Transcript Vital Signs - Dentalelle Tutoring

Vital Signs
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DENTALELLE TUTORING
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Recording of Vital Signs
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 At the New Patient Exam (and in some cases EVERY
appointment) vital signs must be recorded
 Often vital signs are only recorded for adults and older
children – here is the normal range:
 Blood pressure – 115/75 (or 120/80 depending on the
text you read but 115/75 is the normal range under the
‘heart and stroke foundation’.
 Pulse – 60-90 BPM
 Respiration – 14-20 RPM
 Temperature – 97-99 degrees
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Normal Results
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 A normal body temperature taken orally is 98.6°F (37°C), with
a range of 97.8–99.1°F (36.5–37.2°C).
 A fever is a temperature of 101°F (38.3°C) or higher in an
infant younger than three months or above 102°F (38.9°C) for
older children and adults. Hypothermia is recognized as a
temperature below 96°F (35.5°C).
 Respirations are quiet, slow, and shallow when the adult is
asleep, and rapid, deeper, and noisier during and after
activity.
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Average respiration rates at rest are:
infants, 34–40 per minute
children five years of age, 25 per minute
Tachypnea is rapid respiration above 20 per minute.
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Continuation
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 The strength of a heart beat is raised during
conditions such as fever and lowered by conditions
such as shock or elevated intracranial pressure. The
average heart rate for older children (aged 12 and
older) and adults is approximately 72 beats per
minute (bpm). Tachycardia is a pulse rate over 100
bpm, while bradycardia is a pulse rate of under 60
bpm.
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Blood Pressure
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 To record blood pressure, a person should be seated with one arm
bent slightly, and the arm bare or with the sleeve loosely rolled up.
The cuff is placed level with the heart and wrapped around the
upper arm, one inch above the elbow.
 If the blood pressure is monitored manually, a cuff is placed level
with the heart and wrapped firmly but not tightly around the arm
one inch above the elbow over the brachial artery. Positioning
a stethoscope over the brachial artery in front of the elbow with
one hand and listening through the earpieces, the cuff is inflated
well above normal levels (to about 200 mmHg), or until no sound is
heard. Alternatively, the cuff should be inflated 10 mm Hg above the
last sound heard. The valve in the pump is slowly opened. Air is
allowed to escape no faster than 5 mmHg per second to deflate the
pressure in the cuff to the point where a clicking sound is heard over
the brachial artery. The reading of the gauge at this point is
recorded as the systolic pressure.
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Blood Pressure Continuation
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The sounds continue as the pressure in the cuff is released and the flow of blood through
the artery is no longer blocked. At this point, the noises are no longer heard. The reading
of the gauge at this point is noted as the diastolic pressure. "Lub-dub" is the sound
produced by the normal heart as it beats. Every time this sound is detected, it means that
the heart is contracting once. The noises are created when the heart valves click to close.
When one hears "lub," the atrioventricular valves are closing. The "dub" sound is
produced by the pulmonic and aortic valves.
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With children, the clicking noise does not disappear but changes to a soft muffled sound.
Because sounds continue to be heard as the cuff deflates to zero, the reading of the gauge
at the point where the sounds change is recorded as the diastolic pressure.
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Blood pressure readings are recorded with the systolic pressure first, then the diastolic
pressure (e.g., 120/70).
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Blood pressure should be measured using a cuff that is correctly sized for the person
being evaluated. Cuffs that are too small are likely to yield readings that can be 10 to 50
millimeters (mm) Hg too high. Hypertension (high blood pressure) may be incorrectly
diagnosed.
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Pulse – Heart Beat
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 The pulse can be recorded anywhere that a surface artery runs over
a bone. The radial artery in the wrist is the point most commonly
used to measure a pulse. To measure a pulse, one should place the
index, middle, and ring fingers over the radial artery. It is located
above the wrist, on the anterior or front surface of the thumb side of
the arm.
 Gentle pressure should be applied, taking care to avoid obstructing
blood flow. The rate, rhythm, strength, and tension of the pulse
should be noted. If there are no abnormalities detected, the
pulsations can be counted for half a minute, and the result doubled.
However, any irregularities discerned indicate that the pulse should
be recorded for one minute. This will eliminate the possibility of
error. Pulse results should be noted in the health chart.
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Respirations
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 An examiner's fingers should be placed on the
person's wrist, while the number of breaths or
respirations in one minute is recorded. Every effort
should be made to prevent people from becoming
aware that their breathing is being checked.
Respiration results should be noted in the medical
chart
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Temperature
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 Temperature is recorded to check for fever (pyrexia or a
febrile condition), or to monitor the degree of
hypothermia.
 Manufacturer guidelines should be followed when
recording a temperature with an
electronic thermometer . The result displayed on the
liquid crystal display (LCD) screen should be read, then
recorded in a person's medical record. Electronic
temperature monitors do not have to be cleaned after
use. They have protective guards that are discarded after
each use. This practice ensures that infections are not
spread.
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Ergonomics
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Ergonomics for the Dental Assistant
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 As a dental assistant, ergonomics is important to your health and longevity in
the profession.
 Neutral-sitting position is ideal. This is sitting upright with your back straight
and weight evenly distributed over the seat. Legs should be
slightly separated with feet flat on the ring around the base of the chair. Your
thighs should be parallel to the floor and front edge of the chair even with the
patient's mouth. Position your chair close to the side of the patient with knees
facing toward the patient's head. The height of the chair should be such that
your eye level is 4 to 6 inches above the operator. This will give you a good line
of vision into all areas of the patient's mouth.
 If your chair has an arm support, it should be at the level of your abdomen and
be used for reaching and leaning forward. The position of the mobile cart or
cabinet top should be over your thighs and as close as possible.
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Five Categories of Motion
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 Class I is using fingers only such as flipping ends of the
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instrument.
Class II is using fingers and wrist. This could be
transferring an instrument to the operator.
Movement of fingers, wrist and arm are Class III. Oral
evacuation is in this classification.
Mixing of dental materials involves movement of the
entire arm and shoulder. This is classified as Class IV.
Class V is movement of the arm and twisting of the body.
Twisting behind you to adjust the dental light would be
this classification.
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Zones
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 The work area around the patient is arranged into zones
representing hours on a clock. The activity zone for the operator is 7
o'clock to 12 o'clock. All activities of the operator at the chairside are
performed in this zone. The assisting zone is 2 o'clock to 4
o'clock.
 In this zone, the assistant is positioned. The assistant transfers
materials and instruments in the transfer zone, which is 4 o'clock to
7 o'clock.
 Ergonomically, the design of the work area is a 20-inch radius. Keep
frequently used items such as air-water syringe, high volume
evacuator and saliva ejector within easy reach. All equipment and
instruments should be within maximum vertical and horizontal
reach. This is the sweep of your forearm in a reach of vertical and
horizontal direction. Front delivery systems are best.
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Zones Diagram
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Patient Positioning
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 You should keep everything approximately waist high, not above shoulder
level or below the waist. Those levels require twisting, turning of your back
and shoulders. If a side delivery system is utilized, make it your dominant
side. Again, this will require less overextending of your arm and shoulder
 Do not overlook patient positioning. The position of the patient can
greatly affect your posture. When reclining the patient, place his or her
head in the same plane as their feet. Many dental practitioners try to
perform procedures with the patient in an upright position. This causes
practitioners to compensate by twisting their neck and back in order to see.
Do not be afraid to ask patients to turn their heads or tilt their chins up or
down. Patients are willing to comply if asked. This will allow better access
and vision in the oral cavity.
 Try using indirect vision for those hard to access areas such as buccal of the
left side of the mouth and lingual of the right side.
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Other Areas to Consider
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 When deciding on a proper glove size, make sure the glove is not too tight
across the palm or too constricting at the wrist. Also, the finger length
should be adequate to allow for comfortable finger movement.
 Handpieces and air/water syringes have hoses that are coiled and can be
heavy. Their coiled cord places resistance against the wrist and hand. If the
cord is long enough, place it in your lap so the excess is not dangling down.
Swiveling devices can be placed on a handpiece. These devices reduce
handpiece torque. Newer handpieces are much lighter than the older
models. If your air/water syringe has a tightly coiled cord, consider
replacing it with a lightweight hose.
 Climate control of the workplace is important too. Exposure to cold air or
drafts can cause muscles to constrict leading to fatigue or overworking of
the muscles. This affects muscles of the neck, shoulders and back in
particular. Always wash your hands in warm water to decrease hand
fatigue.
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Stretching
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 Routine stretching exercises for your neck,
shoulders, back, arms and fingers can prevent some
work-related injuries and relax the body. Stretching
should be performed every hour and slowly while
exhaling into the stretch.
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Exercises to Perform
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 Neck Rotation Exercises 1. Head rotation * Drop your
head forward * Rotate your head to the right shoulder *
To left shoulder * Then return to front * Repeat this 3-5
times
 Shoulder & Upper Back Exercises 1. Shoulder
rotation * Rotate your right shoulder * Then rotate your
left shoulder * Repeat this series 3-5 times 2. Shoulder
shrug * Shrug your shoulders by raising them * Hold this
position for 5 seconds * Repeat 3-5 times
 Overhead reach * Place your hands and arms straight
over your head and stretch * Hold for 5 seconds * Repeat
3-5 times 4. Elbow spread * Interlock fingers behind
head * Move elbows backward * Hold for 5 seconds *
Repeat 3-5 times
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Continuation of Exercises
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 Arm straightening * Interlock fingers behind your back
and straighten arms * Hold for 5 seconds * Repeat 3-5 times
Lower Back Exercises 1. Backward lean * Place hands on
buttocks and lean backward * Hold for 5 seconds * Repeat 3-5
times
 Spine rotation * While sitting, place your left hand on right
knee * Look over the right shoulder causing spine rotation *
Repeat other side * Repeat series 3-5 times 3. Forward bend *
Bend forward at waist * Try to touch your toes * Hold for 5
seconds * Repeat 3-5 times Wrist & Finger Exercises
 Finger curl * Stretch fingers out * Curl them toward palm of
hand * Repeat 3-5 times 2. Finger pull * Pull fingertips of one
hand back with the other * Repeat with other hand * Repeat
3-5 times
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Dental Procedures
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DENTALELLE TUTORING
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Sealants
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Sealants
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 A sealant is a protective, plastic coating that can be
placed on the occlusal surfaces and buccal/lingual
pits of the teeth
 Usually done to seal the pits and fissures of the first
and second year molars but can be placed on the
premolars as well. Ages 6-7 or 11-14.
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Steps for placement of a sealant
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 Wash the tooth with pumice and water to ensure it is
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clean
Wash and dry the tooth
Apply your cotton rolls, dry angles, etc. to the area
Apply etch and allow to sit for 10-30 seconds
depending on the manufacturers instructions
Wash the etch very well, dry very well. To ensure
proper etching has taken place, the tooth must
appear a chalky white and if not, re-etch for 10-20
seconds
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Continuation
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 Apply the sealant material
 Run an explorer along the sealant to prevent air
bubbles from forming
 Light cure for 10-20 seconds
 Check sealant with explorer to make sure no voids
are present
 Use bite paper to check the bite (articulation), if the
sealant is high, the Dentist can smooth off with a
high speed hand piece
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Recall Appointments
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 The sealants will need to be reviewed at recare
appointments to make sure no voids or pieces of the
sealant have come off
 The patient and parents must be aware that proper
brushing and flossing must still be maintained. A
sealant only ‘helps’ prevent decay but will not stop it
entirely
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Fillings
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Composite Fillings
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 Since they bond to the tooth, composite fillings restore most of the original
strength of the tooth. Silver weakens the teeth, making them more susceptible
to breaking. Since broken teeth are very expensive to restore, composites can
save a lot of expense over the long run.
 Composite fillings restore the natural appearance of the tooth.
 Teeth restored with white fillings are less sensitive to hot and cold than teeth
restored with amalgam, if correct techniques are used.
 Composites are mercury-free. Mercury in the fillings is viewed by some as being
toxic.
 Composites require less removal of tooth structure. Especially
with new cavities, the size of the hole made for the filling can be dramatically
smaller with composites.
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Amalgam Fillings
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 They are generally less expensive. Composite fillings, if they
are done correctly, take about 60% longer, require special expertise and
expensive materials, and are more difficult to place, and so they cost
considerably more than silver.
 General dentists can place amalgam without extra training. Composite
requires the use of special bonding technology that many dentists are
uncomfortable with.
 The proper placement of a white filling requires that the site for the filling
be kept totally isolated from saliva while it is being placed. In the
very back of the mouth, on some patients, it is difficult to keep the tooth
isolated for the duration of the procedure. This can also be uncomfortable
for some patients. A silver amalgam filling does not require this strict
isolation of the tooth.
 The filling by itself is a stronger material, although it weakens the tooth.
 Silver fillings have a longer history of use than mercury-free fillings, thus
some feel that they are more tried and tested.
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Composite vs Amalgam Fillings
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 If a patient has a cavity, the cavity must be removed and an
amalgam or composite filling placed. Depending on the tooth and
the patient, one might be better then the other
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The procedure involves:
Topical/Local anesthetic
Application of the rubber dam
Removal of decay using high speed and slow speed handpieces
Etch, prime/bond and light cure of the materials
Filling material placed and light cured (if composite)
The bite is checked with articulating paper and polishing
**This is a quick recap of the procedure, please review in your notes
from school the exact procedure – questions will be asked in your
next session
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Dental Inlays and Onlays
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 Another form of a dental filling that can be used in place of an
amalgam or composite
 Porcelain or gold inlays are used to repair minor damages to
the teeth and dental onlays for greater damage.
 Simplified, one could describe dental fillings or dental
inlays/onlays as ‘partial crowns’ that are used in cases when there is
enough healthy enamel left on a tooth worth saving rather than
inserting a completely new, artificial dental crown.
 One can say that the dental inlays resemble a small piece of puzzle
which is customised, fitted and glued into the remaining enamel in
order to restore the tooth’s strength and longevity. The inlays are
normally made from either porcelain or gold.
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Inlay and Onlay Procedure
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 To receive dental inlays or dental onlays requires two dentist
appointments. During the first one the tooth that is to have
the dental inlay is examined and prepared.
 Once the tooth is prepared an impression is made and sent to
a dental technological laboratory where the porcelain or gold
inlay/onlay is made. Finally the dentist will fit you with a
temporary dental filling and book a time for your next
appointment.
 During the second appointment the temporary dental filling is
removed. The porcelain or gold inlay/onlay is then tried out to
make sure it fits perfectly. Once the fit is how it should be, it is
then cemented into place.
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Crown and Bridge Procedure
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Crown and Bridge Procedure
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 What are Dental Crowns and Tooth Bridges?
Both crowns and most bridges are fixed prosthetic
devices.
 Crowns and bridges are cemented onto existing teeth or
implants, and can only be removed by a dentist.
 Crowns are placed on teeth that have very large fillings to
begin with and a concern with chipping is apparent, a
crown will go over the tooth given it strength
 Bridges are in place of a tooth – if a tooth is missing and
a space results. Bridges are placed to prevent shifting of
the teeth and to maintain the proper bite.
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Crowns
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 The dentist may recommend a crown to:
 Replace a large filling when there isn't enough tooth
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remaining
Protect a weak tooth from fracturing
Restore a fractured tooth
Attach a bridge
Cover a dental implant
Cover a discolored or poorly shaped tooth
Cover a tooth that has had root canal treatment
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Crown and Bridge Procedure
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 Before either a crown or a bridge can be made, the tooth (or teeth) must be
reduced in size so that the crown or bridge will fit over it properly.
Normally a rubber dam is placed for this but after the teeth have been
reduced in size, the rubber dam is removed to finish.
 After reducing the tooth/teeth, the dentist will take an impression to
provide an exact mold for the crown or bridge. If porcelain is to be used,
your dentist will determine the correct shade for the crown or bridge to
match the color of your existing teeth.
 Using this impression, a dental lab then makes your crown or bridge, in the
material your dentist specifies. A temporary crown or bridge will be put in
place to cover the prepared tooth while the permanent crown or bridge is
being made.
 When the permanent crown or bridge is ready, the temporary crown or
bridge is removed, and the new crown or bridge is cemented over your
prepared tooth or teeth. Normally it takes two weeks at the most for a
crown or bridge to be made.
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Dental Implants
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Dental Implants
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 A Dental Implant is a small titanium screw that serves as
the replacement for the root portion of a missing natural
tooth. It is available in various sizes (both width and
height) for different clinical situations.
 Dental Implants may be used to replace one or more
missing teeth. In case of completely edentulous patients,
implants may be used to fix the dentures to the
underlying bone. Alternately, implants may be used to
provide fixed tooth to edentulous patients without the
use of dentures. Needless to say, an implant offers
several advantages over conventional treatment options.
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Benefits of Implants
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 Implant supported teeth are more comfortable than
conventional dentures because there is no slipping or
movement, because the implants are fixed they feel and
function like natural teeth. This eliminates some of the key
worries of denture wearers and improves self-confidence.
 Dental implants are an alternative to conventional
bridgework. They eliminate the need to prepare healthy
teeth and do not place additional loads on the teeth
supporting the bridge.
 When teeth are missing the surrounding bone shrinks.
Implants stimulate the bone to be maintained which helps
keep shape and structure of the jaw stable.
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Contraindications for Implants
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 Implants are not for everyone!
 There must be enough bone in the area to hold a
dental implant or it will fail
 A lot of dental surgeons will not perform the implant
procedure on a smoker due to the dealing in healing
time
 Also your diabetic patients, healing is reduced so an
implant may not be the best option
 For your dental hygienist – plastic scalers can only
be used on and around the implant to avoid
scratches
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Root Canal
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Root Canal
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 The root canal procedure can be the most daunting
to a new dental assistant, we have outlined some of
the basic steps for you:
 Think of the procedure in steps, what you will be
doing will determine what you will need
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Steps
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Anesthesia.
Rubber dam application.
Making the area aseptic.
Access to pulp chamber.
Pulp extirpation.
Trial radiograph with instrument in place.
Calculating exact measurement.
Reaming and filing of root canal to measurement.
Irrigation.
Desiccation.
Selecting, sterilizing, and fitting the point.
Trial radiograph with point in place.
Cementation of point.
Sealing of access opening.
Final radiograph.
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Preparing the canal
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 Preparing the Root Canal. In gaining access, provide high and low speed burs. A
barbed broach is used for extirpation of the pulp. A monojet syringe or some type
of syringe is typically used to irrigate the tooth with sodium hypochlorite.
Desiccation or drying of the root canal is done by the use of paper absorbent points:
Extra fine, fine, medium, or coarse. The endodontic assistant should set out an
assortment of paper points for the dentist. A radiograph with the measured
instrument placed in the canal is exposed to determine the exact length of the root
canal. The dental assistant then should provide a sequential assortment of reamers
and files of increasing size. The beginning size is determined by the dentist. The
reamers and files should be provided with rubber stops. A corresponding size point,
either silver or gutta-percha, is selected and trial-fitted.
 Once the point passes the trial fit, it is ready for cementation. The dental assistant
should now be prepared to mix the root canal cement. If the zinc oxide and eugenol
technique is used, relatively large portions of powder are added to the liquid and
spatulated until a heavy, creamy, nongranular mix is obtained. When the mix is
complete, the cement should be drawn up from the mixing slab about 1 inch without
separating. This test is done by dabbing the spatula into the mix and drawing it up
slowly. The cement is given to the dentist who places it in the canal with a reamer.
The point is coated with cement and seated into place.
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Filling and Sealing
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 Filling and Sealing the Root Canal. When gutta-percha
points are used, cotton forceps are used to place the
point. Depending on the technique, a plugger, a spreader,
or both, are used to condense the gutta-percha in the
canal.
 In other techniques, both gutta-percha and silver points
are used at the same time. A trial radiograph of the root
canal filling is taken and, if it is satisfactory, a thick mix
of zinc oxide and eugenol or zinc phosphate cement is
made and plugged into the access area to completely seal
the canal. A number three Ladmore plugger is the
instrument of choice for plugging the access opening
with the cement.
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Other Method
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 The sequence of treatment for the multiappointment
method of endodontic therapy differs from the single
appointment method in that the sequence is interrupted
at various stages to allow for drainage of infected
material, for changing of medications in the root canal,
or to alleviate a lengthy appointment.
 Medications commonly used in endodontic techniques
include cresatin and camphorated
paramonochlorophenol, which are placed in dappen
dishes and then placed into the root canal by using paper
points or into the pulp chamber by using cotton pellets.
The tooth is then sealed and kept sealed until the next
appointment.
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Continued
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 Follow-up Appointments. Upon completion of the
treatment by either method, arrangements should be
made to recall the patient 6 months later for a
follow-up radiograph to determine the success of the
treatment. If an abscess forms, the root canal
treatment will have to be redone.
 Sterilization. Successful endodontics depends greatly
upon sterility. Anything placed into the tooth must
be sterilized.
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Orthodontics
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Orthodontics
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 Orthodontics is done by a specialist – additional training is
needed. Working as a dental assistant in an orthodontic office
is an exciting experience. Often you will be trained on the job
for this but it is wise to know the basics for regular practice.
 If your patient does not have a ‘Class I’ bite, this will likely
need to be corrected.
 Acquired malocclusions are caused by:
 Trauma (including delayed weaning from thumb, finger, or
pacifier sucking)
 Mouthbreathing (due to enlarged tonsils or adenoids, blocked
nasal passages etc.)
 Premature loss of baby or adult teeth
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Malocclusions
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 Regardless of whether malocclusions are inherited or acquired,
many of these problems affect not only alignment of the teeth but
also facial development and appearance as well.
 A poor bite does not DIRECTLY cause tooth decay, or periodontal
disease. It may, however, make it difficult to brush and floss
properly which increases the likelihood of dental disease.
 Although a majority of the population have some type of
malocclusion, not all people require or seek orthodontic treatment.
For example, with or without a history of orthodontic treatment,
65% of adults develop crowded, crooked lower front teeth. This is a
natural result of change over time and does not necessarily require
orthodontic treatment.
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Symptoms that may require Orthodontics
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 Permanent teeth coming in (erupting) out of their
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normal position;
Problems with biting the cheek or roof of the mouth;
or
Difficulty chewing or difficulty aligning teeth;
Facial muscle or jaw pain, or speech difficulties.
Obvious rotations and crowding of the teeth
Remember – LOTS of space, teeth far apart, in a
child is a good thing – meaning more room for the
permanent teeth to come in
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Desensitization of Teeth
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 Tooth sensitivity is a very common issue and can happen from
a variety of reasons:
 Recession – seems to be the main reason, if a patient is
brushing too hard over a number of years can result in
recession. Using a soft toothbrush is especially important in
preventing further recession
 Clenching/grinding – if a patient clenches his or her teeth
as well as grinding this can result in very sensitive teeth. A
nightguard is the only solution to this other than stopping the
grinding/clenching.
 Erosion – if a patient has been vomiting or eating/drinking
acidic foods this can cause erosion resulting in sensitivity.
Chronic erosion may no longer be sensitive*
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Toothpastes
52
Desensitizing toothpastes work by blocking transmission of sensations through the
tubules of the dentin layer so that they are unable to reach the nerve. In addition to
regular brushing with a desensitizing toothpaste, Discovery Health recommends placing
a small amount onto sensitive areas and leaving it overnight. Consistent overnight use
should bring some relief within a few weeks.
 Duraflor, or a different type of desensitizing agent can be applied directly to the area in
the dental office.


Some sensitivity may be caused by vigorous brushing with a hard toothbrush. This can
wear away the enamel, exposing the tubules that lead to the tooth's nerve. Harsh
brushing can also cause the gums to recede, exposing the roots of the teeth. Although
enamel cannot be restored once it is lost, using a soft-bristled toothbrush can prevent the
damage from progressing. This will also help with sensitivity.
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Fluoride
53
 Fluoride is found in most toothpastes, but a special rinse or treatment may be
used when teeth are sensitive. Fluoride rinses are available over-the-counter, or
the dentist can prescribe a stronger rinse or varnish.
 The American Dental Association indicates that fluoride strengthens the tooth's
protective enamel layer and reduces the transmission of sensations.
 Custom trays can be made for the patient to be worn at home with fluoride if
the sensitivity is extreme.
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Bleaching
54
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Bleaching (Teeth Whitening)
55
 Teeth whitening procedures have been performed for over
one hundred years. As far back as 1877, procedures involving
the use of oxalic acid to whiten teeth were reported. Hydrogen
peroxide was introduced as a tooth bleaching agent back in
1884 and in 1918, the use of high-intensity lights in
conjunction with the hydrogen peroxide was used to speed up
the bleaching process, according to a report by the ADA.
 No significant adverse health effects have been associated
with the use of dentist-prescribed home use whiteners. Minor
side effects from the procedures may include transient mild
tooth sensitivity to temperature changes and mucosal
irritation. Most side effects associated with the teeth
whitening procedures disappear within seven days.
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Staining
56
 Stains can happen both intrinsically and extrinsically. Smoking, coffee, tea,
aging, medications, etc., all play a part
 A blue/gray hue to the teeth will not whiten well and patients with this
hue should be made aware of this.
 A yellow/brown stain will likely whiten well to any type of procedure
 Everyone responds differently in the length of time it takes to see results.
This is why it is important for you to carefully discuss in advance with your
dentist what the causes of the discolorations are.
 For people with intrinsic staining (from fluorosis, tetracycline staining or
tooth trauma inside the pulp), the results may take longer and it may be
necessary to have a few sessions, or discuss other options for the more
intense stains. Typically these are the streaks or the purplish discolorations
that are harder to lighten. Patients with intense streaks in their teeth will
find that the intensity fades, however, it is almost impossible to totally
remove the streaks, especially using only the home bleaching techniques.
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Take-Home Whitening
57
 This is the most common option and often cheaper
than the in-office whitening
 Custom trays are made of the teeth using alginate
impressions, impressions poured up and whitening
trays are made (using a vacuum former for
whitening)
 The patient comes back to the office and is given
instructions for us along with the bleaching syringes
required
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In-Office Whitening
58
 This is a popular option to get quick results, often the
same bleaching material is used as the take-home
whitening but a stronger concentration
 A light is often used to speed up the process as well
but keep in mind this can lead to additional
sensitivity
 It is often recommended that the patient brushes
with a sensitivity type toothpaste two weeks prior
and two weeks after the whitening procedure to limit
the sensitivity as much as possible
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Extractions
59
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Extractions
60
 Why are teeth extracted? If a tooth has been broken or damaged by decay, your
dentist will try to fix it with a filling, crown or other treatment. Sometimes,
though, there's too much damage for the tooth to be repaired. In this case, the
tooth needs to be extracted.
 The dental assistants role in this is often to help the dentist during the
procedure and provide post-op instructions afterwards
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Additional Reasons to Extract
61
 Some people have extra teeth that block other teeth from coming in.
 Sometimes baby teeth don't fall out in time to allow the permanent teeth to come in.
 People getting braces may need teeth extracted to create room for the teeth that are
being moved into place.
 Infected teeth may need to be extracted.
 Some teeth may need to be extracted if they could become a source of infection after
an organ transplant. People with organ transplants have a high risk of infection
because they must take drugs that decrease or suppress the immune system.
 Wisdom teeth, also called third molars, are often extracted either before or after
they come in. They commonly come in during the late teens or early 20s. They need
to be removed if they are decayed, cause pain or have a cyst or infection. These teeth
often get stuck in the jaw (impacted) and do not come in. This can irritate the gum,
causing pain and swelling. In this case, the tooth must be removed. If you need all
four wisdom teeth removed, they are usually taken out at the same time.
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Preparations
62
 An x-ray of the area will be taken to help plan the best way to
remove the tooth.
 If the wisdom teeth are being removed, you may need to take
a panoramic x-ray. This x-ray takes a picture of all the teeth at
once. It can show several things that help to guide an
extraction:
 The relationship of the wisdom teeth to the other teeth
 The upper teeth's relationship to the sinuses
 The lower teeth's relationship to a nerve in the jawbone that
gives feeling to the lower jaw, lower teeth, lower lip and chin.
This nerve is called the inferior alveolar nerve.
 Any infections, tumors or bone disease that may be present
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Antibiotics
63
 Some doctors prescribe antibiotics to be taken before
and after surgery. This practice varies by the dentist
or oral surgeon. Antibiotics are more likely to be
given if:
 An infection at the time of surgery
 Due to a weakened immune system
 Specific medical conditions are present
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Telling your Patient
64
 You may have intravenous (IV) anesthesia, which can range from
conscious sedation to general anesthesia. If so, your doctor will have
give you instructions to follow. You should wear clothing with short
sleeves or sleeves that can be rolled up easily. This allows access for
an IV line to be placed in a vein. Don't eat or drink anything for six
or eight hours before the procedure.
 If you have a cough, stuffy nose or cold up to a week before the
surgery, call your doctor. He or she may want to avoid anesthesia
until you are over the cold. If you had nausea and vomiting the night
before the procedure, call the doctor's office first thing in the
morning. You may need a change in the planned anesthesia or the
extraction may have to be rescheduled.
 After the extraction, someone will need to drive you home and stay
there with you. You will be given post-surgery instructions.
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Types of Extractions
65
 There are two types of extractions:
 A simple extraction is performed on a tooth that can be seen
in the mouth. General dentists commonly do simple
extractions. In a simple extraction, the dentist loosens the
tooth with an instrument called an elevator. Then the dentist
uses an instrument called a forceps to remove the tooth.
 A surgical extraction is a more complex procedure. It is used
if a tooth may have broken off at the gum line or has not come
into the mouth yet. Surgical extractions commonly are done
by oral surgeons. However, they are also done by general
dentists. The doctor makes a small incision (cut) into your
gum. Sometimes it's necessary to remove some of the bone
around the tooth or to cut the tooth in half in order to extract
it.
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Types
66
 Most simple extractions can be done using just an injection (a local
anesthetic). For a surgical extraction, you will receive a local anesthetic,
and you may also have anesthesia through a vein (intravenous). Some
people may need general anesthesia. They include patients with specific
medical or behavioral conditions and young children.
 If you are receiving conscious sedation, you may be given steroids as well as
other medicines in your IV line. The steroids help to reduce swelling and
keep you pain-free after the procedure.
 During a tooth extraction, you can expect to feel pressure, but no pain. If
you feel any pain or pinching, tell your doctor.
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Post-Op Instructions
67
 Having a tooth taken out is surgery.. Research has shown that taking
nonsteroidal anti-inflammatory drugs (NSAIDs) can greatly decrease
pain after a tooth extraction. These drugs include ibuprofen, such as
Advil, Motrin and others. Take the dose your doctor recommends, 3 to
4 times a day. Take the first pills before the local anesthesia wears off.
Continue taking them for 3 days.
 Surgical extractions generally cause more pain after the procedure than
simple extractions. The level of discomfort and how long it lasts will
depend on how difficult it was to remove the tooth. Your dentist may
prescribe pain medicine for a few days and then suggest an NSAID.
Most pain disappears after a couple of days.
 After an extraction, you'll be asked to bite on a piece of gauze for 20 to
30 minutes. This pressure will allow the blood to clot. You still have a
small amount of bleeding for the next 24 hours or so. It should taper off
after that. Don't disturb the clot that forms on the wound.
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Continued
68
 You can put ice packs on your face to reduce swelling. Typically, they
are left on for 20 minutes at a time and removed for 20 minutes. If your
jaw is sore and stiff after the swelling goes away, try warm compresses.
 Eat soft and cool foods for a few days.
 A gentle rinse with warm salt water, started 24 hours after the surgery,
can help to keep the area clean. Use one-half teaspoon of salt in a cup of
water. Most swelling and bleeding end within a day or two after the
surgery. Initial healing takes at least two weeks.
 If you need stitches, your doctor may use the kind that dissolve on their
own. This usually takes one to two weeks. Rinsing with warm salt water
will help the stitches to dissolve. Some stitches need to be removed by
the dentist or surgeon.
 You should not smoke, use a straw or spit after surgery. These actions
can pull the blood clot out of the hole where the tooth was.
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Risks Involved
69
 A problem called a dry socket develops in about 3% to 4% of all
extractions. This occurs when a blood clot doesn't form in the hole
or the blood clot breaks off or breaks down too early.
 In a dry socket, the underlying bone is exposed to air and food. This can
be very painful and can cause a bad odor or taste. Typically dry sockets
begin to cause pain the third day after surgery.
 Dry socket occurs up to 30% of the time when impacted teeth are
removed. It is also more likely after difficult extractions. Smokers and
women who take birth control pills are more likely to have a dry socket.
 A dry socket needs to be treated with a medicated dressing to stop the
pain and encourage the area to heal.
 Infection can set in after an extraction. However, you probably won't
get an infection if you have a healthy immune system.
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Other Problems
70
 Accidental damage to nearby teeth, such as fracture of fillings or teeth
 An incomplete extraction, in which a tooth root remains in the jaw — Your




dentist usually removes the root to prevent infection, but occasionally it is
less risky to leave a small root tip in place.
A fractured jaw caused by the pressure put on the jaw during extraction —
This occurs more often in older people with osteoporosis (thinning) of the
jaw bone.
A hole in the sinus during removal of an upper back tooth (molar) — A
small hole usually will close up by itself in a few weeks. If not, more surgery
may be required.
Soreness in the jaw muscles and/or jaw joint — It may be tough for you to
open your mouth wide. This can happen because of the injections, keeping
your mouth open and/or lots of pushing on your jaw.
Long-lasting numbness in the lower lip and chin — This is an uncommon
problem. It is caused by injury to the inferior alveolar nerve in your lower
jaw. Complete healing may take three to six months. In rare
cases, the numbness may be permanent.
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Calling a Professional
71
 The swelling gets worse instead of better.
 You have fever, chills or redness
 You have trouble swallowing
 You have uncontrolled bleeding in the area
 The area continues to ooze or bleed after the first 24 hours
 Your tongue, chin or lip feels numb more than 3 to 4 hours after the procedure
 The extraction site becomes very painful -- This may be a sign that you have
developed a dry socket.
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Tooth Impactions
72
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Wisdom Teeth
73

Wisdom teeth are known as “third molars,” and generally develop in a person between
the ages of 17 and 25, although approximately 25% to 35% of the population never
develops wisdom teeth. More often than not, however, wisdom teeth need to be extracted
because of problems and complications.


Impaction of the Wisdom Teeth
The majority of wisdom teeth fall into this category, primarily because there isn’t enough
room in your jaw to accommodate the teeth. A horizontal impaction occurs when the
wisdom tooth grows in sideways, approximately ninety degrees in direction from the rest
of the teeth.

With a horizontal impaction, the wisdom tooth grows towards the rest of the teeth. A
distal impaction occurs when the tooth grows in at approximately a forty-five degree
angle, opposite the direction of the other teeth. Finally, vertical impaction occurs when
the tooth is growing upright.

Aside from impaction, there are several other problems that can result if these teeth are
left in your mouth. Even though the age-old justification for the removal of wisdom teeth
is the misalignment or shifting of other teeth in your mouth if wisdom teeth are left to
grow, some of these justifications are debatable and up for interpretation. It’s certainly
the case that not everyone’s wisdom teeth need to be extracted.
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Incision and Drainage
74
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Surgical Incision and Drainage
75
 Dr. Reena Talwar says that Surgical incision and drainage is a commonly used
technique in oral surgery to treat dental infections which have progressed to oral
swellings. If cavities of the teeth are left untreated, they can eventually progress to
infections that spread into the jaw bones and later into the surrounding soft
tissues. Not only is this process extremely painful for the individual, but it is also
extremely dangerous. This is because untreated dental infections which have
penetrated into the surrounding tissues can lead to a spreading of the infection to
the brain or heart in a short period of time, causing severe illness and potentially
death.
 The first sign of a dental infection that has penetrated through the jaw bone into the
surrounding soft tissues, other than pain, is a noticeable swelling of the individual’s
mouth and/or face.

 The way in which these types of infections are treated first begins with a complete
review of the patient’s medical and dental history. It is crucial for the clinician to
know the history of the current infection in order to develop an appropriate
treatment plan to treat the infection.
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Continuation
76
 In some situations, the tooth responsible for the infection may
be salvaged. This is based on clinical assessment of the tooth
and the relative prognosis for treating the infection by
retaining the tooth. In most instances however, the tooth in
question is often extracted in conjunction with performing the
incision and drainage procedure. In this case, the extraction is
performed at the same time as the surgical incision and
drainage procedure.

 The procedure is generally performed in an out patient setting
under local anesthetic. For those individuals who are
extremely apprehensive, oral and or intravenous sedation can
be utilized in conjunction with the local anesthetic.
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Infection
77
 In general, once the region of the infection has been appropriately anesthetized or
“frozen”, a small incision/cut is made in the gums at the most prominent point of
the oral swelling. The pus (purulence) is then drained and the site is irrigated with
sterile saline solution. In certain instances where a significant amount of swelling
and pus are present or when the infection has been long standing, the clinician may
elect to place a rubber drain to keep the surgical site patent. This allows for any
residual drainage of pus to occur and prevents the need for any further surgery at
this site. The drain must be removed by the clinician in 24 to 72 hours
after placement. The patient is required to follow-up with the clinician on a
regular basis during the healing period. The timeline for follow-up is determined by
the clinician based on his/her clinical assessment of the patient.
 The patients are often placed on antibiotic therapy following the surgical procedure
for a period of 7 to 10 days. A prescription for pain medication is also often
provided.

 Surgical incision and drainage is a routinely performed procedure for locally
spreading dental infections which has demonstrated excellent outcome for patients.
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Dental Assisting Anatomy
78
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80
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Paired Cranial Bones
82
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Parietals
83
 The Parietals are paired left and right. Externally, each possess a Superior,
and Inferior Temporal Line, to which the temporal muscle is attached. The lines
run from the Frontal Crest of the anterior frontal bone to the Supra-Mastoid
Crest on the posterior portion of the temporal bone. The parietals articulate with
each other by way of the Mid-Sagittal Suture, and with the frontal bone
anteriorly by way of the Coronal Suture. These two sutures generally form a right
angle with one another. Posteriorly, the parietals articulate with the Occipital
Bone by way of the Lambdoid Suture. The intersection of
the Lambdoid and Sagittal Sutures approximate a 120 degree angle on each of
the parietals and the occipital bone. Among the sutures the Lambdoid is by far more
serrated than either the Sagittal or the Coronal. Inferiorly the Parietal articulates
with the temporal bone by way of the Squamosal and Parieto-Mastoid Sutures.
On the external surface near the center of the bone is the Parietal Eminence.
Slightly posterior to the eminence there may be a Parietal Foramen.
 Internally, the bones possess a number of Meningeal Groves as well as perhaps
some number of Arachnoid Foveae. The groves generally branch from the
inferior/anterior edge of the bone to superior/posterior, while the foveae are
frequently found along the sagittal suture. At the area of intersection of the
lambdoid and parieto-mastoid sutures there is a brief portion of the Sigmoid (i.e.,
Transverse) Sulcus.
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Temporal Bone
84
 The Temporal Bone is another paired cranial bone which is difficult to describe
due to its various features, and projections. It consists of two major portions,
the Squamous Portion, which is flat or fan-like and projects superiorly from the
other, very thick and rugged portion, the Petrosal Portion.
 The squamous portion assists in forming the Squamous Suture which separates
the temporal bone from the adjacent and partially underlying parietal bone. The
petrosal portion contains the cavity of the middle ear and all the ear ossicles; the
Malleus, Incas and Stapes. This portion projects anterior and medially beneath the
skull. Projecting inferiorly from the petrosal portion is the slender Styloid
Process which is of variable length. The styloid process serves as a muscle
attachment for various thin muscles to the tongue and other structures in the throat.
Externally the petrosal portion possesses the External Auditory Meatus while
internally there is an Internal Auditory Meatus. Anterior to the external meatus
the Zygomatic Process has its origin. This process projects forward toward the
face and its articulation with the temporal process of the zygomatic. Just anterior of
the external meatus and inferior of the origin of the zygomatic process is
the Glenoid or Mandibular Fossa which assists in forming the shallow socket of
the Tempro-Mandibular Joint. Posterior to the external auditory meatus is the
inferiorly projecting Mastoid Process which serves as an attachment for the
sternocleidomastoid muscle. Above the mastoid process is the Supramastoid
Crest to which the posterior portion of the temporal muscle is attached.
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Unpaired Cranial Bones
85
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The Frontal Bone
86
 The frontal bone may be divided into two main portions, a vertical squamous
portion which articulates with the paired parietals along the Coronal Suture and
forms the forehead, and two orbital plates, which contribute to the ceiling and
lateral walls of the left and right eye orbits. On the external surface the squamous
portion frequently possesses a left and right Frontal Eminence. Additionally, the
bone possesses two Supra-Orbital Ridges (i.e., Superciliary or Brow Ridges)
which are bumps above each of the eye orbits. In early hominids these ridges
formed a Torus or large shelf-like process protruding from above the eyes.
Associated with each Superior Orbital Margin of the eye orbit the frontal bone
may posses a Supra-Orbital Notch or if completely surrounded by bone,
a Supra-Orbital Foramen. Above the fronto-nasal suture which allows
articulation between the frontal and nasal bones there is generally a trace of the
vertical Metopic Suture. In early life the metopic suture divided the frontal bone
into left and right halves. With in the bone, and above and the metopic suture, is
the Frontal Sinus. The left and right Frontal Crest, begins at each Zygomatic
Process of the frontal bone, and provides the anterior origin of the Temporal
Line to which the left and right temporal muscle is attached.
 Internally, the frontal bone possesses the Median Sagittal (i.e., SagittalFrontal) Crest which separates the two frontal hemispheres of the brain.
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The Occipital Bone
87
 The Occipital Bone consists of a large squamous, or flattened
portion separated from a small thick basal portion by the Foramen Magnum on
either side of which is a left or right Occipital Condyle. The occipital condyles
articulate with the first cervical vertebrae (the Atlas). Externally, the squamous
portion of the bone possesses Superior, Middle, and Inferior Nuchal Lines to
which the muscles at the back of the neck are attached. The External Occipital
Protuberance lies on the superior nuchal line in the mid-sagittal plain. Lateral to
each occipital condyle are the Condylar Fossae and Foramen while
the Hypoglossal Canal is medial to them.
 Internally, are the Sagittal and Transverse Sulci, or grooves which converge at
the Confluence of Sinuses. A single internal Occipital
Protuberance or Cruciform Eminence is also found in this area. Running
inferior from the eminence to the foramen magnum is the Internal Occipital
Crest which separates the Cerebellar Fossae. The transverse sulci assist in
directing the developing jugular vein to the Jugular Notch on either side of the
basilar portion of the occipital.
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The Sphenoid
88
 The Sphenoid has a number of features and projections, which allow it to
be seen from various views of the skull. It is a single bone that runs through
the mid-sagittal plane and aids to connect the cranial skeleton to the facial
skeleton. It consists of a hollow body, which contains the Sphenoidal
Sinus, and three pairs of projections: the more superior Lesser Wings, the
intermediate Greater Wings, and the most inferior projecting Pterygoid
Processes. Internally upon the body is the Sella Turcica where the
pituitary gland rests in life. The smaller lesser wings possesses the Optic
Foramen through which the optic or second cranial nerve passes before
giving rise to the eye.
 The Supra-Orbital Fissure separates the lesser wing superiorly from the
greater wing below and can best be viewed on the posterior wall of each eye
orbit. The left and right greater wings assist in forming the posterior wall of
each of the eye orbits where it forms an Orbital Plate.
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Continued
89
 Just inferior to the supra-orbital fissure near the body of the sphenoid, each of
the greater wings also possess a Foramen Rotundum which in life transmits
the maxillary branch of the fifth, or trigeminal, cranial nerve. Each of these
wings also possesses a much larger Foramen Ovale more laterally, which
transmits the mandibular branch of the same nerve. More posteriorly is the
smallest of the three pairs of foramena, the Foramen Spinosum which
transmits the middle meningeal vessels and nerve to the tissues covering the
brain.
 The left and right pterygoid processes project inferiorly from near the junction
of each of the greater wings with the body of the sphenoid. These processes run
along the posterior portion of the nasal passage toward the palate. Each process
is formed from a Medial and Lateral Pterygoid Plate to which the
respective medial and lateral pterygoid muscle is attached during life. In life the
muscles assist in creating the grinding motion associated with chewing.
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The Ethmoid
90

It has a number of features and projections, but unlike the sphenoid it cannot be seen from
various views of the skull. It is a single bone that runs through the mid-sagittal plane and aids
to connect the cranial skeleton to the facial skeleton. It consists of various plates and paired
projections. The most superior projection is the Crista Galli, found within the cranium. It
assists in dividing the left and right frontal lobes of the brain. Lateral projections from the
Crista Galli are the left and right Cribriform Plates which in life cradle the first cranial nerves
i.e., the olfactory nerves. The nerves brachiate through the porosity of these plates into the nasal
cavity below. Directly inferior to the Crista Galli and running in the mid-sagittal plane is
the Perpendicular Plate of the ethmoid which articulates with the vomer more inferiorly and
assists in separating the left and right nasal passages. The Perpendicular Plate can be viewed
anteriorly through the nasal cavity.

Descending off each of the Cribriform Plates is a left or right Orbital Plate which aids to form
the medial wall of the respective eye orbit. Each Orbital Plate is rectangular in shape and gives
rise to two medial projections, the Superior and Middle Nasal Concha. These projections,
like the separate Inferior Nasal Concha, assist in increasing the surface area within the nasal
cavity and thereby the exposure of the brachiating olfactory nerve to inhaled odors. The
Superior or Supreme Nasal Conche are smaller, and cannot be viewed through the anterior
nasal opening because it is blocked from view by the more inferior Middle Nasal Conche.
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Paired Facial Bones
91
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The Lacrimal Bone
92
 The Lacrimal bones are the smallest and most fragile of the facial
bones. They are paired left and right and assist in forming the
anterior portion of the medial wall of each eye orbit. They are
basically rectangular with two surfaces and four borders. Each of
the borders articulate with the bones that surround the Lacrimal.
The Orbital or Lateral Surface contributes to the eye orbit, while
the Medial Surface assists in forming a small portion of the nasal
passage. The orbital surface possesses a sharp superior-inferior
running ridge called the Posterior Lacrimal Crest which divides
this surface into an Orbital Plate and the Lacrimal Sulcus. The
sulcus, along with a contiguous sulcus on the maxillae, assists in
forming the lacrimal fossa which contains the lacrimal duct in life.
The duct connects the medial corner of the eye to the nasal passage
and allows tears from the eye to be shunted into the nasal passage.
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The Nasal Bones
93
 Each of the nasal bones is a small rectangular bone which together form the
bridge of the nose above the Nasal Cavity also called the Piriform
Aperture. They articulate with each other by way of the Internasal
Suture and with the frontal bone superiorly by way of the Fronto-Nasal
Suture just below the glabellar region of the frontal bone. The intersection of
these two sutures marks the anatomical landmark called Nasion. Laterally,
each of the nasal bones articulates with the frontal process of the maxilla.
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The Zygomatic Bones
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 Each cheek or zygomatic bone possesses three major processes
which articulate with the bones which surround it.
 The Frontal Process of the zygomatic forms the lateral margin
and wall of the eye orbit and projects superiorly to articulate with
the zygomatic process of the frontal bone. This portion of the bone
separates the eye orbit from the temporal fossa and possesses a
posterior projecting edge called the Marginal Process.
The Temporal Process of the zygomatic runs lateral and
posterior toward an articulation with the zygomatic process of the
temporal bone. Together these two processes assist in forming the
zygomatic arch which serves as the attachment for the masseter
muscle in life, one of the primary muscles used in mastication. The
temporal muscle runs beneath the arch and is also a primary mover
of the mandible in chewing. The Maxillary Process of the
zygomatic articulates with the zygomatic portion of the maxilla by
way of the Zygo-Maxillary Suture.
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The Maxillary Bone
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 The Maxillae are the paired facial bones which contain the upper dentition
and thus form the upper jaw. Each is basically hollow with a large Maxillary
Sinus. A superior projection, the Frontal Process, assists in forming the
lateral margin of the nasal aperture and ends by articulating with the frontal
bone. An Orbital Plate forms the floor of the eye orbit, while the Zygomatic
Process articulates with the zygomatic bone. On the anterior surface of the
bone, near the maxillo-zygomatic suture, there is an Infra-Orbital Foramen.
The Alveolar Process of the Maxilla contains the upper dentition and assists
in giving rise to the Palatine Portion which forms the anterior half of the
hard palate. The left and right Maxillae articulate with one another by way of
the Inter-Maxillary Suture. The superior end of this suture frequently
terminates with the Nasal Spine.
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The Palatine Bones
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 The Palatine Bones are paired left and right and articulate
with one another in the mid-sagittal plane at
the Interpalatine Suture. Both bones assist in forming the
posterior portion of the hard palate as well as a portion of the
nasal cavity. Each bone possesses a Horizontal Part, with
an inferior surface which forms the posterior portion of the
hard palate and a superior surface that assists in forming the
posterior portion of the floor of the nasal cavity. The Vertical
Part of each contributes to the lateral wall of the nasal cavity.
Near the posterior junction of the Vertical and Horizontal
Parts on the palatal surface is a Palatine Foramen. Each
bone possesses a number of processes and articular surfaces
which touch the bones that surround it.
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The Inferior Nasal Concha
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 The Inferior Nasal Concha is a very thin, porous, and
fragile, paired bone basically elongated and curled upon
itself. It lays in the horizontal plane and is attached to the
lateral wall of the nasal cavity. By way of the Maxillary
Process on the bone's lateral surface, it is attached to
the maxilla, and by way of the Lacrimal,
Ethmoid and Palatine Processes to each of the bones
which assist in forming the lateral wall of the nasal
cavity. By projecting into the nasal cavity, the medial
surface of the Inferior Nasal Concha assists in increasing
the surface area within the cavity and thus increases the
amount of mucus membrane and olfactory nerve endings
exposed to inhaled odors.
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Unpaired Facial Bones
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The Vomer Bone
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 The Vomer is a single relatively flat bone located in the
mid-sagittal plane. It articulates with the perpendicular
plate of the ethmoid superiorly and together aid in
forming the nasal septum. While it is frequently deflected
slightly to the left or right, in general the septum is
aligned perpendicularly and divides the nasal aperture
into the left and right nasal passages. In addition to
the Perpendicular Portion, superiorly the Vomer
mushrooms out into a pair of Alae which terminate and
articulate with the sphenoid in a heart shaped process.
Inferiorly the Vomer rests on both the maxillae and the
palatines.
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The Mandible
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 The Mandible or lower jaw consists to four major portions, a left and
right Mandibular Ramus and the left and right Body. The Alveolar Process of
the body is that portion of the mandible which contains the lower dentition. The
junction of the ramus and the body occurs at the Gonial Angle where externally
one of the masseter muscles is attached. The left and right masseters make up a set
of two sets of muscles used in chewing. At the gonial angle on the internal surface
the Pterygoid Attachments are found. These attachments are for the medial and
lateral pterygoid muscles which assist in the grinding motion of chewing.
 The external surface of the mandibular body possesses the Mental Foramen and
at the midline, the Mental Protuberance or chin. The internal surface of the body
possesses the Lingual Foramen, the Mandibular Canal, and the longitudinal
running Mylohyoid Ridge. The Genio Tubercle is located in the mid-sagittal
plane on the internal surface of the mandible. The superior margin of each ramus
possesses both a Mandibular Condyle or Head, for articulation with the
temporal bone at the tempro-mandibular joint, and the Coronoid Process, for the
attachment of the temporalis muscle (one in the set of primary muscles used in
mastication). The mandible articulates with each of the Maxillae by way of their
contained respective lower and upper dentition.
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The Hyoid Bone
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 The hyoid is a single small "U" shaped bone in the adult which does not
articulate with any other bone. It is suspended from the styloid process of each
temporal bone by means of the stylohyoid ligaments. It is located in the midsagittal plane, at the front of the throat, and beneath the mandible but above
the larynx near the level of the third cervical vertebrae. It is formed from three
separate parts (i.e., the Body, and the left and right Greater and Lesser
Cornu) which fuse in early adulthood. The base of the "U" shaped bone is
located anteriorly while the Cornu project posteriorly.
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The Hard Palate
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
The hard palate is vaulted. Its bony skeleton is made up of the palatine processes of
the maxillae (anterior two thirds) and the horizontal plates of the palatine bones
(posterior third). The mucosa of the hard palate is tightly bound to the underlying
bone.
At the anterior end of the hard palate are transverse palatine folds which assist with
the manipulation of food during chewing. In the midline is a narrow whitish streak,
the palatine raphe, which marks the site of fusion of the embryonic palatal processes.
The blood supply is chiefly from the greater palatine artery of each side. The greater
palatine vessels emerge from the greater palatine foramina. There is one
of these on each side in the lateral border of the hard palate, medial to the
upper 3rd molar tooth. The nasopalatine nerve supplies the mucous membrane of
the anterior part of the hard palate. The nasopalatine nerve passes from the nose
through incisive canals that open into the incisive foramen which is posterior to the
central incisor teeth. Behind each greater palatine foramen and more laterally, is the
pterygoid hamulus of each side.
 The most posterior end of the hard palate is extended a little bit in the midline and
this process is called the posterior nasal spine.

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TMJ
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TMJ
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 There are three basic types of joints in the human body, and the TMJ
incorporates characteristics of all three.
1. The hinge joint, like a knee or elbow, the joint moves like a door opening
and closing.
2. The ball and socket joint, like the hip or shoulder, a wide range of motion
is achieved by circular motion around a central point.
3. The glide joint, like the wrist wherein motion is achieved when bones
essentially glide together and apart.
The TMJ acts like a ball and socket joint when you chew your food, and it acts
like a gliding joint when you jut your jaw forward.
To add to the complexity of the TMJ, it is the only joint in the body wherein its
motion directly affects the other joint on the other side of the head.
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More about the TMJ
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 TMJ is the abbreviation used to represent the jaw joint. It stands for
temporomandibular joint. TMJ is an anatomical term but is often used to
refer to any problem with this joint or the associated jaw muscles. Dentists
will generally use the term temporomandibular disorders (TMD) to refer
to abnormalities that affect the TMJ or the associated jaw muscles.
 The upper part of the mandibular joint is a hollow (mandibular fossa)
formed by the temporal bone of the skull. The lower part is formed by
the mandibular condyle (end of the lower jaw), hence the term
temporomandibular joint. The right and left lower joint bones are joined
together by the body of the mandible, and are able to rotate and also move
in and out of the upper part of the fossa. This makes the mechanics of jaw
movement complex. When one joint is not working well the other is often
affected.
 There are 3 paired and powerful muscles that close the jaw and bring the
teeth together for the biting and grinding of food: the masseter,
temporalis, and medial pterygoid muscles. The paired
lateral pterygoids protrude the lower jaw and produces jaw opening.
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 Mandibular fossa - the hollow formed from the temporal bone of the
skull where the mandibular condyle (lower joint bone) sits when the mouth
is closed.
 Mandibular condyle - the lower joint bone that is rounded and moves in
and out of the fossa during mouth opening and closing. The right and left
condyles are joined together by the mandible (lower jaw).
 Articular disc - a firm pad of tissue occupying the space between the
upper and lower joint bones. The disc helps to maintain smooth movement
and position between the 2 joint bones. Changes in disc position are often
the cause of noises occurring in the joint during mouth movements. The
disc itself does not have sensation but the surrounding ligaments such as
the posterior attachment are sensitive and may become painful due to a
disc disorder. The posterior attachment connects the disc to the
mandibular fossa.
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 Temporalis muscle - one of the large jaw-closing muscles that when
strained can cause headache in and around the temples.
 Masseter muscle - one of the powerful jaw-closing muscles that is
attached on the outside of the lower jaw.
 Mandible (lower jaw) - ends on both sides of the face to form the
mandibular condyle, the lower joint bones.
 Lateral pterygoid muscle - when this muscle contracts the condyle is
pulled forward and down producing mouth opening.
 A firm pad of tissue (the articular disc) occupies the space between the
upper and lower joint bones. Ligaments attach the disc to the lower bone
and the upper fossa. Changes in disc position are common and can cause
jaw clicking and locking. A ligament attached to the upper and lower joint
bones surrounds the joint parts. Ligaments help to provide stability to the
disc and condyle during movements.
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