acti-
ling to understand the irrelevance of the dentures
vation of osteoclasts.
with regard to their mental health and also to elimi-
● This resorption due to pressure is minimal at the
nate their fears. The patient’s symptoms are given
stress-bearing areas of the jaws.
first priority.}
● Hence, excessive pressure applied to the nonstress-
bearing areas produces RRR.

● Continuous pressure is required for activation of os-
{SN Q.9}
teoclasts; hence, RRR is common in patients who
7. Gagging wear their dentures continuously overnight.
● Gag reflex – normal, healthy defence mechanism Pattern of resorption}
which functions to prevent foreign bodies from
entering the trachea. (SE Q.5 and SN Q.11)
● It is triggered by tactile stimulation of the soft
● {(It occurs more rapidly in first 6 months after teeth
palate, posterior part of tongue and fauces. extraction and at a slower pace till 12 months.)}
● Other stimuli like sight, smell, taste, noise and
psychological factors can produce gagging. [SE Q.5]

● In sensitive patients, new dentures may stimulate
gagging but this disappears as the patient adapts ● {It progresses after 65 years of age.
to the dentures. ● It is more rapid in females than males.
● It is precipitated by systemic diseases or ill-fitting
● Persistent gagging can occur due to overextended
denture borders, especially in the posterior part of dentures.

● All denture patients should be examined periodically
maxillary denture and the distolingual part of
mandibular denture. Gagging usually produces on an annual basis. Rate of osseous changes can be
displacement of the denture. retarded when complete dentures are readapted by
● Gagging may occur due to unstable occlusal condi-
relining/rebasing during the first signs and symptoms
tions. For example, increase in vertical dimension of loss of adaptation.
of occlusion, because the unbalanced occlusal con- Rate of RRR
● During first year after extraction, the amount of RRR
tacts may displace the denture and trigger gagging.
● It can also result from other systemic conditions like
is 2–3 mm in the maxilla and 4–5 mm in mandible.
● Later annual rate of reduction of height in mandible
GIT disorders, adenoids or tumours in the upper re-
spiratory tract, alcoholism and severe smoking is 0.1–0.2 mm and it is four times less in the edentu-
● Limiting the posterior extension of the dentures
lous maxilla.
● The degree of RRR results from a combination of
and exercises help to decrease gagging.
anatomical, metabolical and mechanical determinants.
Severe RRR of mandible can be related to a small ● Movement of lower denture in a backward di-
gonial angle. rection which may lead to traumatic changes in
● The main factor that affects the rate of residual ridge the supporting structures of the mandible.
remodelling is the mechanical force transferred from ● Movement of the lower jaw anteriorly, with an
the denture base and the tongue to the tissues. ensuing prognathic appearance.
● The rate of RRR is increased in patients who wear Mandibular rotation causes severe damage in the
their dentures throughout the night without giving denture-supporting tissues over a long period of un-
rest to the tissues.} supervised denture wear. As the mandible moves
anteriorly, denture also moves along with it. But, this
is prevented by the locking mechanism of the cusped
{(Clinical features teeth. Hence, the denture shows posterior displace-
● Reduction in depth and width of sulcus due to ment in relation to the mandible.}
ridge resorption, till the level of the muscle attach-
ment. Hence, muscles appear to be inserted on the
crest of the ridge obliterating the sulcus. {(Treatment
● Decreased vertical dimension at occlusion. Preprosthetic surgery can be done to increase the
● Reduction of the lower facial height (due to de- height of the ridge (ridge augmentation) or depth of
creased Vertical Dimension of Occlusion (VDO)). the sulcus (vestibuloplasty).)}
● Anterior rotation of the mandible. 9 . Overdenture abutments: caries and periodontal diseases
● Increase in relative prognathism. Overdentures are tooth-supported complete dentures.
● Resorption is centripetal (towards the centre) in the Teeth, which support the complete denture are called
maxilla, and centrifugal (away from the centre) in overdenture abutments. These abutments are usually
the mandible. Hence, the size of the maxillary arch endodontically treated and reduced in size, so that a
will decrease with resorption and the size of the denture can be fabricated to fit over them.
mandibular arch will increase with resorption. Common problems associated with overdenture abut-
● Sharp, spiny and uneven ridge crest due to differ- ments are caries and periodontal diseases, because it is
ence in rate of resorption from one place to an- difficult to achieve good plaque control in the presence
other. of a denture base all around it.
● Long-term resorption affects support stability and Pathogenesis
retention of dentures.)} Bacterial colonization may easily be left unchecked
due to the presence of an overdenture. Gingivitis is
[SE Q.5]
produced within three days of colonization of Strep-
{Changes in the maxilla tococcus sp. and Actinomyces sp. Caries is initiated
Resorption of the bone of the maxillae usually causes in the presence of a high proportion of Lactobacilli
the upper denture to move up and back in relation to and Streptococcus mutans.
its original position. However, the occlusion also may Preventive measures and management
force the maxillary denture forward. ● Plaque control: It can be established using me-
Changes in the mandible chanical methods like brushing and flossing, and
The mandible will move to a higher position during chemical methods using mouthwashes. The den-
occlusion than the one it occupied before the re- tures should also be cleaned effectively to provide
sorption. This will lead to a decrease in the inter- better plaque control.
arch space. The mandibular movement is rotatory ● Fluoride application and chlorhexidine mouth-
around a line approximately passing through the washes.

condyles. ● Avoiding nightwear of dentures: This helps the
The effect of this rotatory movement varies from saliva (with its buffering capacity, antibodies and
patient to patient and occurs due to several features: antibacterial enzymes – lysozyme) to clean and
● The duration and magnitude of bone resorption. guard the abutments.
● The mandibular postural habit. ● Metal copings can be placed around the teeth in
● Tooth morphology. order to protect the tooth structure from caries.

● The amount of material present. ● Periodontal therapy to eliminate periodontal pockets.
The mandible’s rotation may produce the following i. Indirect sequelae of wearing complete dentures
consequences: 1. Atrophy of masticatory muscles
● Loss of centric occlusion in the dentures. Masticatory function depends on skeletal muscle
● Changes in the structures that support the force and coordination of orofunctional move-
upper denture. ments. The skeletal force or the bite force decreases
with age. Hence, most denture wearers use less bit- least fabricate an overdenture in order to
ing force and do not use their muscles to their reduce the sequelae. Especially for the man-
maximum function causing their atrophic degen- dible, as destabilization occurs more easily
eration. due to excessive ridge resorption.
● Atrophy of a muscle due to poor usage is ● In the absence of overdenture abutments,
called disuse atrophy. the dentist should try to at least plan an
● It is more common in women and older implant-supported complete denture. Im-
people. plant-supported dentures also help to re-
● Common muscles that undergo disuse atro- duce the rate of resorption of the ridge.
phy are the masseter and the medial ptery- ● Regular follow-up should be conducted, so
goids. that a stable occlusion can be maintained.
Diagnosis ● Overdenture patients should be frequently re-
● The patient is asked to chew a specific quantity called to examine the status of the abutment.
of test food and the time taken to chew the test ● Patient should be motivated to follow opti-
food into small particles is measured. The mum denture wearing and maintaining habits.
number of chewing cycles taken to crush the ● Patient’s cooperation is important to the
test food is recorded. (Generally complete den- success of treatment. This should be ex-
ture patients take around seven times more ef- plained and emphasized.
fort than dentulous patients to obtain the same
Q.4. Classify denture stomatitis and write its causative
result. In other words, what a dentulous person
factors.
can do with one chewing cycle will take seven
chewing cycles in a complete denture wearer). Ans.
● These patients prefer soft diet and try to swal-
low them as large pieces. {SN Q.6}

Preventive measures and management
● Overdentures do not produce disuse atrophy, Denture stomatitis
since the proprioceptive impulses are gener- ● It is the pathological reaction of the palatal por-
ated from the abutment teeth and the biting tion of the denture-bearing mucosa.
force is not decreased as much as in a conven- ● It is commonly known as ‘Denture-induced stoma-
tional complete denture patient. titis’, ‘Denture sore mouth’, ‘Denture stomatitis’,
● In the absence of overdenture abutments, im- ‘Inflammatory papillary hyperplasia’ or ‘Chronic
plants can be inserted and an implant-supported atrophic candidiasis’.
complete denture can be fabricated in order to ● It is seen in 50% of the complete denture wearers.
preserve the biting force. A. Classification (by Newton)

2. Nutritional deficiencies ● Type I: Localized simple infection with pin-
Causes for malnutrition in old people point hyperaemia.

The principal causes of proteocaloric malnutri- ● Type II (erythematous type): Generalized sim-
tion among elderly denture wearers are: ple type presenting a more diffuse erythema
● Poor general health. involving a part or the entire denture covered
● Poor absorption. mucosa
● Intestinal, anabolic and catabolic distur- ● Type III (granular type): It involves the central
bances. part of the hard palate and alveolar ridge. Often

● Anorexia. seen in association with types I and II. Type I is
● Reduced rate of salivary secretion during usually trauma-induced, types II and III are as-
mastication. sociated with microbial plaque accumulation.
General precautions to prevent and/or control of
sequelae from complete dentures are as follows: ● Candida associated denture stomatitis is often seen
● Modified dietary habits wherein balanced along with angular cheilitis or glossitis.
diet is administered. B. Diagnosis
● Food particles can be mechanically broken CADS is confirmed by
down before eating to reduce the burden on ● The presence of mycelia or the pseudohyphae in a
the oral musculature. direct smear.

● The dentist should try to preserve the re- ● The isolation of more than 50 candidial colonies
maining teeth as much as possible and at from the lesions.

● Candida usually resides on the fitting surface of Patient is advised not to use the dentures at night
●
the denture. or leave it exposed to air. Rough areas in the tissue

Aetiology surface of the denture should be smoothened or
● Direct factor that produces denture stomatitis relined using a soft tissue conditioner.
is the presence of the denture in the oral cavity. ● Polishing of the external surface of the dentures
● It is usually seen in patients who wear their should be done routinely in order to facilitate
dentures both day and night. denture cleansing.
● Trauma from the denture in addition to plaque Drug therapy
accumulation can stimulate the turnover of ● Local therapy with nystatin, amphotericin B, mi-
palatal epithelial cells thereby reducing the conazole and clotrimazole are usually preferred to
degree of keratinization and barrier function. systemic therapy.
● ‘CADS’ is also correlated with angular cheili- ● Antifungal drugs that remove Candida albicans
tis. The infection may start beneath the maxil- are given mainly after the clinical diagnosis has
lary denture and later spread to the angle of the been confirmed by mycological examination.
mouth. ● In patients with associated burning sensation in
Predisposing factors the mucosa.

These factors do not directly produce denture ● In patients where the infection has spread to
stomatitis, but they favour the progress or initia- other sites of the oral cavity and the pharynx.
tion of the lesion. ● In patients at increased risk of systemic my-
Systemic factors cotic infections due to systemic diseases.

i. Old age. To reduce the risk of relapse, the following precau-
ii. Diabetes mellitus. tions are followed:
iii. Nutritional deficiency: Iron, folate, vitamin ● Antifungal treatment should continue for 4 weeks.
B2, etc. ● When lozenges are prescribed, patient should be
iv. Malignancy: Acute leukaemia, agranulocyto- instructed to retain the dentures during its use.
sis, etc. Surgical management
v. Immune defects: Due to the use of corticoste- ● Elimination of deep crypts in type III denture
roids and other immune suppressants. stomatitis by cryosurgery.

Local factors Q.5. Tissue conditioners.
● Dentures
● Environmental changes due to dentures.

Ans.
● Trauma. Tissue conditioners
● Denture usage, nightwear. ● Kydd and Mandley (1967): Tissue lining materials per-
● Denture cleanliness. mit wider dispersion of forces and hence, aid in decreas-
● Xerostomia ing the force per unit area transmitted to the supporting
● Sjogren syndrome. tissues. Such soft liners could serve as an analogue of the
● Irradiation. mucoperiosteum with its relatively low elastic modulus.
● Drug therapy. ● The prolonged contact of denture bases (rigid) with the
● High carbohydrate diet: Increases plaque underlying tissues produces changes in tissues. Mucosal
accumulation. health may be promoted by hygienic and therapeutic
● Use of broad-spectrum antibiotics: They de- measures and tissue conditioning techniques done in
stroy normal symbiotic colonies leading to the appropriate situations.
formation of pathological colonies. A. Composition
● Smoking tobacco: Affects oral hygiene and Tissue conditioners are composed of polyethylmethac-
also produces other effects. rylate and a mixture of aromatic ester and ethyl alcohol.
C. Management and preventive measures They are available as three component systems:
Supportive measures ● Polymer (powder).
● Institution of efficient oral and denture hygiene ● Monomer (liquid).
habits. Correction of denture wearing habits. The ● Liquid plasticizer (flow control).
patient is advised to store the dentures in 0.2%– A gel is formed when these materials are mixed with
2% chlorhexidine during the night. ethyl alcohol having a greater affinity for the polymer.
● The patient should be instructed to remove the B. Major uses of tissue conditioners
denture after meals and scrub before reinserting it. ● Tissue treatment.
The mucosa in contact with the denture should be ● Temporary obturator.
hygienically maintained and massaged with a soft ● Baseplate stabilization.
toothbrush. ● To diagnose the outcome of resilient liners.

● Liners in surgical splints. ● A ratio of 1.25 parts of polymer, 1 part of mono-

● Trial denture base. mer and 0.5 cm3 of plasticizer is usually recom-
● Functional impression. mended. The plasticizer should be added to the
A. Temporary obturator monomer.
Tissue conditioners may be added as a temporary ob- ● The ingredients are mixed to form a gel which is
turator over the existing complete or partial denture. applied in sufficient thickness to the tissue surface
This may be done directly in the mouth or indirectly of the denture.
after an impression of the surgical area has been made. ● The denture is inserted and border movements are
B. Stabilization of baseplates and surgical splints or carried out to mould the setting material.
stents D. Care and maintenance
When undercuts are present on an edentulous cast, ● Tissue conditioners should not be cleaned by scrub-
an acrylic temporary denture base cannot be used, as bing with a hard brush in order to prevent tearing of
it may get locked into the undercut and break the the material.
cast during removal. In these cases, tissue condition- ● The use of soft brush under running water is recom-
ers of a stiffer consistency are used to stabilize mended.

record bases and prevent breakage of cast. ● Tissue conditioners are versatile and ease to use.
C. Adjunct to an impression or as a final impression ● They can be easily misused and their longevity
material against wear is very limited and they tend to harden

These materials are used when it is difficult to deter- and roughen within 4–8 weeks due to the loss of
mine the extent of the denture base due to the pres- plasticizer. Hence, they require close observation.
ence of movable oral structures. These materials re-
cord the extensions of the denture in a dynamic form Q.6. What are the various postinsertion problems and
that will later help in preparing an impression tray their management?
for the final impression. Ans.
D. Adjunct to determine the potential benefits of a
treatment modality [Same as LE Q.1]
Sometimes patients with well-constructed dentures
Q.7. Discuss in brief the postinsertion management in
develop chronic soreness and find it difficult to wear
complete denture prosthodontics.
the dentures comfortably. Tissue conditioners can be
used to determine if this problem can be resolved Ans.
with the use of a resilient liner.
E. Adjuncts for tissue healing [Same as LE Q.1]
Tissue conditioners prepare the selected oral struc- Q.8. What are the postinsertion problems in complete
tures to withstand all the stress from the prosthesis. dentures? Discuss the methods of rectifying the same.
They are used to preserve the residual ridge and to
heal irritated hyperaemic tissues prior to denture Ans.
fabrication.
[Same as LE Q.1]
C. Procedure for applying tissue conditioners
i. Preparation of the dentures Q.9. Give your method of fitting complete denture pros-
● The tissue part of the denture base, which crosses thesis and instruction and aftercare to patients.
an undercut, should be reduced.
● The tissue surface of the denture, which covers
Ans.
the crest of the ridge, should be reduced by 1 mm. [Same as LE Q.2]
● Dentures should allow sufficient room for the
placement of the tissue conditioner in order to Q.10. What is the importance of patient education?
promote the recovery of displaced and trauma- What insertion instructions you will give to a patient
tized tissues. receiving complete denture prosthesis?
ii. Mixing and placement of the tissue conditioner
Ans.
● Tissue conditioners are available as three compo-
nent systems [Same as LE Q.2]

● Polymer (powder).
● Monomer (liquid).
Q.11. Conditioning of abused and irritated tissues.
● Liquid plasticizer (flow control).
Ans.
● The mixing ratio can be changed according to the
consistency required. [Same as LE Q.5]

SHORT ESSAYS: Denture cleansing agents

Dentures can be cleaned manually or through chemical
Q.1. Importance of finishing and polishing of complete cleaning agents. Usually two of them are combined.
denture. A. Chemical denture cleansers
Ans. Commercial preparations
● Safe and effective.
Importance/role of the finished and polished surfaces of ● Most commercial solutions contain a bleaching
complete dentures agent such as sodium hypochlorite.
i. It contributes to aesthetics by replacing lost tissue and ● Some are available in the form of tablets which ef-
by giving support and fullness to the cheeks and lips. fervesce when dropped in water releasing bubbles.
ii. Reproducing gingival anatomy gains more importance The dentures are left in this for at least 15 min or
when the patient has a high lip line. During talking or even overnight. The dentures are rinsed before use.
smiling in such patients a large portion of the denture Removal of calculus
base may be visible. Overnight soaking in white vinegar is effective in
iii. A thick or improperly contoured palate can create removing and controlling calculus build-up on the
phonetic problems. dentures. The acetic acid in vinegar decalcifies calcu-
iv. By supporting the cheeks, lips and the modiolus, it lus deposits.
contributes to facial expressions. B. Manual cleansing
v. An excessively concave buccal flange can cause food i. With denture brush
entrapment in the buccal sulcus. ● They are used along with a mild detergent or
vi. Improper contour of the gingival embrasure area can a denture paste (which is low in abrasive) and
cause food lodgement and poor oral hygiene. water.
vii. A properly contoured buccal and lingual flange re- ● Regular paste use is contraindicated, as they con-
duces the destabilizing effect of the buccinator, the tain abrasives which can cause excessive wearing
modiolus and the tongue. of resin.
viii. A proper finish and polish is essential for patient com- ● Gentle brushing with a soft brush and a nonabra-
fort, aesthetics and hygiene of the denture. sive cleanser combined with overnight soaking is
ix. The denture borders should retain the shape that was an effective cleaning method.
achieved during border moulding. Thinning of the Precaution
denture borders can lead to a loss of peripheral seal i. Stiff bristles along with abrasive cleansers can
and possible food entrapment. Thin sharp borders can cause severe abrasion and therefore should be
also cause injury to the tissues. avoided.
Q.2. Write about the instructions given to complete ii. Dentures should be brushed over a basin filled
denture patient at the time of denture delivery. with water to prevent breakage, if they are ac-
cidentally dropped.
Ans.
iii. The impression surface of the denture should
[Ref LE Q.2] not be brushed too aggressively.
Q.3. Problems associated with complete denture use and ii. Sonic cleansers
methods for rectifying the same. These use vibratory energy (not ultrasonic energy) to
clean the dentures.
Ans. In combination with hypochlorite solutions, they are
[Ref LE Q.1] very effective in removing calculus as well as cigarette
and coffee stains.
Q.4. Denture stomatitis.
Formula for a homemade cleanser by The Buffalo School
Ans. of Dental Medicine:
[Ref LE Q.3]
Sodium hypochlorite (Chloroxa) 1 tbsp
Q.5. Compare the RRR in maxillary and mandibular
Calgon (detergent softens and loosens food deposits) 1 tsp
ridges.
Water 114 cm3
Ans.
a
Household bleach – germicidal and mild bleach.
[Ref LE Q.3]
Q.6. Denture cleansing agents. A 30 min soaking once a week is sufficient to remove most
stains.
Ans.
Note: After chemical soaking, the patient should thor- B. Advantages

oughly brush and rinse the denture under running water. ● Nontoxic, nonirritant, insoluble and noncorrosive in
This ensures that all the food deposits which have been oral fluids.
softened by the chemical cleaner are removed. In addition, ● Excellent aesthetics.
brushing is necessary to remove all traces of the chemical ● Good colour stability.
cleanser. ● Easy to repair, rebase and alter contour.
Caution: Cleansers containing sodium hypochlorite are ● Low density.
not indicated with chrome cobalt or other metal-based den- ● Take good polish.
tures. The hypochlorite may pit or damage the metal. ● Heat discolouration temperature too high.
C. Disadvantages
Q.7. Denture resins.
● Relatively low modulus of elasticity, so require
Ans. greater bulk than desirable to produce strength.

● High coefficient of thermal expansion.
Denture resins
● Abrasion resistance not good enough.
These include either heat-cure or self (cold)-cure acrylic ● Low thermal conductivity.
resins. ● Radiolucent material.
These materials are usually supplied as powder and as ● Nonwettable surface.
liquid parts.
Q.8. Importance of patient education.
A. Composition
a. Powder Ans.
● Polymethylmethaacrylate: To undergo further po-
lymerization, reduce polymerisation shrinkage, Patient education and preparation

● Before actually inserting the denture in the mouth, the
and facilitate the fabrication technique.
● Copolymers of Polymethylmethaacrylate (PMMA): patient should be psychologically prepared.
● Previous instructions are reinforced.
To increase the solubility of polymer in monomer
● The patient should be made aware that only after the
and improve strength and fracture resistance.
● Benzoyl peroxide: To initiate polymerization of dentist has completed evaluation and adjustment of
monomer after being added to powder. the denture in the mouth and is satisfied with it, will the
● Dibutyl phthalate: To increase the solubility of patient be allowed to view it.
polymer in monomer and produce soft and more a. First oral feelings: These are a temporary feeling of
resilient polymer. fullness. The patient should be reassured that this
● Colour pigment: To obtain various tissue-like feeling will disappear over time.
shades. b. Excessive salivation: New dentures often stimulate
● Opacifiers: To increase the opacity of material, so excessive salivary flow, as mouth considers the new
that its translucency matches to that of oral tissues. dentures as foreign objects. The denture may appear to
● Dyed synthetic fibre: To stimulate minute blood float. The patient should be reassured that this is a nor-
vessels underlying oral mucosa. mal reaction to new dentures and will gradually decrease
● Inorganic particle: To improve stiffness of denture over time. Compulsive spitting or rinsing should be
base. avoided, as it can cause denture dislodgment. Swallow-
● Heavy metal compound: To impart radiopacity. ing should be encouraged to remove the excess saliva.
b. Liquid c. Excessive looseness: Often the trial denture may be
● Methyl methacrylate: To produce PMMA on loose, because of faulty tongue position or excessive
polymerization. relief of denture base. Patient must be reassured that
● Comonomer higher methacrylate: To dissolve this will disappear in final denture.
polymer beads of powder. d. Final viewing: Once the dentist has finished evalua-
● Hydroquinone inhibitor: To improve properties tion and correcting the errors, patient is allowed to
of denture base and prolong the shelf life of view the denture with mirror kept at normal conver-
liquid. sational distance and under natural light.
● Dibutyl phthalate: To produce softer and resilient e. Patient is instructed to relax, smile, talk or count. He
polymer. must not look at the denture too closely or the teeth
● Butyl methacrylate: To improve physical proper- alone, rather he should look at the overall effect of
ties of denture. denture on his face.
● Cross-linking agent – ethylene glycol dimethacry-
Q.9. Describe the steps in complete denture delivery.
late: To increase the resistance of denture to craz-
ing, fatigue resistance. Ans.
During the insertion appointment, all the factors verified These factors are usually examined thoroughly during
during try-in are rechecked. try-in. Hence, a simple verification would be sufficient.
The two major characteristics that determine the suc- B. Checking of the denture function
cess of a denture are its fit and function. i. Evaluating the retention and stability of the denture
Fit includes proper adaptation, patient comfort, ade- Retention is evaluated by checking for the periph-
quate extension and aesthetics of the denture. eral seal of the denture.
Function includes occlusal harmony, speech, accurate First, posterior seal is checked followed by anterior
jaw relation, retention and stability during mastication, etc. seal.
Steps in complete denture delivery ● Posterior seal checked by gently pressing the
A. Checking for the fit of the prosthesis anterior teeth perpendicular to the path of inser-
i. Examining the dentures tion. This procedure tends to lift the posterior
● Before inserting the denture, the clinician should part of the denture. If there is adequate seal, the
feel the borders of the denture to check for any dentist can feel the resistance offered by the
sharp projections or rough ends. denture against this force.
● The tissue surface of the denture is examined for ● Next, anterior seal is evaluated. The denture is
the presence of voids or nodules. pulled against the path of insertion. The resis-
ii. Examining the patient’s mouth tance offered by the denture against this force
● The oral mucosa is examined thoroughly to rule gives the anterior seal.
out overextension of the denture. Stability is examined by checking for any kind of
iii. Checking for adaptation displacement during chewing cycle, speech, etc.
● The denture is placed in the patient’s mouth ii. Checking the jaw relation
along its path of insertion. First, the adaptation of The vertical and horizontal jaw relations are exam-
the denture is checked at the posterior palatal ined thoroughly as done in try-in and patient’s per-
seal area using a mouth mirror. ception of comfort is also verified.
● There should not be any space left between the iii. Speech
posterior border of the denture and the tissues. It is the most challenging functions that should be
The patient is asked to say ‘ah’ in unexaggerated reproduced in a denture.
short bursts and the palatal seal reverified. Man- ● Denture wearers have a shallow pronunciation,
dibular denture adaptation is checked at distolin- because of the smooth palatal surface.
gual extension. ● In a natural environment, the rugae enhance
iv. Checking for border extension speech.

● The cheeks are elevated and the denture borders ● In a denture, speech is affected due to the ab-
are examined. sence of rugae.

● The buccal and labial mucosa is stretched to ● Use of a metal denture base improves speech,
check for any denture displacement. If the den- because the metal can be fabricated thin enough
ture has overextended borders, then it will get to reproduce the rugae on the external surface.
displaced while stretching the mucosa. ● Other factors that affect speech like injury to the
v. Checking for frenal relief external laryngeal nerve and presence of tongue-
● The labial frenum is thin and hence requires a tie should also be ruled out.
deep notch-like relief at the middle of the labial ● Dentures play different roles in the production of
flange. different sounds:

● The buccal frenum is more compressible (less ● Bilabial sounds (b, p and m): These are con-
sensitive to compression than labial frenum). trolled by lip support and become defective
This frenum tends to bend and adapt to the den- due to its absence or alteration in vertical di-
ture. Hence, it does not require a critical relief. mension at occlusion.
● Secondly, there are multiple frena on either side, ● Labiodental sounds (f and v): These are gov-
hence providing a shallow notch in this region erned by relation of the incisal edges of the
will be sufficient. It should be remembered that upper anterior teeth to the lower lip. If the teeth
the buccal frena are attached to active muscle fi- are set too high then ‘f’ will sound like ‘v’.
bres and, if not relived, may tend to displace the ● Linguodental sounds (‘th’): These are gov-
denture during function. erned by position of tongue between upper

vi. Evaluating the denture aesthetics and lower anteriors. Normally, the tongue
Patient’s lip support, cheek support, vertical height, should project 3 mm anteriorly between the
low lip line, high lip line, smile line etc., are examined. teeth. If the tongue gets positioned about
6 mm in front of the teeth, then, it means, the ii. Using articulating paper: In this, high points
teeth have been set very lingually. (premature, deflective contacts) are detected
● Linguoalveolar sounds (t, d, s, z, v and 1): by placing the articulating paper between the
These are made when the tongue touches the teeth and the patient is asked to bite on it. The
anterior part of palate. These are the most paper is dragged away slowly. There should
important of all sounds in a complete denture, be even resistance to the movement of the ar-
because it is determined by the thickness of ticulating paper. If the paper slides freely,
the denture base. If the denture is very thick, then, it means there is no contact. If the paper
the patient is forced to pronounce the sounds does not slide away at anyone particular point,
in a shallow blunt manner. it indicates the presence of a high point. The
● ‘S’ sound: It is controlled by the anterior part articulating paper itself marks the high points.
of the palatal plate of the denture base. The high points are reduced till the marking
● It is considered separately because it is pro- colour fades away and occlusion is rechecked.
duced in two tongue positions and also called
If all the above factors are satisfactory, then initial insertion
as the dental and alveolar sound.
is complete.
● A narrow groove formed by the tongue in the
The patient is called after 24 h to check for any soft tis-
midline against the palate results in a space.
sue reaction. Patient is then called after a week for review.
The size of this space determines the quality
Finally, periodic review is conducted once in every
of the sound.
3–6 months to check for soft and hard tissue changes etc.
During the ‘s’ sound, the following articulatory
characteristics are noticed. Q.10. Burning mouth syndrome.
● The tip of the tongue is near (not touching) the
Ans.
upper anteriors.
● The dorsum of the tongue is flat and a groove [Ref LE Q.3]
is formed in the midline of the tongue.
Q.11. Postinsertion problems in complete denture patient.
● The mandible moves forward and upward till
the teeth are almost in contact. Ans.

● The acoustic character of ‘s’ sound is a strong
[Same as SE Q.3]
high-frequency sound wave of 3–4 kHz. Audi-
tory character of ‘s’ sound is a sharp loud Q.12. Ridge resorption.
sound.
Ans.
● Linguopalatal and linguoalveolar sounds
(year, she) are not very important in a com- [Same as SE Q.5]
plete denture, as they are independent of the
Q.13. Mechanism of action of denture cleansers.
denture base.
iv. Occlusal harmony Ans.
● If the jaw relation is accurate, errors in occlusion
[Same as SE Q.6]
are very rare.
● Usually, occlusal disharmony is not corrected Q.14. Importance of counselling for a complete denture
during the insertion appointment. wearer.
● The patient is asked to wear the denture
Ans.
continuously for 24 h and then the occlusal cor-
rections are made. [Same as SE Q.8]
● Occlusal disharmony can be identified using in-
terocclusal check record or an articulating paper.

i. Using interocclusal check records: When the
SHORT NOTES:
patient reports after 24 h, interocclusal check Q.1. Perleche.
record is obtained. Interocclusal record mate-
Ans.
rial like ZnOE is placed on the teeth and
the patient is asked to bite. High points are Perleche
detected by the presence of perforations in ● It is also known as angular cheilitis.
interocclusal records. The high points are re- ● It is a deep crease formed at the corner of the mouth.
duced carefully using a bur and the occlusion Constant wetness due to saliva leads to infection and
is reverified. soreness.
● Corners of mouth are moist and drooping. ● Bioadhesion by carbonyl groups: Carbonyl
● Fungal infection is seen at the folds. groups in the adhesive material provide strong
● This condition is seen in cases of decreased vertical bioadhesive and biocohesive forces, which im-
dimension and also in cases of vitamin deficiency or prove the retention of the denture, e.g. poly-
secondary to fungal (candida) infection in the mouth. methyl vinyl ether maleic – anhydride or PVM/
MA has a high level of these carbonyl groups.
Q.2. Epulis fissuratum.
● PVM/MA and zinc and calcium salts with
Ans. CMC have superior retention, because of the

stronger covalent bond that develops due to its
[Ref LE Q.3] divalent interaction.
Q.3. Postinsertion problems of complete denture. Indications for the use of denture adhesives
● To improve retention and stability of the dentures
Ans. (that are poorly retained or unstable).
Postinsertion problems of complete denture ● To improve stability of a denture for a new or
Postinsertion problems can be divided into three broad inexperienced patient.

categories: ● To improve retention and stability of denture that
a. Decrease in denture retention is poorly retained or unstable.

● Lack of seal. ● To stabilize trial bases during fabrication and
● Air beneath the impression surface of denture/ insertion of the trial denture.
lack of seal. ● For handicapped patients.
● Xerostomia. ● Patients with xerostomia.
● Neuromuscular control. ● Geriatric patients.
b. Decrease in denture stability ● Patients with poor muscle tone (such as those
● Overextension of denture borders in depth and with Parkinson disease, Tardive dyskinesia and
width. dysarthria).
● Denture is not in optimal space (denture bor- ● To provide a psychological sense of security for
ders are not in the neutral zone). specific patients (such as actors and teachers).
● Occlusion: Uneven initial contact can cause ● To simplify the insertion for patients with tactile
displacement. or movement deficiency, e.g. cerebral trauma

● Poor fit of supporting tissues (recoil of dis- patients.
placed tissues lifts dentures). ● As an adjunct to the maxillary prosthesis.
c. Decrease in denture support Q.5. Need for periodic recall of complete denture patients.
● Lack of ridge support.
● Fibrous displaceable tissue: Due to which, dur- Ans.

ing mastication the denture tends to sink in. ● Regular recall to check for proper denture extension and
● Bony prominences are covered with thin mu-
occlusion.
cosa, e.g. prominent maxillary midline suture, ● Patient is recalled after 24 h of insertion to correct oc-
tori and posterior nasal spine. clusal disharmony and to check for immediate tissue
● Nonresilient soft tissue: This does not adapt
reaction.
the tissue surface of denture. ● Next, patient is called after 1 week to check for tissue
Q.4. Denture adhesives. reaction and his/her comfort enquiry done and problems
corrected.
Ans. ● Next, patient is recalled after 3–6 months to determine
tissue reaction and see the amount of residual ridge

Denture adhesives
resorption.
Denture adhesives enhance denture retention, stability,
● Postinsertion instructions should be reinforced during
and function.
recall appointments.
Mode of action
● In the case of any tissue reactions like ulcers and sore-
Its effectiveness depends on both physical and chem-
ness, the patient is advised to stop wearing the prosthe-
ical factors of the material.
sis and report immediately to the dentist.
● Water absorption: The adhesive tends to swell
● Yearly recall visit to check the need for relining/rebasing.
from 50% to 150% by volume in the presence
of water. Water absorption of the adhesive Q.6. Denture stomatitis.
results in the formation of anions that are
Ans.
attracted to cationic proteins in the mucus
membrane producing stickiness. [Ref LE Q.4]
Q.7. Denture cleansing agents. Q.10. Articulating paper.

Ans. Ans.
Denture cleansing agents Articulating paper
Dentures can be cleaned manually or through chemical Articulating paper is used to detect high points inden-
cleaning agents. Usually two of them are combined. ture (occlusal errors) either intraorally or during lab
Manual cleansing remounting.
i. Denture brush Procedure
● It is used along with a mild detergent or a denture ● Articulating paper is placed between the occlusal
paste (which is low in abrasive) and water. surfaces of the upper and lower dentures bilater-
● Regular paste use is contraindicated, as they con- ally (placing the articulating paper on one side
tain abrasives which can cause excessive wearing alone may cause the patient to deviate to or away
of resin. from that side).
● Gentle brushing with a soft brush and a nonabra- ● The patient is asked to occlude repeatedly through
sive cleanser combined with overnight soaking is a firm tapping motion.
an effective cleaning method. ● Initially, the occlusal errors in centric relation are
ii. Sonic cleansers corrected by selective grinding. The marks should
These use vibratory energy (not ultrasonic energy) to be distributed widely and evenly.
clean the dentures. In combination with hypochlorite ● Next, working side, balancing side, protrusive
solutions they are very effective in removing calculus errors or prematurities are corrected.
as well as cigarette and coffee stains. Disadvantages
Chemical denture cleansers Correction using articulating paper alone is less
Commercial preparations accurate when compared to clinical remounting.
● They are safe and effective. ● Inaccurate mouth closure by the patient.
● Most commercial solutions contain a bleaching ● It also requires a lot of patient cooperation.
agent such as sodium hypochlorite. ● The patient should have good neuromuscular
● Some are available in the form of tablets which ef- control.
fervesce when dropped in water releasing bubbles. ● Besides there is also the problem of saliva.
● The dentures are left in this for at least 15 min or
Q.11. Residual ridge resorption.
even overnight. The dentures are rinsed before use.
● Caution: Cleansers containing sodium hypochlo- Ans.
rite are not indicated with chrome cobalt or other
[Ref LE Q.3]
metal-based dentures. The hypochlorite may pit
or damage the metal. Q.12. Injection moulding technique.
Q.8. Diet in complete denture. Ans.
Ans. Injection moulding technique
● There is decrease in mastication ability in complete den- This technique requires special equipment and material
ture wearer, due to absence of natural teeth and propriocep- (a special thermoplastic resin).
tive impulses and therefore decreased chewing efficiency. Procedure
● A stone mould is created in a special flask and
● Patient is asked to prefer soft diet and avoid biting on
hard food, as it may cause denture fracture. material is introduced into this through a sprue.
● Resin is softened by heat in an injector and intro-
● More of protein intake to counteract weakness due to
less food intake, and avoid fatty food. duced under pressure into the mould. It is kept
● Intake of tea/coffee may cause denture discolouration.
under pressure, until it hardens.
● Avoid extremely hot food/drink, as it causes war page of
Advantages
● Dimensional accuracy.
denture.
● Low free monomer content.
● Avoid acidic food and drinks, as they cause abrasion of
● Good impact strength.
denture and teeth.
● No trial closures required.
Q.9. Gag reflex. Disadvantages
● High cost of equipment.
Ans.
● Difficult mould construction.
[Ref LE Q.3] ● Less craze-resistants.

Q.13. Bilabial sounds. Q.14. Denture irritation hyperplasia.

Ans. Ans.
Bilabial sounds [Same as SN Q.2]
Bilabial sounds (b, p and m) are controlled by lip sup-
port and become defective due to its absence or altera- Q.15. Denture hyperplasia.
tion in vertical dimension at occlusion. Ans.
They require both the lips for their production.
Test sentence – BOBBY POPPED MY BALLOON. [Same as SN Q.2]
Topic 9
Relining and Rebasing in Complete Dentures
LONG ESSAYS:
1. Patient aged 55 years, complete prosthesis wearer for last 15 years complains of skidding of prosthesis on
examination and both maxillary and mandibular ridges are hyperplastic. Give your method of treatment for the
patient.
2. What is relining and rebasing of complete dentures? How would you proceed to reline the maxillary complete
denture? [Same as LE Q.1]
3. State the clinical indication for relining and rebasing of complete dentures and discuss the hazards of relining
procedures. [Same as LE Q.1]
SHORT ESSAYS:
1. Indications, diagnosis and contraindications for relining and rebasing. [Ref LE Q.1]
2. Open-mouth relining technique. [Ref LE Q.1]
3. Midline fracture of complete denture.
4. Complete denture repair.
5. Closed-mouth relining technique of denture repair. [Ref LE Q.1]
6. Age changes in edentulous patients.
7. Relining and rebasing of complete denture. [Same as SE Q.1]
8. Denture relining. [Same as SE Q.1]
9. Causes for midline fracture of maxillary complete denture. [Same as SE Q.3]
10. Repair and relining of complete denture. [Same as SE Q.4]
11. Define the term gerodontology. What are the age changes that occur in geriatric patients? [Same as SE Q.6]
SHORT NOTES:
1 . Relining and rebasing.
2. Resilient liners. [Ref LE Q.1]
3. Complete denture repair.
4. Tissue preparation for relining.
5. Denture relining. [Same as SN Q.1]
6. Steps in rebasing of complete dentures. [Same as SN Q.1]
7. Soft liners. [Same as SN Q.2]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Patient aged 55 years, complete prosthesis wearer I. Clinical procedures
for last 15 years complains of skidding of prosthesis on Tissue preparation
examination and both maxillary and mandibular ridges Health of tissue is important. It includes following
are hyperplastic. Give your method of treatment for the procedures:
patient. ● Surgical removal of hypertrophic tissues.
● Dentures left out of mouth before making final

Ans.
impression for 2–3 days.
[SE Q.1] ● Daily massage of tissue.
● Use of tissue conditioners.

{Relining of complete dentures Denture preparation
The procedures used to resurface the tissue side of a ● Relief of pressure areas and large undercuts.
removable dental prosthesis with new base material, ● Tissue side of denture relieved by 1.5–2 mm.
thus producing an accurate adaptation to the denture ● Correction of occlusal disharmony.
foundation area (GPT). ● Periphery of denture is shortened to obtain a flat
Indications of relining border.
i. Change in denture-bearing area due to resorption Final impression: Techniques
which include I. Static impression techniques
● Loss of retention, stability and support.
a. Closed-mouth technique.
● Loss of vertical dimension.
b. Open-mouth technique.
● Incorrect occlusal relationship and reorienta-
II. Functional impression technique
tion of occlusal plane. ● Using a tissue conditioner.
ii. Immediate denture cases after 3–6 months of I. Static impression techniques
fabrication.
iii. Socioeconomic condition – patient cannot afford [SE Q.5]
new dentures.
iv. Geriatric/chronically ill patients. {a. Closed-mouth technique
v. Patient unable to come for multiple appoint- Procedure
ments for new denture. It is a two-step technique.
● Centric relation is recorded using interocclusal
vi. Ill fitting of new denture at the time of denture
delivery. record (wax or compound) which guides the den-
Contraindications for both relining and rebasing tures into position while making reline impression.
● Borders are reduced to 1–2 mm except in poste-
● Denture base of poor condition or quality.
● Excessive resorption of ridge.

rior region and are reformed to functional con-
● Abused oral tissues (should be allowed to recover).
tours using low-fusing compound.
● For large undercuts 1.5–2 mm relief should be
● TMJ problems which should be treated first.
● Poor teeth arrangement and poor aesthetics.

provided.
● Palate centre portion can be removed for vis-
● Unsatisfactory jaw relationship.
● Severe bony undercuts – surgical removal should

ibility of maxillary denture positioning. In this
be done. case, quick setting plaster is used as impres-
● Major speech problem with denture.}
sion material.
● ZnOE is used as impression material and pa-
Relining materials and techniques
● Relining with autopolymerizing acrylic resin.
tient is asked to close lightly into the newly
● Relining with permanent soft liners.
made interocclusal record.
● Relining with tissue conditioning material (tem-
Advantages
● Opening of palate allows better seating of den-
porary soft liner).
Procedure ture and correct recording of vertical dimension.
● It helps to orient dentures into articulator.
It is divided into two parts:
● Forward movement of maxillary denture is pre-
I. Clinical procedures – same for relining and rebasing.
II. Laboratory procedures – different for both. vented and hence reliable.
● Premade interocclusal record helps in position- II. Laboratory procedures for relining
ing denture during impression making. i. Articulator method
Disadvantages ● Maxillary cat mounted on a semiadjustable
● Less accurate wax interocclusal record. articulator using facebow.

● Dentures cannot be relined/rebased simultane- ● Modelling clay is adapted on denture to block
ously.} all surfaces except the occlusal teeth surfaces.

● Stone index of occlusal surface is made
[SE Q.2] ● Impression material is removed along with
{b. Open-mouth technique: By Boucher (1973) thin resin layer from denture inside.
Procedure ● Tinfoil substitute is coated, autopolymerizing
● Dentures are used as impression trays and both resin mixed, and placed on denture and cast.
upper and lower denture relined at the same ● Denture is seated in stone index and articula-
time. tor closed.

● Posterior palatal seal (PPS) is formed in model- ● Once set, fired in pressure chamber (at 15–20 psi
ling compound. for 30 min).

● Borders are shortened and 1 mm space on tissue ii. Chair-side reline technique
side is made by bur. ● Dentures relined directly in the patient’s mouth.
● To lower denture, modelling compound handle is ● But it is not recommended because
attached. ● Chemical burns can occur from the monomer.
● Overpolished surface adhesive tapes are placed. ● Porosity, poor colour stability and poor odour.
● Border moulding done with green stick com- ● Difficulty in removal of material.
pound. iii. Flask method

● Final impression is taken using ZnOE/elastomers. It is done using silicone mould material.
● Centric record made using impression as record
[SE Q.1]
bases.
Disadvantage {Rebasing of complete dentures
● Demanding, laborious and require more chair It is the laboratory process of replacing the entire den-
and laboratory time.} ture base material on an existing prosthesis (GPT8).
Indications
● When denture base needs to be changed due to
{SN Q.2} some processing defects, e.g. due to discoloura-
II. Functional impression technique with tissue con- tion and porosity.
● When porcelain teeth are used.
ditioner (temporary soft liner)
● Observed clinical changes are mild to moderate.
Tissue conditioners are used both as functional im-
● Denture teeth are in good condition.
pression material and to bring tissues back to health.
● Clinical procedure same as relining.}
Procedure
● Existing intercuspation is used to stabilize the
Laboratory technique for rebasing
denture. Jig or articulator method
● Impression technique is same as relining.
● Centric record made using compound/wax.
● Cast poured and mounted on articulator.
● Denture preparation same as above technique.
● Stone index – imprint of the occlusal surface of
● Where flanges are underextended, border
moulding is done. teeth is made.

● Teeth are separated from denture base and reas-
● Tissue conditioner is placed, excess material
trimmed off, and patient is sent. sembled in stone index.

● Waxing of denture is done followed by flasking
● After 3–5 days, denture is examined for de-
nuded areas, which are marked and relieved and curing.

and tissue conditioner reapplied there. Q.2. What is relining and rebasing of complete den-
● Patient is reviewed periodically and material
tures? How would you proceed to reline the maxillary
renewed until the tissues regain health. complete denture?
● Old material is removed and new one applied
for taking final impression and kept for 30 min. Ans.

● Once set, it is removed and cast poured.
[Same as LE Q.1]
Q.3. State the clinical indication for relining and rebasing B. Cast pouring
of complete dentures and discuss the hazards of relining i. Undercuts blocked out.
procedures. ii. Plaster poured into denture to make cast.
C. Preparation of fracture site
Ans.
i. Denture separated from cast and 2–3 mm acrylic
[Same as LE Q.1] is removed from fracture site.
ii. Wide bevel created on either side of fracture line.
SHORT ESSAYS: iii. Separating media is applied followed by replac-
ing back the denture on cast.
Q.1. Indications, diagnosis and contraindications for D. Repairing and curing
relining and rebasing. i. Self-cure acrylic powder and liquid applied in-
Ans. crementally and alternatively until the fracture
site is filled in excess.
[Ref LE Q.1] ii. Curing carried out in a pressure pot at 100°F at
Q.2. Open-mouth relining technique. 30 psi pressure for 30 min.
iii. Pressure curing increases density and strength.
Ans. iv. Once curing is completed, denture removed
[Ref LE Q.1] from cast, trimmed and polished.
Problems with denture repair
Q.3. Midline fracture of complete denture.
i. It may not fit well after repair.
Ans. ii. Occlusal changes might occur.
Contraindications for denture repair
Causes for midline fracture
i. Accurate assembly of fractures pieces is not
i. Accidental dropping during removal or cleaning.
possible.
ii. Inability to handle denture due to poor neuromuscular
ii. Poor fit and excess occlusal wear requires
control, e.g. senility and Parkinsonism.
replacement with new dentures.
iii. Faulty denture design resulting in areas of inadequate
thickness. Q.5. Closed-mouth relining technique of denture repair.
iv. Prominent median palatine raphe with inadequate relief.
Ans.
v. Faulty occlusion.
vi. Excessive amounts of masticatory force applied by [Ref LE Q.1]
some individual.
Q.6. Age changes in edentulous patients.
vii. Poor laboratory techniques during deflasking and pol-
ishing procedures. Ans.
Q.4. Complete denture repair. Gerodontology is the branch of dentistry dealing with oral
health problems of the elderly.
Ans.
Age changes in geriatric patient
Denture repair Physiological changes
Material for Denture Repair ● Oral mucosa becomes thin, gets easily abraded,
● Self-cure/autopolymerizing acrylic resin is sim- and reacts unfavourably to pressure-form dentures.

ple, quick and accurate, but less strong. ● Skin becomes thin, dry, wrinkled and accumula-
● Heat cure not used due to chances of warpage of tion of melanin increases. Repair potential is
denture under heat. depleted.
● Visible light cured (VLC) is new, easy to use, can be ● Gross reduction in residual ridge height and width
carved, gives quick cure, and there is no warpage. due to long-term wear of denture.
Procedure ● Tongue becomes smooth, glossy and inflamed
A. Segment assembling leading to soreness; there is burning and abnormal

i. Fracture site is cleaned of debris. taste and nodular varicose enlargement of superfi-
ii. Pieces are accurately assembled and stabilized cial veins is seen on tongue undersurface.
using a rigid material like an old bur and sticky ● Decreased secretion of saliva due to atrophy of
wax (not placed over fracture site for better visu- salivary glands leading to dry mouth and decrease
alization) or quick acting cyanoacrylate super in denture retention and increased functional
glue. trauma to mucosa.
Reduced neuromuscular coordination, decrease in

● Q.11. Define the term gerodontology. What are the age
masticatory ability, sagging of cheeks due to re- changes that occur in geriatric patients?
duced muscle tone and decreased nerve conduction.
Psychological changes Ans.
● High incidence of depression and insecurity feel- [Same as SE Q.6]
ings in geriatrics.
● Tooth clenching habit which place extra stress on
tissues.
SHORT NOTES:
● Increased usage of drugs. Q.1. Relining and rebasing.
Pathological changes
Ans.
● Presence of chronic disorders, such as heart dis-
eases, hypertension, TB, diabetes (more bone re- Relining

sorption), bone diseases and cancer. Death may These refer to the procedures used to resurface the
occur due to cerebral haemorrhage, heart disease tissue side of a removable dental prosthesis with new
and arteriosclerosis. base material, thus producing an accurate adaptation to
● Thiamine deficiency leading to accumulation of the denture foundation area (GPT).
pyruvic acid and peripheral neuritis. Rebasing
● Difficult to clean the denture due to arthritis of It is the laboratory process of replacing the entire
terminal joints of fingers. denture base material on an existing prosthesis
● Osteoarthritis of TMJ has associated difficulty in (GPT8).
making mandibular movements. Steps in rebasing
Age changes in teeth of geriatric patient Clinical procedure
● Enamel: Attrition of occlusal and proximal surface, a. Tissue preparation.
localized increase in nitrogen and fluorine content, b. Denture preparation.
teeth become darker, and there is increased resis- c. Final impression techniques
tance to decay and reduced permeability to fluids. i. Static impression technique
● Dentine: Development of dead tracts, reparative den- ● Closed-mouth technique.
tine formation and collagen fibres appear in dentinal ● Open-mouth technique.
tubules. ii. Functional impression technique

● Pulp: Cell number, size and number of organelles ● Using a tissue conditioner.
decrease; there is less perinuclear cytoplasm and Q.2. Resilient liners.

presence of long processes; there is accumulation of
collagen fibre leading to fibrosis, presence of pulp Ans.
stones and plaque in pulpal vessels. [Ref LE Q.1]
Q.7. Relining and rebasing of complete denture. Q.3. Complete denture repair.
Ans. Ans.
[Same as SE Q.1] Denture repair
Material for denture repair
Q.8. Denture relining. ● Self-cure/autopolymerizing acrylic resin is simple,
Ans. quick and accurate, but less strong.

● Heat cure not used due to chances of warpage of
[Same as SE Q.1] denture under heat.
● VLC is new, easy to use, can be carved, there is
Q.9. Causes for midline fracture of maxillary complete
denture. quick cure and there is no warpage.
Procedure
Ans. ● Segment assembling.
● Cast pouring.
[Same as SE Q.3]
● Preparation of fracture site.
Q.10. Repair and relining of complete denture. ● Repairing and curing.
Ans. Problems with denture repair

● It may not fit well after repair.
[Same as SE Q.4] ● Occlusal changes might occur.
Q.4. Tissue preparation for relining. Q.6. Steps in rebasing of complete dentures.
Ans. Ans.
Tissue preparation includes following procedures: [Same as SN Q.1]
● Surgical removal of hypertrophic tissues.
● Dentures left out of mouth before making final impres-

Q.7. Soft liners.
sion for 2–3 days. Ans.
● Daily massage of tissue.
● Use of tissue conditioners.

[Same as SN Q.2]
Q.5. Denture relining.

Ans.
[Same as SN Q.1]
Topic 10
Special Complete Dentures and Miscellaneous
LONG ESSAYS:
.
1 Enumerate the advantages and disadvantages of overdenture.
2. What are the indications and contraindications for an immediate complete denture?
3. Define interim removable denture and give indications for use.
4.
Define overdenture. Discuss in detail the following in treatment planning of an overdenture:
Selection and preparation of an abutment tooth.
Objectives or goals of overdenture treatment. [Same as LE Q.1]
5. What are overdentures? Describe their indications, contraindications, advantages and disadvantages. [Same as LE Q.1]
6. What is ‘preventive prosthodontics’? Give the advantages, disadvantages and principle of overdentures. [Same as LE Q.1]
7. What are the advantages and disadvantages of immediate denture service? [Same as LE Q.2]
SHORT ESSAYS:
1. Immediate complete denture. [Ref LE Q.2]
2. Overdenture. [Ref LE Q.1]
3. What is refractory cast? Write about its fabrication.
4. Implant dentures.
5. Laboratory remounting.
6. Single complete denture.
7. Granular porosity in denture.
8. Importance of study cast.
9. What is immediate denture? Write about indications and contraindications. [Same as SE Q.1]
10. Rationale, advantages and disadvantages of immediate complete dentures. [Same as SE Q.1]
11. What are overdentures? Write the advantages and disadvantages. [Same as SE Q.2]
12. Write the requirements (indications) of an overdenture. [Same as SE Q.2]
13. Types of implant dentures. [Same as SE Q.4]
14. Clinical remounting procedures. [Same as SE Q.5]
15. Drawbacks of single complete denture. [Same as SE Q.6]
16. Problems encountered in single complete denture. [Same as SE Q.6]
SHORT NOTES:
. Enumerate different types of obturator, their functions and the materials used for making them.
1
2. Immediate obturator.
3. Write in brief the treatment planning for maxillary obturator prosthesis.

4. Overdenture advantages. [Ref LE Q.1]
5. Abutment considerations of overdenture. [Ref LE Q.1]
6. Rationale of overdentures.
7. Types of bar-retained overdentures.
8. Advantages and disadvantages of immediate complete denture. [Ref LE Q.2]
9. Temporary prosthesis.
10. Appliance versus prosthesis.
11. Kelly combination syndrome.
12. Occlusal refining.
13. Define implants. Enumerate the various materials used for implants.
14. Implant denture.
15. Name the different maxillofacial prostheses and the materials used.
16. Occlusal pivots.
17. How will you make a treatment plan for a cleft palate patient?
18. Transitional denture.
19. Interim denture.
20. Split-cast technique.
21. Gunning splint.
22. Screw-retained prosthesis.
23. Obturators. [Same as SN Q.1]
24. Write the concept and advantages of overdenture. [Same as SN Q.4]
25. Immediate overdentures. [Same as SN Q.4]
26. Tooth-supported overdentures.[Same as SN Q.4]
27. Hybrid dentures. [Same as SN Q.4]
28. Laboratory remounting procedures in complete denture. [Same as SN Q.12]
29. Advantages of metal denture implant. [Same as SN Q.14]
SOLVED ANSWERS
LONG ESSAYS:
Q.1. Enumerate the advantages and disadvantages of ii. Coping
overdenture. ● With endodontic therapy (short coping).
● Without endodontic therapy (long coping).

Ans. iii. Attachments.
(SE Q.2 and SN Q.4) Based on the type of overdenture
i. Immediate overdenture.
{(Overdentures ii. Transitional overdenture.
Overdentures are also known as tooth-supported iii. Remote overdenture.
dentures, overlay dentures, onlay dentures, telescoped Indications for overdentures
dentures, hybrid dentures, biologic dentures, coping ● Patients with few remaining teeth.
prosthesis and superimposed dentures. ● Patients with poor prognosis for routine complete
Definition dentures
Any removable dental prosthesis that covers and i. High palatal vault.
rests on one or more remaining natural teeth, the ii. Xerostomia.
roots of natural teeth and/or dental implants; a dental iii. Poor mandibular ridges.
prosthesis that covers and is partially supported by iv. When high rate of resorption is expected.
natural teeth, natural tooth roots and/or dental im- v. When opposing natural teeth are present.
plants (GPT8).)} vi. Smaller dental arches.
● Patients with congenital or acquired intraoral defects
[SE Q.2]
i. Partial anodontia and microdontia.
{Classification ii. Cleft palate.
Based on method of abutment preparation iii. Amelogenesis imperfecta.
i. Noncoping ● In case of severe attrition, vertical height can be
● With endodontic therapy. restored with an overdenture.
● Without endodontic therapy. ● Very young patients facing total extraction.
Patients with few remaining natural teeth.

● lips. Spaces between the tissues and the flange
Low caries index and good oral hygiene.
● can also create a food trap.
Contraindications ● Tooth arrangement is difficult in some cases, be-
● High caries index and poor oral hygiene cause of the reduced interocclusal distance.}
i. When the abutments have a doubtful prognosis. Basic principles to be followed:
ii. When endodontic treatment is not possible. ● Abutment tooth should be surrounded by
iii. When periodontal therapy and reduction of healthy periodontal tissue.

crown–root ratio does not improve periodontal ● Maximum reduction of coronal portion of
health. abutment tooth should be done to attain better

● Failure to establish a sufficient zone of attached gingiva. crown–root ratio and avoid interference during
● Uncooperative, terminally ill or senile patients.} placement of artificial teeth. Endodontic ther-
apy may be done, if required.
(SE Q.2 and SN Q.4) ● A simple tooth preparation without any inter-
{(Advantages nal attachment can be done in a single visit

● Preservation of the alveolar bone. Presence of the especially for elderly patients and compro-
abutment teeth reduces resorption. mised patients.
● Preservation of the proprioception. Oral function ● Treatment should be accompanied with fluo-
and feeling is improved, because of the proprio- ride gel application and other oral hygiene
ceptive feedback from receptors in the root. measures.
● Improved support, because of the abutment teeth. ● Gold copings or crowns and sleeve coping re-
● Improved retention. Retention devices can be at- tainers can be given for grossly destructed
tached to abutment teeth when better retention is abutments after assessing the patient’s suscep-
needed tibility to caries.
● Less psychological trauma, as patients are able to ● Gold coping can be prepared with posts and
retain their original teeth. retentive pins depending on the amount of

● Can be converted to a routine complete denture in tooth structure above the gingival attachment.
case of abutment failure. ● Attachments may be added to cast copings for
● To preserve the alveolar bone for as long as pos- additional retention which may be resilient or
sible. The overdenture is a logical method for use nonresilient types.
in preventive prosthodontics.
● Preserving the remaining natural teeth not only {SN Q.5}
preserves the alveolar bone but also gives the pa- Selection and preparation of an abutment tooth
tient better function and control over the dentures, Dentist should preserve the ideal teeth and extract
because of the presence of nerve receptors.)} the remaining to reduce the cost of the prosthesis.
[SE Q.2] Factors to be considered while selecting abutment
for overdenture are:
{Disadvantages i. Periodontal status of the abutment teeth
● High caries risk, especially for the noncoping ● Periodontally compromised teeth with hori-
abutments due to coverage of the teeth by the zontal bone loss have a better prognosis
denture. than the ones with vertical bone loss.
● Risk of periodontal problems due to improper ● A favourable crown–root ratio should be
care by the patient. present in cases with slight tooth mobility.
● High initial cost due to the castings, precision ● A circumferential band of attached gingiva
attachments, preceding endodontics, periodontal is an absolute necessity for an overdenture
therapy and other therapies. abutment.
● Long bony undercuts are often found near the ii. Abutment location
abutment teeth. They cause many problems like ● Cuspids and bicuspids are frequently se-
i. Tissue injury during insertion and removal. lected as overdenture abutments.
ii. To avoid the undercuts, the flanges are some- ● Anterior teeth are not selected, as the ante-
times shortened which can reduce the periph- rior alveolar ridge resorbs easily under stress.
eral seal. ● Maxillary incisors can be used as overdenture
iii. Blockage of the undercuts results in a flange abutments, if the mandibular arch is intact.
placed away from the tissues. This can result ● At least one tooth should be retained in the
in aesthetic problems due to the bulging of the quadrant to maintain the health of oral tissues.
(SE Q.1and SN Q.8)

● The number and location of the abutment
teeth and the status of the opposing one should {(Advantages
be evaluated during treatment planning. It serves as a splint, reduces pain, controls bleed-
●
iii. Endodontic and prosthodontic status ing and protects from trauma during the healing
● Usually anterior teeth (canines and premo- period.
lars) are preferred as overdenture abut- ● Patient regains function faster, e.g. speech and
ment, as they are easier to prepare and mastication.

economical too. ● Inconvenience and stress of edentulous period is
● When there is pulpal recession or calcifica- spared and patient can learn to manipulate the
tions along with extensive tooth wear, end- denture while recovering from surgery.
odontic therapy can be avoided. ● More compatible with oral surroundings as the
tongue, lips and cheeks have not yet changed their

Rationale/objectives/goals of ovedenture treatment position.
● Natural teeth aid in vertical relation positioning
● Reduction of crown–root ratio and the resulting
forces on the abutment teeth and supporting and selecting artificial teeth.
● Less change in facial appearance and more
tissues.
● Shortening the natural tooth changes the crown–
aesthetic.
● Less temporomandibular joint (TMJ) disturbance.
root ratio which reduces the lateral stresses and
● Aids in contouring the healing residual ridge.
lever action on the tooth. The load is now in a
● Psychological benefits.
more occlusal direction which is better tolerated
● Easy to refit by relining.
by the tooth.
● The complete denture resting on these shortened
Disadvantages
● Time-consuming and precise technique.
teeth exerts largely vertical forces directed towards
● More appointments needed.
the bone which are better tolerated by the teeth.
● More costly.
● It also forms the basis of using mobile teeth which
● No opportunity for try-in of anterior teeth.)}
otherwise would have been indicated for extraction.
Reducing the crown–root ratio reduces the mobility Q.3. Define interim removable denture and give indica-
of these teeth and improves their prognosis. tions for use.
Q.2. What are the indications and contraindications for Ans.
an immediate complete denture?
Interim removable denture
Ans. ● Interim removable denture is a temporary partial
denture used for a short period to fulfil aesthetics,

[SE Q.1]
mastication or convenience, until a more definitive
{Immediate complete denture form of treatment can be rendered.
Immediate complete denture is ‘a complete or remov- Indications for use
able partial denture constructed for insertion immedi- ● Long edentulous span: As Removable Partial denture
ately following the removal of natural tooth’ (GPT7). (RPD) can take support from the tissues along the ridge
Indications and helps to distribute forces over the ridge evenly.
● For patients with periodontally weak teeth indi- ● Age: In cases where fixed partial denture is contrain-
cated for extraction. dicated such as young people, because of large dental
● For socially active people who are very conscious pulps and lacks sufficient crown height and in old
about their appearance. age due to reduced life expectancy.
Contraindications ● In cases of absence of abutment tooth for support.
● Patient who is not fit to undergo multiple extrac- ● In cases of reduced periodontal support of remaining
tions, e.g. blood dyscrasias and cardiac disease. tooth: As it requires less support from remaining teeth as
● In acute periapical or periodontal infection. compared to fixed partial denture and also splints them.
● Debilitating diseases. ● For cross-arch stabilization: To stabilize teeth against
● Patient incapable of showing responsibility to- lateral and anteroposterior forces with the help of
wards the treatment, e.g. senile, mentally retarded major connectors.
and indifferent patients. ● In cases with excessive bone loss.
● In cases of extensive bone loss adjacent to ● Aesthetics: Denture base gives appearance of a
remaining teeth.} natural tooth arising from the gingiva with life-like
appearance and can be arranged more easily to sat- Spacer relief appears as an elevation on the eden-
●
isfy phonetic and aesthetic requirements. tulous ridge.

● For immediate tooth replacement after extraction: ● The stopper holes on the spacer will appear as a
Later relining can be done, as resorption occurs. depression on the elevated saddle area.
● Patient’s desires: In order to avoid operative proce- ● Gingival relief appears as an elevated band on the
dures on sound healthy teeth and for economic reasons. refractory cast.
Fabrication of refractory cast
Q.4. Define overdenture. Discuss in detail the following
● Refractory or investment material is measured and
in treatment planning of an overdenture. Selection and
mixed according to manufacturer’s instructions, so
preparation of an abutment tooth. Objectives or goals of
that the expansion of the mould during burnout will
overdenture treatment.
match the shrinkage of alloy.
Ans. ● Gypsum-bonded investments (low heat investments)
are used for casting type IV gold alloy and ticonium.

[Same as LE Q.1]
This refractory material can be burned out at 704°C
Q.5. What are overdentures? Describe their indications, without causing breakdown of the investment.
contraindications, advantages and disadvantages. ● Investments for cobalt chromium, vitallium, etc.,
(high heat investments) are burned out at tempera-

Ans.
tures of 1037°C. These are phosphate-bonded invest-
[Same as LE Q.1] ment material and require a special liquid to be
mixed with the refractory material.
Q.6. What is ‘preventive prosthodontics’? Give the ad-
● Colloid mould in the duplicating flask is cleaned of
vantages, disadvantages and principle of overdentures.
debris and poured with refractory material. The ma-
Ans. terial is introduced into moulds in small amounts to
prevent air entrapment in the area of teeth.
[Same as LE Q.1]
● Remaining refractory material is added to mould
Q.7. What are the advantages and disadvantages of im- with minimum vibration and mould kept aside cov-
mediate denture service? ered with wet towel to keep the colloid moist, while
the refractory material sets.
Ans.
● Once it sets, the refractory cast is removed from the
[Same as LE Q.2] mould and kept in drying oven at 93°C for 1–1.5 h.
● When dry, the cast is trimmed within 6 mm of the
proposed design. Trimming always should be done on

SHORT ESSAYS: dry cast, if wet, the slurry material can accumulate on
the cast and change the contours and dimensions.
Q.1. Immediate complete denture.
● Dried refractory cast is dipped in hot beeswax (138–
Ans. 149°C for 15 sec) to ensure a smooth, dense surface

to eliminate the need for soaking the cast before
[Ref LE Q.2]
investing.
Q.2. Overdenture.
Q.4. Implant dentures.
Ans.
Ans.
[Ref LE Q.1]
Implant dentures
Q.3. What is refractory cast? Write about its fabrication. ● Dentures which take support from the underlying
implants placed in the bone are called implant

Ans.
dentures.
Refractory cast ● These increases retention, stability and support of the
● Refractory cast used in RPD fabrication is made up denture.

of refractory material (silica- or phosphate-bonded Depending on the way in which the dentures are at-
investment) to withstand the high-temperature metal tached to implants, they are of two types:
framework casting. i. Fully bone anchored
It is not similar to master cast and has the following ● Also called as Toronto denture.
characteristics: ● It is screwed or cemented onto implant, there-
● All the blocked out undercuts will be invisible in fore not meant to be removed routinely by the
the refractory cast. patient.
● It is designed in such a way that it can be cleaned Presence of saliva makes detection by articulating
●
without removing convex tissue contact. paper difficult.

ii. Partially bone anchored ● Occlusal errors (including minute errors) are
● It is supported partly by implants and partly by more accurately detected, viewed and corrected
mucosa. on an articulator rather than directly in the
● It can be removed by the patient for the pur- patient’s mouth.
pose of cleaning and oral hygiene. ● Corrections can be made away from the patient’s
● It is designed like an overdenture and can be view, thus preventing any objection the patient
attached using bar and clip attachment or pre- might have when he sees his dentures being ground.
cision attachment. ● Clinical remounting is the most commonly pre-
Denture is attached to implants by: ferred method of occlusal correction.

● Screws. Procedure
● Cement. ● Dentures are inserted in mouth and the patient is
● Precision attachment. trained to close in centric relation stopping just

● Bar and clip mechanism. before the teeth make contact.
● Magnets. ● A suitable bite registration material is selected
and placed between the occlusal surfaces bilat-

Q.5. Laboratory remounting.
erally.
Ans. ● Before remounting the upper denture, petroleum
jelly is applied to the tissue surface. Undercuts are

Laboratory remounting
blocked using tissue paper or pumice putty.
● Laboratory remounting is used to correct only pro-
● Plaster is poured into the blocked out dentures to
cessing errors (e.g. mild tooth displacement).
form remount casts.
● It cannot be used to correct errors due to faulty im-
● The upper denture is remounted on the articulator
pression making, jaw relations etc.
with the help of the face-bow index.
Procedure
● The lower denture is mounted using the bite
● Remounting can be done using the same articula-
registration.
tor used for teeth arrangement.
● The accuracy of the mounting is verified using a
● Denture should not be separated from the cast
new centric relation record.
after processing.
● The condylar guidance angles and incisal table
● Identified contacts are ground in relation to the
angles are reset according to the previous values.
opposing teeth.
New protrusive and lateral records may also be
● After grinding, dentures removed from the cast
obtained.
and polished.
● The occlusion is corrected using the selective
● New centric and eccentric records should be
grinding technique.
obtained, if new dentures are planned.
● Initially, centric occlusion errors are corrected,
Clinical remount procedure
followed by protrusive, right and left lateral inter-
● Clinical remounting is done in order to perfect the
ferences.
occlusion. The dentures are remounted on to an
articulator from new interocclusal records made Q.6. Single complete denture.
in the patient’s mouth. Corrections are done by
Ans.
selective grinding.
Advantages of clinical remounting SCD is a single arch denture, either upper or lower, some-
● Corrects errors made during recording of jaw times opposing the natural teeth in the other arch.
relations. Types
● Corrects errors made while mounting the cast on i. SCD opposing natural teeth.
the articulator. ii. SCD opposing a (pre-existing) complete denture.
● Less chair-side time needed to correct occlusal iii. SCD opposing a removable partial denture.
errors. iv. SCD opposing an overdenture.
● The level of patient cooperation required is mini- Problems with the SCD
mized. Many difficulties are often encountered with the
● Direct intraoral correction of occlusal errors is dif- SCD when it opposes remaining natural teeth which
ficult, because of shifting of the dentures or incor- are as follows:
rect closures made by the patient. Corrections on ● The remaining natural teeth are often tipped,
the articulator provide a stable working foundation. supraerupted or malposed which results in an
uneven occlusal plane making it difficult to Cause: It is due to vaporization of monomer when the
obtain a harmonious balanced occlusion. temperature of resin increases above its boiling point
● Unfavourable occlusal forces can destabilize (100.8oC). Exothermic heat is produced during resin
the denture causing soreness and ultimately curing, which dissipates easily into the plaster from the
ridge resorption. resin present near surface. However, in deep thick areas,
● Supraerupted teeth reduce the space available, heat does not dissipate fast resulting in rise of tempera-
making setting of artificial teeth a laborious ture above the boiling point of monomer in these areas.
process. Prevention: Includes use of long, low-temperature cur-
● A mandibular SCD opposing upper natural ing cycle.
teeth is extremely complicated. . External porosity: It occurs near the surface of den-
b
● The reduced surface area of the lower ridge tures and gets exposed as a result of finishing and pol-
results in excessive forces on the ridge result- ishing procedures.
ing in rapid resorption. The lower SCD is Cause
therefore rarely indicated. i. Lack of homogeneity: It causes the dough with
● The upper SCD opposing lower natural ante- more monomer to shrink more than adjacent areas
rior teeth often results in the combination syn- resulting in voids and resin appears white.
drome. ii. Lack of adequate pressure: Inadequate pressure
● Occlusal wear – Acrylic wears quickly when during polymerization or flask closure/packing
opposing natural teeth is seen. On the other too early results in nonspherical voids. Mix does
hand, if one uses porcelain teeth to counter not have sufficient density to pack well and the
this, the porcelain teeth results in the wear of resin is lighter.
the natural teeth. Prevention
● The fixed position of lower anterior natural ● Use proper monomer-powder ratio.
teeth gives us less flexibility for aesthetic ● Mix well to a homogenous mass of uniform
placement of upper natural teeth. density.
● The fixed position of lower natural teeth cou- ● Packing during dough stage.
pled with the marked resorption of upper natu- ● Use of hydraulic press with pressure gauge to
ral teeth often places teeth in crossbite rela- ensure sufficient packing.
tionships as well as other functionally ● Use slight excess quantity of dough than required.
compromised positions. Formation of flash should be there during trial
● Fracture of the SCD is a common problem, closure.
especially if opposed by natural teeth, because
Q.8. Importance of study cast.
of the forces generated by the natural teeth.
Ans.
Q.7. Granular porosity in denture.
Importance/uses of study cast or diagnostic cast are as follows:
Ans.
● To measure the extent and depth of undercuts.
Granular porosity in denture ● To determine the path of insertion of denture.
Porosity in denture is one of the defects of denture ● To identify and plan the treatment for interferences
processing. like tori.
It is the presence of voids within the structure of resin. ● To perform mock surgeries for maxillofacial prosthesis.
It results in: ● To determine the amount of preprosthetic surgery
● Unaesthetic and difficult to polish denture. required.
● Surface porosity can trap food, making denture unhy- ● To evaluate the size and contour of the arch
gienic and foul smelling. ● To get an idea about retention and stability offered by
● Voids act as area of stress concentration and cause the tissues.
warpage of denture, as the stresses relax. ● To determine the need of additional retentive features
● It weakens the denture and makes cleaning of denture like overdenture abutments and implant abutments.
difficult.
Q.9. What is immediate denture? Write about indica-
It is of two types: tions and contraindications.
a. Internal porosity: It occurs in the form of voids within
Ans.
the structure of resin and found in the thicker sections of
the denture. It does not occur uniformly. [Same as SE Q.1]
Q.10. Rationale, advantages and disadvantages of imme- Functions of obturator

diate complete dentures. ● It closes the defect in hard palate.
● It provides a stable matrix for surgical packing.

Ans.
● It permits speech and deglutition.
[Same as SE Q.1] ● It prevents regurgitation of food into nasal cavity
by acting as a barrier.
Q.11. What are overdentures? Write the advantages
● It prevents burping of air.
and disadvantages.
● It reduces the psychological impact of surgery.
Ans. Q.2. Immediate obturator.

Q.12. Write the requirements (indications) of an over- Immediate obturator
denture. A surgical obturator placed immediately after surgery is
known as immediate obturator.
Ans.
Principle
[Same as SE Q.2] ● To give patient, the benefit of rehabilitation before
he becomes seriously debilitated.

Q.13. Types of implant dentures.
Advantages of immediate obturator
Ans. ● It provides a stable matrix for surgical packing.
● It reduces oral contamination and chances of

[Same as SE Q.4]
infection.
Q.14. Clinical remounting procedures. ● It enables the patient to speak postoperatively.
● It allows the patient to swallow and thus the naso-

Ans.
gastric tube may be removed early.
[Same as SE Q.5] ● It lessens the psychological impact of surgery.
● It may reduce the period of hospitalization.

Q.15. Drawbacks of SCD.
Q.3. Write in brief the treatment planning for maxillary
Ans. obturator prosthesis.
Q.16. Problems encountered in SCD. Treatment planning for maxillary obturator prosthesis is as
follows:
Ans.
● Diagnosis: Type of defect determines the size, loca-
[Same as SE Q.7] tion and extent of obturator.
● Preliminary impression using alginate: Useful for
careful recording of undercuts and the junction of

SHORT NOTES: graft and mucosa. It is an important retentive feature.
Q.1. Enumerate different types of obturator, their func- ● Custom tray fabrication: The tray is oriented prop-
tions and the materials used for making them. erly into the defect.
● Acrylic special trays are preferred.
Ans.
● Border moulding: Velopharyngeal extension re-
Obturators corded by asking the patient to swallow or doing

Obturators area prosthesis used to close a congenital or other exercises like turning the head from side to side
acquired tissue opening primarily of the hard palate and placing the chin down on the chest.
and/or contiguous alveolar structures. ● Final impression with elastic impression material:
Types of obturator Proper positioning of tray and accurate recording of

i. Surgical obturator. scar band area. Elastic recoil (purse string action) seen
ii. Treatment/temporary/transitional obturator. in scar band tissue serves in retention of obturator.
iii. Definite obturator. ● Jaw relation: Acrylic denture bases are preferred, as
Materials used for making obturator it is difficult to position other denture bases.
● Methyl methacrylate resin. ● Teeth arrangement: To obtain balance occlusion.
● Latex.
Q.4. Overdenture advantages.
● Synthetic latex.
● Vinyl plastisol.
Ans.
● Silicone rubber. [Ref LE Q.1]
Q.5. Abutment considerations of overdenture. Q.8. Advantages and disadvantages of immediate com-
plete denture.
Ans.
Ans.
[Ref LE Q.1]
[Ref LE Q.2]
Q.6. Rationale of overdentures.
Q.9. Temporary prosthesis.
Ans. Ans.
Rationale/objectives/goals of overdenture treatment ● Temporary prosthesis is also called as interim prosthesis,
i. To preserve the alveolar bone for as long as possible. provisional prosthesis or provisional restoration.
The overdenture is a logical method for use in pre- ● It is defined as a fixed or removable dental prosthesis, or
ventive prosthodontics. Preserving the remaining maxillofacial prosthesis, designed to enhance aesthetics,
natural teeth not only preserves the alveolar bone, stabilization and/or function for a limited period of time,
but also gives the patient better function and control after which it is to be replaced by a definitive dental or
over the dentures, because of the presence of nerve maxillofacial prosthesis.
receptors in the root. ● Often, such prostheses are used to assist in determina-
ii. Reduction of crown–root ratio and the resulting tion of the therapeutic effectiveness of a specific treat-
forces on the abutment teeth and supporting tissues ment plan or the form and function of the planned for
● Shortening the natural tooth changes the crown– definitive prosthesis.
root ratio which reduces the lateral stresses and
lever action on the tooth. The load is now in a Q.10. Appliance versus prosthesis.
more occlusal direction which is better tolerated Ans.
by the tooth.
● The complete denture resting on these shortened
Appliance is defined as something developed by the appli-
teeth exerts largely vertical forces directed to- cation of ideas or principles that are designed to serve a
wards the bone which are better tolerated by the special purpose or perform a special function.
teeth. Prosthesis is defined as:
● It also forms the basis of using mobile teeth which
i. An artificial replacement of an absent part of the
otherwise would have been indicated for extraction. human body.
Reducing the crown–root ratio reduces the mobility ii. A therapeutic device to improve or alter function.
of these teeth and improves their prognosis. iii. A device used to aid in accomplishing a desired
surgical result.
Q.7. Types of bar-retained overdentures.
Q.11. Kelly combination syndrome.
Ans.
Ans.
Bar-retained overdentures Kelly combination syndrome (by Kelly in 1972)
● One of the methods of retention of overdenture is bar
It is seen in patients wearing maxillary complete den-
attachment. ture opposing a mandibular distal extension prosthesis.
● The typical bar attachment consists of a bar connect-
Pathogenesis
ing two or more abutments. Joining the two abut- i. Patient concentrates the occlusal load on remain-
ments enables splinting. ing natural teeth (mandibular anteriors) for pro-
● A metal or plastic clip fixed to the tissue side of the
prioception resulting in more force acting on the
denture attaches it to the bars. anterior part of the maxillary denture.
The bars are attached to the abutment copings by soldering. ii. Above leads to increased resorption of the anterior
Classification part of maxilla replacing it with flabby tissue.
There are two types of bar attachments. They are iii. Occlusal plane gets tilted anteriorly upwards and
i. Bar joints permit rotational movement. They posteriorly downwards due to lack of anterior
are used as a splint connecting the abutments support.
together.
iv. Labial flange gets displaced irritating the labial
ii. Bar units (rigid fixation) permits no move- vestibule leading to formation of epulis fissuratum.
ment. They are placed as a single unit on the v. Posteriorly, fibrous overgrowth of tissues of
abutment teeth like a stud attachment. maxillary tuberosities occurs.
There are many bar attachments available. Among the vi. Reduced mandibular distal extension denture-
famous ones are the Baker clip, the Hader bar and the bearing area due to shift of occlusal plane poste-
Dolder bar, etc. riorly downwards.
vii. Vertical dimension of occlusion is decreased Implant denture

resulting in decreased retention and stability. Dentures which take support from implants placed in
viii. Tilt of occlusal plane disoccludes the lower ante- underlying bone are called implant dentures.
riors causing them to supraerupt resulting in their Depending on the way in which the dentures are attached
decreased periodontal support. to implants, they are of two types:
ix. These supraerupted anteriors increase the amount i. Fully bone anchored
of force acting on the anterior part of complete ● It is also called as Toronto denture.
denture and the cycle continues. ● It is screwed or cemented onto implant and is
Remedy therefore not meant to be removed routinely by

● Combination syndrome should be identified at an the patient.
early stage and prevented. ● It is thus designed in such a way that it can
● Overdentures and implant-supported dentures are be cleaned without removing convex tissue
some of the treatment alternatives to prevent it. contact.
ii. Partially bone anchored
Q.12. Occlusal refining.
● It is supported partly by implants and partly by
Ans. mucosa.
● It can be removed by the patient for the pur-
Occlusal refining refers to correction of occlusal errors in
pose of cleaning and oral hygiene.
complete denture after processing.
● It is designed like an overdenture and can be
It is done by remounting procedure.
attached using bar and clip attachment or pre-
Laboratory remounting
cision attachment.
It is used to correct only processing errors (e.g. mild
Advantages
tooth displacement).
These increase retention, stability and support of the
It cannot be used to correct errors due to faulty impres-

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QUICK REVIEW SERIES for

BDS 4th Year

BDS 4th Year

Content Strategist: Nimisha Goswami

Laser typeset by GW India

Conservative Dentistry and Endodontics

Oral Medicine and Radiology

Oral and Maxillofacial Surgery

Foreword vii Topic 8 Tooth Morphology and Access Cavities 174

Topic 9 Cementation of Fixed Partial Topic 7 Principles of RPD Design 1019

Topic-Wise Solved Questions

PART I CONSERVATIVE DENTISTRY

Topic-Wise Solved Questions

III. Treatment planning C. Criteria for restoring

1. General considerations l Low frequency of routine dental care because of

l A treatment plan is carefully designed to lack of motivation.

existing damage and create a functional, l Cavitation or a defect is present.

maintainable environment. l Lesion extends to the dentinoenamel junction

l A proper treatment plan depends on thorough (DEJ).

standing of indications and contraindications l Age of the patient.

and a prediction of the patient’s response to l Aesthetic treatment.

treatment. l Treatment of abrasion, erosion and attrition.

The development of a dental treatment plan l Treatment of root surface caries.

for a patient consists of four steps: D. Treatment of root surface sensitivity

the order in which treatment is sequenced. an acceptable form of treatment.

iii. Cast ceramic graphs are employed to diagnose dental caries. Of

metal restorations. wing radiograph due to the complicated three-

material. evident as a radiolucent zone.

[SE Q.2] l Radiolucency may be due to caries, wear, fracture or

gular area in the proximal enamel with its base

Disadvantages vally leads to:

Contact placed too occlusally l Hatchets

l Contact placed too buccally/lingually leads to a flat- l Stones

tened restoration at the expense of buccal/lingual l Discs

proximal wall. 2. Condensing instruments:

[SE Q.1] l Polishing points

Q.2. Discuss the methods of diagnosis of proximal caries Right Left

Ans. Mandible EDCBA ABCDE

Ans. Maxilla 87654321 12345678

Disadvantages Q.4. Diagnostic aids to detect caries.

l Opposing and contralateral teeth are indicated by the

vidual teeth. Ans.

{SN Q.3} formation is completed.

Q.5. Uses of radiographs. l This is localized to the area of irritation.

hangs or poorly contoured restorations, posterior bitewing Ans.

b. Chemical method l Patient experiences less pain.

(ii) Chemicomechanical methods equate retraction.

noradrenaline. They cause haemostasis and restoration.}

energy. As a lot of heat is generated, there is permeable plastic or perforated cassettes.

bonization. arranged to allow free circulation of the pres-

Ans. Flash 134 30 7–10

in the vegetative and spore forms. It is necessary to clean tion.

i. Steam pressure sterilization (autoclave) l Sterilization can be verified.

ii. Dry heat sterilization (dryclave) Disadvantages

iv. Ethylene oxide sterilization agent may be used to prevent this).

permeable plastic. The sterilizer must be preheated

heated chambers to allow air to circulate by grav- Advantages

times, blowers and fans are provided to distribute Disadvantages

aluminium foil. Paper and cloth packs should be increased ventilation.

Apparatus Temperature (°C) Time (min) (iv) Ethylene oxide sterilization

Foreword vii Topic 8 Tooth Morphology and Access Cavities 174

Topic 9 Cementation of Fixed Partial Topic 7 Principles of RPD Design 1019

phous calcium phosphate and casein phospho l Chronic