• It is the surgical resection of the apex of the root.
• It is the procedure done in case of root canal treatment failure.
• If an infection does not subside even after root canal treatment,it may concern enquire a surgical procedure.
• In this procedure, the apical region of root is visualised by reflecting a flap and performing an osteotomy.

• Aberrant Anatomy: Dilaceration of root apex do not allow endodontic restoration of apex.
• Obliteration of apex by secondary dentin.
• Iatrogenic repair: A broken endodontic file which cannot be retrieved by conventional means.
• Apex perforation.
• Improper apical seal which cannot be removed.
• Increased drainage of pus from root canal will not allow adequate apical seal.
• Open apex.
• Non healing periapical granuloma.
• Fracture of apical third of root.
• Periapical cyst/granuloma.


  1. Local Contraindications:
    • Poor periodontal status of tooth.
    • Grossly decayed tooth.
    • Inadequate tooth length.
    • Acute infection.
    • Traumatic occlusion.
    • Uncooperative patients.
    • Close proximity of root apex to vital anatomic structures such as Maxillary antrum & Nasal floor.
  2. Systemic Contraindications:
    • Poor medical status of diabetes,Bleeding disorders.etc


  1. Cleaning of the area involved with antiseptic solutions.
  2. Local anaesthesia.
  3. Design of mucoperiosteal flap & reflection of flap.
  4. Bone removal for access to root tip.
  5. Root tip resection & curettage.
  6. Retro preparation & retrograde filling.
  7. Suturing & Follow up.

• Mobility of tooth/adjacent tooth.
• Haemorrhage.
• Nasal perforation.
• Oroantral Fistula.
• Mental Nerve Damage.
• Inferior Alveolar Nerve damage.

• Textbook of Oral & Maxillofacial Surgery, Chitra Chakravarthy (2nd Edition)
• DentaGama.com


• Fluoride can be toxic, if administered in excess quantity.
• The toxic effects of fluoride can be either acute or chronic.
• Acute toxicity occurs due to a single ingestion of large amount of fluoride.
• Chronic toxicity occurs dụe to long-term ingestion of small amounts of fluoride excessive than the required optimal level.

Acute Fluoride Toxicity:
• Acute fluoride poisoning can occur either as a result of accidental ingestion or from deliberate attempts like suicide
• This can be from the use of fluoride containing products such as toothpaste, mouth rinse, tablets or household insecticides.
• Acute fluoride poisoning can also occur from overfeeds in community and school water fluoridation systems.
• Most of the time overfeeds occur in small water supplies.

Terms used in relation to fluoride toxicity:
Safely Tolerated Dose (STD): Dose below which symptoms of toxicity are unlikely to occur
(1 mg/kg of body weight).

Potentially Lethal Dose (PLD): Lowest dose associated with a fatality.

(5 mg/kg of body weight).

Certainly Lethal Dose (CLD): Survival after consuming this amount of fluoride is unlikely (32-64 mg/kg of body weight).

Features of acute toxicity of fluorides are:

  1. Nausea
  2. Vomiting
  3. Diarrhoea
  4. Abdominal pain
  5. Hypocalcaemia
  6. Acidosis
  7. Progressive hypotension
  8. Ventricular tachycardia and fibrillation.

The ingested fluoride combines with hydrochloric acid in the stomach to form hydrofluoric acid which exhibits a corrosive effect on the gastric mucosa causing nausea, vomiting, diarrhoea and abdominal pain.

*Hypocalcemia is caused by the affinity of fluoride to cations in the serum.
**Hypocalcemia is associated with paresthesia, paresis, muscle fibrillation, tetany, convulsions, decreased myocardial contractility and cardiovascular collapse.

Death usually occurs due to:

  1. Convulsions
  2. Cardiac arrhythmias
  3. Coma.

Chronic Fluoride Toxicity:
• Long-term ingestion of small amounts of excessive fluoride will lead to chronic fluoride toxicity which is often referred to as fluorosis.
• Fluorosis usually affects the bones and the teeth.
• Fluorosis of the bone is called as osteofluorosis and the fluorosis of the teeth is called as dental fluorosis.



  • Pediatric Dentistry: Principles & Practice, MS Muthu(2nd Edition)
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• Nitrous oxide is a non-irritating, sweet smelling, colourless inorganic gas.
• Specific gravity: 1.53 (heavier than air).
• This allows nitrous oxide to occupy the region nearest to the alveolar basement membrane by displacing air.
• Enables better absorption in the blood stream.
• It has low gas partition coefficient i.e, remains insoluble in the blood stream.
• Minimally (absorbed) metabolized by the body.
• Rapid onset and recovery.
• Is a weak anaesthetic with a Minimum Alveolar Concentration (MAC) of 105.
• As MAC is 100, it is theoretically impossible to anaesthetize a patient with nitrous oxide alone.

• To reduce or eliminate anxiety.
• To reduce untoward movement and reaction to dental treatment.
• To enhance communication and patient co-operation.
• To raise the pain reaction threshold.
• To increase tolerance for longer appointments.
• To aid in treatment of the mentally/physically
• To reduce gagging.


• Fearful/conscious patients for whom basic behaviour guidance technique have not been successful.
• Patient unable to cooperate due to lack of physiological/emotional maturity.
• To protect to developing patient’s psyche.(young children)
• To reduce patient’s medical risk.

• May be contraindicated in some chronic obstructive pulmonary diseases.
• Patients with severe emotional disturbance or drug related dependencies.
• Patients with sickle cell disease.
• Patients treated with Bleomycin sulfate


• Nausea.
• Vomitting
• Diffusion Hypoxia.
• Claustrophobia
Effects Associated with Gas Accumulation:
• Tooth pain due to accumulation of gas in sinus cavity.
• Vertigo.
• Middle Ear Pain.

• Pediatric Dentistry: Principles and Practice, MS Muthu (2nd Edition).
• Pedodontics: Practice and Management, Badrinatheshwar GV.


Wright’s Classification of Cooperativeness of Children in Dental Office (1975)

Wrights classification of children’s operative behaviour under the following categories:
• Cooperative children
• Children lacking cooperative ability
• Potentially cooperative children

  1. Uncontrolled behaviour
  2. Defiant behaviour
  3. Timid behaviour
  4. Tense cooperative behaviour
  5. Whining behaviour

• Most of the children whom we see in day to day practice fall under this category.
• They show minimal apprehension and are reasonably released.
• These children usually have good rapport with the dentist and the dental team.
• They show interest in the dental procedures and often enjoy the situation.
• The dentist can work effectively and efficiently with these children.
• They follow the guidelines established, perform within the framework provided and present reasonable level of cooperation.

• Children lacking cooperative ability are in total contrast to the cooperative children as they lack the ability to cooperate because of their mental and physical immaturity due to age or some special condition.
• This includes two group of children:
One,being very young who are emotionally immature because of age (less than 2% years). These children can pose a major behavior problem and are often referred to as ‘preoperative children or children in pre-cooperative stage.

The second includes children with specific debilitating or handicapping conditions with mental and physical deficiencies. The severity of the condition will not allow them to cooperate like normal children of their same age. These are called special children’ and the number of these children you see in dental office is increasing recently.

• These children are otherwise termed as ‘behaviour problem’ children.
• They differ from the children lacking cooperative ability because they have the ability to cooperate but they do not.
• This can be because of objective/subjective no other face which can influence behavior can children in dental setting.
• The behaviour of these children can be modified by different techniques and can become operative children.

  1. Uncontrolled behaviour:
    • This type of behaviour is seen in a young child of age to 6 years.
    • The reaction is seen in the form of a tantrum, which may begin at the reception area or even before the child enters the dental clinic.
    • This behaviour is also known as incorrigible.
    • It is characterized by tears, loud cry, physical lashing out, flailing of hands and legs. All are suggestive of a state of acute anxiety or fear.
    • These children are termed as hypermotive by Lampshire.
    • School age children tend to model their behaviour on adults or other older children.
    • Uncontrolled and immature behaviour is not seen in older children, but if it is seen there will be deep rooted reasons for it and these children may reveal adjustment problems in other settings.
    • Immediate measures to manage the uncontrolled behaviour is seen.

2. Defiant Behaviour:

This behaviour is typical of the elementary school years but can be observed in other age groups also.
• Defiant behaviour is controlled to an extent and is distinguished by “I don’t want to’, I don’t need to’,
• They protest as they would do at home when they were brought to the dental office against their wish.
• These children are often referred to as ‘stubborn’ or ‘spoiled’.
• They frequently become highly cooperative after establishment of guidelines for their behaviour and gaining their confidence.
• Defiance can be passive as seen in older children approaching adolescence.
• Failure of communication results when the dentist tries to involve the child in the dental procedure and the youngster refuses to respond verbally.
• He may avoid eye contact and also reject the situation by clenching his teeth when an intraoral exam nation is attempted.
• Passive resistance is often observed in older children approaching adolescence.
They have the freedom to express their likes and dislikes at home and when brought to the dental office unwillingly their self-image is affected and they rebel.

3.Tense cooperative behavior:
• The behaviour of these children is termed borderline.
• They accept the treatment and cooperate but are extremely tense, which is typical of these children.
• The tension is often revealed by the body language.
• The child patient’s eyes may follow the movements of both the dentist and the dental assistant.
• A tremor in the voice heard when they speak, perspiration on the palms of the hands or the eye brows are some features of tense cooperative behaviour.

4. Timid Behaviour:
• Timidity is milder when compared to uncontrolled and defiant behaviour but when managed incorrectly they may become uncontrolled.
• The timid child may hide behind a parent but usually offers no physical resistance during the separation procedure.
• Some may pause or hesitate when given directions. They may sob or whimper out but not cry hysterically.
• They lift their hands occasionally to cry but withhold tears.
• Reasons for timidity can overprotective home environment, living in isolated areas without any contact with strangers.
• They are often overawed by strangers and strange situations.


5. Whining Behaviour:
• Whining can be seen in timid or tense-cooperative children.
• Since whining plays the prominent role in their behaviour, it is described as a separate entity.
• They allow the dentist to perform the procedure but whine through out despite encouragement.
• They frequently complain of pain.
• Whining can be a compensatory mechanism to control their fear.
• The cry is controlled, constant and not particularly loud, often without any tears.
• Continuous whining can be a source of irritation and frustration to those involved in the treatment and great patience is required in dealing with whining children.

• Pediatric Dentistry: Principles and Practice, MS Muthu (2nd Edition).
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• Collegevillepediatricdentist.com
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• Also known as PARTSCH II or CYSTECTOMY.
• Enucleation is the surgical removal of the entire cystic lining in to-to.
By definition, it means shelling out of the entire cystic lining without rupture.
This surgical procedure leaves behind a hollow cavity in bone covered by oral mucoperiosteum.
This gets filled up with blood clot which eventually organizes to form healthy bone.

• Is the treatment of choice for removal of cysts of jaws+ should be employed with any cyst of the jaw, that can be safely removed without sacrificing underlying structure.


  1. Entire pathological tissue is removed from the lesion.
  2. Tissue available for histopathological examination
  3. Chances of recurrence are less.
  4. Healing time is faster and less appointments for the patient.
  5. Enucleation with primary closure eliminates the repeated appointments for packing medicated gauze irrigation & fabrication of plug.


1.Relatively radical procedure.

2.Chances of devitalising the adjacent teeth.

3.Chances of fracture of the jaw.

4.Risk of creation of oroantral/oronasal communication



Enucleation with Primary Closure:
• Small cysts can be removed under local anaesthesia
• large cyst should be taken out under general anesthesia, as they are close to vital structures and blood vessels.
• After achieving adequate anesthesia, a mucoperiosteal incision is made such that the incision rests on sound bone.
• Mucoperiosteal flap is reflected taking care not to perforate rate the cystic lining.
• If the bone is perforated by the cyst, the lining will be adherent to the periosteum and will be difficult to reflect it.
• The cystic lining is exposed and now carefully teased away from the bone.
• It is relatively easy to separate the cystic lining from the bone because there is a layer of fibrous tissue between the two which is easily separabl.
• In case of infected cysts or an odontogenic keratocyst. the cystic lining is friable and more difficult to remove entirely.
• Every attempt is made to remove the entire cystic lining in a single piece without perforating it.
• This ensures complete removal.
• After the cyst is removed completely, the cavity in irrigated thoroughly, hemostasis ensured, sharp bone debris are filed and the flap replaced and sutured.

Enucleation with Open Packing :
• In case of a large cyst which was previously infected closure may not be possible
• After enucleation, the wound is then packed with me impregnated with bismuth iodoform paraffin paste (BIPP) or Whitehead’s varnish.

Enucleation with Peripheral Osteotomy:

  • In this procedure, instead of using a curette, a large round bur may be used to remove around 1-2 mm of bone around the entire periphery of the cystic cavity.
  • This is done to ensure that any remaining epithelial cells present in the cystic wall or bony cavity are removed.

Enucleation with Bone Curettage:
• After enucleation, if there is a doubt that a part of the line has been left behind, it can be curette out.
• A bone curette is used to scrape the band remove any remaining lining
Enucleation with Peripheral Osteotomy
• In this procedure, instead of using a curette, a large round bur may be used to remove around 1-2 mm of bone around the entire periphery of the cystic cavity.
• This is done to ensure that any remaining epithelial cells present in the east wall or body cavity are removed.

Enucleation with Chemical Cauterisation:
• It is indicated mainly in cases of odontogenic keratocyst.
• After enucleation, to remove any remaining lining of the cyst chemical cauterising agent Carnoy’s solution is applied along the walls of the cystic cavity.
• It is left for about 5-7 minutes and then irrigated thoroughly with saline.
• This solution chemically cauterizes any remaining cells of the system.

Enucleation with Bone Grafting
• Bone grafting with autogenous cancellous bone grafts can be done in case of large bony defects.
• The bone graft obliterates the cavity and stimulates osteogenesis.
• There is, however, a risk of wound breakdown and infection of the bone graft which may lead to failure.

• Risk of bone fracture due to cyst.
• Inferior dental nerve involvement.
• Management of teeth related to cyst.
• Oroantral Communication.
• Hematoma formation.
• Infection.
• Dead Space: At surgical procedure, a hollow dead space is formed. It is usually filled up with blood clot and eventual bone formation.
However, there are chances of infection of the clot, breakdown of suture line and pus discharge.

• Textbook of Oral & Maxillofacial Surgery, Chitra Chakravarthy (2nd Edition)
• SlideShare


PARTSCH(1892) described a type of compression procedure for treatment of cyst.
• In this procedure a window/fenestrations made in the bone and cystic content is evacuated.
• The cyst lining is left behind.
• Once the cyst contents are evacuated, the intracystic pressure reduces.
• Hollow cavity is packed till it gets obliterated by bone over a period of time.
• The cystic lining then becomes continuous with normal oral mucosa.

• In extremely large cysts.
• Risk of cyst opening into maxillary sinus/nose due to surgical removal of complete lesion.
• In very young patients, where it will permit eruption of enclosed tooth,underlying developing tooth.
• Patient with poor general condition for allowing minimal surgical procedure.
• In cases, where surgical procedures may cause pathological fracture of jaws.


1) Anaesthesia
2) Aspiration
3) Incision:
Circular, oval or elliptical. Inverted U Shaped incision with broad base the buccal sulcus. Mucoperiosteum is reflected in this case.
4) Removal of bone
5) Removal of cystic lining specimen
6) Visual examination of residual cystic lining
7) Irrigation
8) Suturing of cystic cavity
• Cystic lining sutured with the edge of oral mucosa.
• In Y Shaped incision the mucoperiosteal flap can be turned into cystic cavity covering the margin.
• The remaining is sutured to oral mucosa.

9) Packing- Prevents food contamination & covers wound margins. Done with ribbon gauze soaked with WHITEHEAD VARNISH

• Benzoin – 10g
• iodoform-10g
• Storax -7.5g Balsam of Tolu -5g
• Solvent ether to 100ml

Pack removed after 2 weeks.
10) Maintenance of cystic cavity
Instruct the patient to clean and irrigate the cavity regularly with oral antiseptic rinse with a disposable syringe.
11) Use of plug:
• Prevents contamination, Preserves patency of cyst orifice.
• Plug should be stable, retentive and safe design.
• Should be made of resilient material (to avoid irritation) like acrylic.
12) Healing:
• Cavity may or may not obliterate totally. Depression remains in the process.

• Once the cystic lining is evacuated, there is a tendency of the cystic lining to contract. This stimulates endosteal bone formation.
• Marginal ingrowth of normal mucoperiosteum occurs as the cystic lining shrinks. It provides with additional bone regeneration factors.
• Not much surgical skill is required.
• No risk of oroantral/oronasal fistula.
• No damage to adjacent vital structures.
• No risk to adjacent vital tooth.

• Entire pathological tissue is left behind.
• High chances of recurrence.
• As the bony cavity is large, healing and filling up with normal bone takes longer time.
• Use of cyst plug is required with repeated cleansing.
• Time consuming & repeated appointment for patients.


  • Textbook of Oral & Maxillofacial Surgery, Chitra Chakravarthy(2nd Edition)
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• Digit Sucking is defined as the placement of the thumb/one or more fingers in varying depths into the mouth.
• It may be practiced even during intra-uterine (IU) life.
• Presence of this habit is quite normal till 3½ – 4 yrs.

A number of theories have been put forward to explain why thumb sucking occurs. The following are some of the accepted ones:

  1. Freudian theory: This theory was proposed by Sigmund Freud in the early part of this century.
    • He suggested that a child passes through various distinct phases of psychological development of which the oral and the anal phases are seen in the first three years of life.
    • In the oral phase, the mouth is believed to be an oro-erotic zone.
    • The child has the tendency to place his fingers or any other object into the oral cavity.
    • Prevention of such an act is believed to result in emotional insecurity and poses the risk of the child diversifying into other habits.
  2. Oral drive theory of Sears and Wise: Sears and Wise in 1950 proposed that prolonged suckling could lead to thumb sucking.
  3. Benjamin’s theory:
    • Benjamin has suggested that thumb sucking arises from the rooting or placing reflex seen in all mammalian infant.
    • Rooting reflex is the movement of the infant’s head and tongue towards an object touching his cheek.
    • The object is usually the mother’s breast but may also be a finger or a pacifier.
    • This rooting reflex disappears in normal infants around 7 – 8 months of age.
  4. Psychological aspects: Children deprived of parental love, care and affection are believed to resort to this habit due to a feeling of insecurity.
  5. Learned pattern: According to some authors, thumb sucking is merely a learned pattern with no underlying cause or psychological bearing.



The severity of malocclusion caused by thumb sucking depends on:

DURATION: Amount of time spent indulging in the habit.

FREQUENCY : The number of time the habit is activated in a day.

INTENSITY: Vigour with which the habit is performed.
The following are some effects:

  1. Effects on Maxilla
    • Constricted maxilla due to lowered tongue position + buccinator action, while sucking.
    • V-shaped narrow palate.
    • Posterior cross-bite may occur.
    • Increased SNA angle.

2. Effects on Maxillary Teeth:
• Spacing in maxillary anterior teeth.
• Increased maxillary arch length.
• Labial flaring of maxillary anterior teeth.

3. Effects on Upper Lip :
• Short, hypotonic incompetent upper lip

4. Effects on Thumb:
• Presence of clean nails & callus on fingers.

5. Effects on the Lower lip:
• Hyperactive lower lip with increased mentalis activity.

6. Effects on the Mandibular Teeth:
Retroclination of lower teeth.

7. Effects on Inter-arch Relationship:
• Increased overjet due to flaring of maxillary incisors
• Spacing of maxillary anterior teeth.
• Increased maxillary arch length.
8. Effects on Tongue:
• Lowered tongue position.
• Increased chance of developing tongue thrust habit.


    • Parents should be counseled to provide child with adequate love, affection and spend quality time with the child.
    • Success of any habit interception largely depends on the subject’s willingness to be helped to discontinue his/her habit.

Dunlops Theory of Beta Hypothesis
States that the best way to break a habit is by conscious purposeful repititions, i.e the child should be made to sit in front of a large mirror &asked to observe himself as he indulges in the habit.

    • Keeping track of the habit free days and rewarding the child can give the child a sense of pride.

• Reminding appliances that assist the child who is willing to quit the habit but is not able to do as the habit has entered a subconscious level.
• Following types of habit louis used as mechanical reminding aids in treatment of thumb sucking.
Passive removable appliances, that consist of a crib &is anchored to the oral cavity by the means of clasps on the posterior teeth.

Heavy gauge stainless steel wire can be designed to form a frame, that is soldered to bands in the molars.


Use of the bitter tasting/foul smelling preparation placed on the thumb, that is sucked can make the habit distasteful.

  • Pepper dissolved in volatile medium.
  • Quinine
  • Asafoetida


  • ORTHODONTICS:The Art & Science,S.I BALAJHI (7th edition)
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