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Under block anesthesia the clot devoided socket with whitish and necrosed appearance was thoroughly curetted, both from the floor of the socket as well as from the bony walls, the sharp margins were trimmed, rounded and any foreign bodies if present were thouroghly removed. The detached gingival margins were also scraped with the help of sharp instrument like Bared Parker knife No=11. The whole above-mentioned procedure .The desired medications as well as precautions were thoroughly explained to the patient.It was almost always that the patient was not only without pain, but was also comfortable both physically as well as psychologically from the very next day.
Shock is a medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood. This deprives the organs and tissues of oxygen (carried in the blood) and allows the buildup of waste products. Shock can result in serious damage or even death.
PRESENTED BY –DR. SHEETAL KAPSE1st YEAR, P.G. STUDENTMODERATOR -DR. SUNIL VYASDR. M. SATISHDR. DEEPAK THAKURDR. MANISH PANDIT
INTRODUCTIONScience the earliest period of history of the extraction of thetooth has been considered a very formidable procedure by thelayman, & it is because of the horrifying experiencesassociated with the tooth extraction in the past that eventoday the removal of a tooth is dreaded by a patient almostmore than any other surgical procedure.Many patients suffer from extractionfobia & are often difficult tocare for, despite modern methods of anesthesia.Many dentists still believe that speed is essential whenextracting the teeth.
DEFINITION• The ideal tooth extraction is –The painless removal of the whole tooth, orroot, with minimal trauma to the investing tissues, so thatthe wound heals uneventfully & no post-operativeprosthetic problem is created.(Geoffray L Howe)
The 1st dentist was an EGYPTIAN– HESI RE (3100-2181BC)The history of dental extraction forceps is very old andgoes back to the time of Aristotle (384 to 322 BC)where Aristotle described the mechanics of oral surgeryforceps .This was over 100 years beforeArchimedesstudied and discussed the principles of the lever.
Dental history arabic dentist cauterizingdental pulpThe Martyrdom of St. Apollonia, shows thetorturous extraction of teethCuring aToothache with FireThefumes from henbane seedsGermanTraveling Dentist
Traveling Dentist in a DutchVillageThe Italian "Oral Surgeon"That EffortlesslyRemoves Jawbones
until the 16th century, dedicated dentists did not exist anddentistry was practiced by general physicians and barbers. A number of tools were invented for performing this procedure.Dental Pelican, which was invented in the 14th century by Guy deChauliac and used until the late 18th century.
The instrument is a combination of theattributes of the an extracting forceps and atoothkey 1843 to 1863In the 20th century, the key was replaced bythe forceps, which are still in use today
1. Allen 1994 – caries in 48.8% cases – abscess2. Periodontal diseases – in 40.7% cases – to prevent alveolar ridgeresorption3. Tooth with necrosed pulp & periapical lesion – not responding toendodontic treatment4. Over retained deciduous tooth – but take radiograph first5. Orthodontic purpose6. Prosthetic purpose7. Unrestorable tooth8. Impacted tooth9. Supernumerary tooth10. Grossly decayed 1M / 2M – make room for 3rd molarHOTZ & SMITH11. Tooth in fracture line12. Teeth directly involved by cyst & tumor
13. Teeth in the area of therapeutic irradiation14. Teeth acting as foci of infection –ex. – bacterial endocarditis- rheumatic feverRICHARDS (1932) – bacteremia after infected tooth extractionOKELL & ELLIOTT (1935) – STREPTOCOCCUS VIRIDANS inblood stream (75% of 40 patient)Use of local anesthetic solution (vasoconstrictor) - rate of spread ofinfection
It may be judicious to delay the extraction until certainlocal or systemic condition corrected or modified. In the era of antibiotics acute infection of odontogenicorigin are not considered as absolute contraindication ofimmediate extraction. NUG / HERPETIC GINGIVOSTOMATITIS – spread ofinfection & greater degree of systemic reaction. Previously irradiated area (within 1 year) – less trauma +pre & post-op antibiotic prophylaxis
Other relative systemic contraindications – Acute blood dyscrasias – acute leukemia , agranulocytosis, Untreated coagulopathies – congenital or acquired Adrenal insufficiencies Within 6 months of myocardial infarction
A. Absolute : Central Haemangioma. May cause uncontrolled bleeding.A-V malformation.B. Relative :When some precautions have to be taken.1. Local Acute cellulitis.ANUG.2. Systemic Uncontrolled Diabetes Mellitus,Hypertension.Bleeding disorders.Cardiovascular diseases.Liver disorders.Patients on long-term steroid therapy.Teeth that have undergone radiation [6 months – 1 yr ].
Expansion of bony socketspecially for forcep extractionsufficient tooth structureelastic bone (children)multiple small fractures of buccal cortical bone1. Use of a lever & fulcrumremove the tooth/root along the path of least resistancebasic factor governing the use of elevators
2. The insertion of wedge orwedges between tooth-root& bony socket wall
Take history of –1. general disease2. nervousness3. resistance to inhalational anesthesia4. previous difficulty with extraction Oral hygiene status of the patientoral prophylaxisantiseptic mouth rinse Clinical examination of the tooth Clinical examination of the oral cavity- any prosthesis
PREOPERATIVE RADIOGRAPHS –Indicationsi. H/O difficult & attempted extractionsii. Resistance to forcep extractioniii. Planning to remove the tooth by dissectioniv. Close approximation with important anatomical structuresv. Abnormal root pattern – third molars, in standing premolars, misplaced caninevi. Tooth having periodontal problem & some sclerosis – hypercementosisvii. Trauma to tooth – fracture of tooth, roots & alveolar boneviii. Isolated & Unopposed maxillary molarsix. Partially erupted, unerupted tooth & retained rootsx. Delayed erupting or having abnormal crownxi. Condition indicating dental or dentoalveolar deformities –osteitis deformans - hypercementosiscleido-cranial dysosteosis - hooked roottherapeutic irradiationosteopetrosis
GENERAL ANESTHESIA• 5-10 min.• uncooperative patients• 30-45 min.• No pre-op preparation• Respiratory tract disease• Cardiovascular diseasesLOCAL ANESTHESIAGeneral factors
Local factors Acute infection at the site of injection Hemangioma
Is defined as –removal of all micro-organisms from a given object. Hands of operator Instruments Operation area Engines, lights & chairs are inevitably sources of cross-infection. Use the sterile gauze /cloth – to change the position of light.
1. Position of the operator –- Stand erect , equal distribution of weight on both feet- Force delivery – with arm & shoulder not with hand- application of force without stress to shoulders & back- generally on right hand side- for Right posteriors – back side- operating box
2. Position of the patient –make the patient comfortable on dental chair3. Height Of Dental Chair –maxillary teeth – 8 cm / 3 inch below the shoulder levelof operatormandibular teeth – 16 cm / 6 inch below the elbow ofoperator
4. Angulation of the chair –maxillary teeth – 45-60 degreemandibular teeth – parallel or 10 degree5. Light –good illumination
6. Role of opposite hand Reflection of soft tissue Protection of other teeth Stablization of patient’s head Supporting & stablizing the mandible Supports alveolar bone Tactile information Compress socket Deliver the whole tooth, root, dislodged filling
7. Role of assistant Helps the surgeon to gain access & visualize the field Suction Protect the teeth of opposite arch Support the head Support the mandible Psychological & emotional support Avoid casual , offhand comments– increase patient’s anxiety- decrease patient’s cooperation
Clear access to & vision of the surgical field. Use of controlled force Unimpeded path of removal
Separation of tooth from alveolar bone withcrestal & principal periodontal fibers. Alveolar expansion Bleeding is arrested by pressure pack.
Severing SoftTissue AttachmentThe straight and curved desmotomes
Commonly used Not used in – hypercementosis- root deformities- grossly decayed crown- grossly decayed root- brittle root Advantages - least trauma- gingival fibers reduces the size of extraction orificeso promotes healing
1. Beaks should seated as far apically as possible2. Beaks should be parallel to the long axis of tooth3. Excess force should be avoided.HOWTO HOLDTHE FORCEPThumb – just below the jointHandle in palmLittle finger – inside the handle
Buccally & lingual parallel to long axis of tooth. Forced through periodontal membrane, towards apex. Firm pressure. 1st apply on less accessible side of tooth under direct vision 2ndly on other side Cervical caries - 1st movement towards carious part
Time spent in careful application of forcepblades to the radicular portion of tooth isnever wasted.
Pressure applied by the operator by moving his trunkfrom hips not from elbow. Movements – linguobuccal & buccolingual- firm, smooth & controlledrotatory / figure of 8looseremoval
Maxillary buccal bone is thinner – buccally removal of teeth Mandibular buccal bone till molar is thinner - buccally removal ofteeth Mandibular buccal bone in molar region is thicker - linguallyremoval of teeth Socket compression Avoid soft tissue laceration
In multiple extraction cases canine should be extractedprior to extraction of incisors, as prior extraction ofincisors weakens the labial cortex.
Factors –1. Permanent successors2. Limited accessSo use fine bladesWarwick jameselevators can be usedExtraction of deciduous molar with forceps.Forceps are positioned mesially or distallyon the crown and not the center of the tooth
Works on lever & fulcrum principle It forces the tooth / root along the line of withdrawal R/G Fulcrum – bone or adjacent tooth Elevator grasping
Application –in periodontal space450 to long axis of toothPlacement of gauze between finger andlingual side, for protection from injury incase the elevator slips
Application of elevator –BuccallyMesiallydistally
Movement –rotate the elevator along its long axis
a During luxation of a tooth, thealveolar ridge is used as a fulcrum, notthe adjacent tooth.b Incorrectplacement of the instrument.c Photoelastic modelshowing extraction of the thirdmandibular molar using astraight elevator. Using the adjacenttooth (second molar) asa fulcrum creates great tension aroundthe tooth, with a riskof injury to tissues surrounding the root
Positioning of straight elevator on the distal surface of theroot, either perpendicular to, or at an angle to the root
Removal of the root of mandibular premolar with thespecial instrument (endodontic file-based action) for rootextraction
Separation of roots of the mandibularfirst molar with fissure bur
Roots of mandibular first molar.Extraction is accomplished by sectioningroots using a straight elevator
Positioning of the elevator and the fingers of the left hand for separation of molar roots
Using an elevator withT-shaped handles to remove intraradicular bone
Diagrammatic illustrations showing luxation of the root tip of themandibular second premolar, usingdouble-angled elevators
Technique for removing the tip of a mesialroot of a mandibular molar. Removal of intraradicular boneand luxation of the root tip using a double-angled elevator
Removal of the tip of the distal root of a maxillary molar
Removal of the root tip using an endodonticfile. After the endodontic file enters the root canal, the roottip is drawn upwards by hand (a), or with a needle holder (b)
Irrigation of the socket Squeezing of the socket Mouth rinsing with warm bland water for once Suturing if require Moist gauze pack Medication Post extraction instructions – verbal & written
1. Intra-alveolar attempt is failed2. Retained roots in proximity with maxillary sinus & not accessibleto forcep3. History of difficult or attempted extraction4. Heavily restored tooth5. Geminated / dilacerated tooth
Dens in dente of maxillary left canineFusion of teeth
Deciduous mandibular molar, whose rootsembrace the crown of the succedaneouspremolar. Risk of concurrent luxation withthe simple extraction technique.
Main components of transalveolar extraction –1. Design of mucoperiosteal flap2. Method to be used to deliver the tooth / root from socket3. Bone removal used to facilitate tooth / root removal
Raise to render the operative site clearlyvisible & accessibleSuture should not be placed over blood clotObliteration of buccal sulcus should be avoidedBase – broad
Sharp scalpel Firm pressure Mucousa + periosteum Avoid Button hole formation in case of sinus Incision of sufficient length at once
Minnesota retractors forretraction of the cheek and tongueAustin’s retractor
To expose root/tooth Facilitated by large flaps Provides point of application After tooth/root removal – remove all sharp edges & boneprominences Instruments used -
Round / rose head provides – less clogging, better control. It doesnt cut the tooth that easily Should not contact soft tissue Avoid overheating Postage stemp method then join with chisel
Different line of removal for different roots Divide the root from furcation area Make space for application of forcep / elevator Osteotome / burs
Engage the elevator in a notch on side of root If notch is not present then create it with round bur directed at 450angle to the long axis of root.
Irrigation of the socket Suturing Moist gauze pack Medication Post extraction instructions – verbal & written Recall after 48 hours Normally 7 days Within 2 days – if it was for control of hemorrhage OAC repair – 10 days
Steps in the surgical extraction of an intactmaxillary first molar. Reflection of the envelope flap,sectioning of two buccal roots from the crown (a), removalof the crown together with the palatal root, and then finallyremoval of the mesial and distal roots (b)
An L-shaped incision is made and the flap is reflected.The buccal plate covering the surface of the root isremoved, and the tooth is extracted using forceps
a, b. Surgical extraction of a mandibularmolarwith hypercementosis at the distal root tip.The envelopeflap is reflected, part of the buccal plate isremoved, and thetooth is sectioned buccolingually at the crownas far as theintraradicular bone
Extraction of the mesial portion of the tooth,which includes the crown and rootWidening of the alveolus with a round bur, sothat removal of the root is possible withoutfracturing the bulbous root tip
The surgical technique is indicated for its removal
Radiograph of roots of the mandibular first molar.The surgicaltechnique is indicated for their removal
INDICATIONS –1. Patient Under Coverage of BISPHOSPHONATE2. Hemophilic patientsPROCEDURE –Dentin bulge (arrows)preventing elastics from slidingapically.Root canal treated and split mandibular molar duringexfoliation process. Note extrusion of mesial root.
Sockets immediately after exfoliation of both teeth.
Take careful history Take care of – airway, support of mandible & position ofpatient’s headThe dental surgeon should never act as bothoperator & anesthetist.
1. Accompanying person2. No driving3. 6 hrs of NPO4. Emptying the bladder5. Loose the tight clothing6. Patient Comfortable in dental chair7. Head slightly extended8. Mandible should be parallel to floor9. Arm & leg position of patient10. Waterproof apron11. Hearing of patient’s each breath
1. Identify the tooth2. All prosthesis are removed3. All instruments should be keep ready4. Larger the anesthesia – increase risk of anoxia &aspiration5. Ideal time – 5-10 min.
1. Tooth priorities2. Avoid excess force to mandible3. Soft tissue injury should be avoided4. Postpone – remove pulp if it is exposed5. Fractured root v/s resorbed root
1. Hemorrhage & clot formation – 1-2 days2. Organization of clot by granulation tissue – 3-7 days3. Replacement of granulation tissue by connectivetissue & epithilialization of wound – 4-35 days4. Replacement of connective tissue by coarse fibrillarbone – 6-8 weeks5. Reconstruction of alveolar process & replacement ofimmature bone by mature bone tissue
1. Infection2. Size of wound3. Blood supply4. Resting of part5. Foreign bodies6. General condition of the patient
Technological Advances in ExtractionTechniques and OutpatientOral SurgeryAdamWeiss, DDS*, Avichai Stern, DDS, Harry Dym, DDSDepartment of Dentistry and Oral and Maxillofacial Surgery, The BrooklynHospital Center,121 Dekalb Avenue, Brooklyn, NY 11201, USA* Corresponding author.E-mail address: email@example.comKEYWORDSPowered periotome Polyurethane foam PiezosurgeryImmediate implants Orthodontic extrusion Bone graftingPhysics forcepsDent Clin N Am 55 (2011) 501–513doi:10.1016/j.cden.2011.02.008 dental.theclinics.com0011-8532/11/$ – see front matter 2011 Elsevier Inc. All rights reserved.
Piezosurgery is an innovative bone surgery technique that producesa modulated ultrasonic frequency of 24 to 29 kHz, and amicrovibration amplitude between 60 and 200 mm/s. The amplitude of the vibrations created allows a very clean andprecise surgical cut. It works selectively, without harming soft tissues such as nerves andblood vessels even with accidental contact with the cutting tip. The surgical control of the device is effortless compared withrotational burs or oscillating saws because there is no need for anadditional force to oppose rotation or oscillation of the instrument.
Despite the longer time of the procedure, the investigators alsonoted that the piezoelectric osteotomy reduced postoperativefacial swelling and trismus. Uses of piezosurgery device to cut and elevate a precisely definedbone lid on the lateral cortex of the mandible to provide access tothe teeth needing extraction or even a lesion that needs to beexcised. The bone window is then elevated with the help of a curvedosteotome. After the visual confirmation of an undamaged IAN and adjacenttissues, the bone lid is placed back into its original position andfixated with absorbable miniplates.
For the surgical extraction of the teeth, the covering bone was firstablated, layer by layer, using the Er:YAG laser. In the case of the fiber-optic Er:YAG [erbium:yttrium-aluminumgarnet ], laser the fiber is closely guided around the teeth, creating anarrow gap with minimal bone loss. The benefits of laser therapy include the creation of a bloodlesssurgical field and thus improved visualization during surgery,decreased postoperative pain, and limited scarring and contraction. Time consuming, sound and smell, significantly inhibition thelaser cutting because of the overall volume of irrigation and bloodcovering the bone surface.
Third molars in close proximity to the IAN have a significantnegative impact on recovery for pain and oral function. The advantage of this technique is that the risk of direct traumato the nerve is eliminated, due to both the increased distancebetween the roots and the mandibular canal and the decreased needfor surgical manipulation during the extraction.
A potential problem with this technique is soft tissue damage fromimpingement on the mucosa of the cheek and the gingiva. In addition, working in this area of the mouth presents greatdifficulty, and the action of the masseter muscle leads to cheekcompression against the orthodontic appliances. This technique will be of no value for a tooth that cannot movebecause of ankylosis. This technique should be used only in carefully selected cases inconjunction with an orthodontist, being certainly difficult, timeconsuming, and not always successful.
Panoramic radiograph at initial consultation. The mandibularthird molars are mesially impacted with the roots close tothe alveolar canal.
Postoperative radiograph after second sectioning ofthe right mandibular third molar. A pulpotomy has been performed.More space was created distal to the right mandibular secondmolar to allow further migrationPostoperative radiograph after the right mandibularthird molar was surgically sectioned. The spacedistal to the second molar would allow mesialmigration of the impacted tooth.
3 months after odontectomy. Thethird molar moved mesially.However, the mesial root was stillin contact with the alveolar canal.A second sectioning was required.Periapical radiograph obtained 2 months aftersecond sectioning. At that time, the roots wereaway from the alveolar canal, and a risklessextraction could be scheduled.
The Physics Forceps uses first-class level mechanics to atraumaticallyextract a tooth from its socket. One handle of the device is connected to a “bumper,” which acts as afulcrum during the extraction. Together the “beak and bumper” design acts as a simple first-classlever. A squeezing motion should not used with these forceps. By contrast, thehandles are actually rotated as one unit using a steady yet gentlerotational force with wrist movement only. Once the tooth is loosened, it may be removed with traditionalinstruments such as a conventional forceps
GMX-100R - Upper Right - Extracts Teeth 2 to 5GMX-100L - Upper Left -Extracts Teeth 12 to 15GMX-100A - Upper Anterior - Extracts Teeth 6 to 11GMX-200 -Lower Universal -Extracts Teeth 18to 31
Coronectomy can be beneficial but success requires both good patientselection and operator technique. Renton et al.reported no IDNI in 58 successful Coronectomy patientsand a 19% IDNI rate in those having traditional extractions. Leung et al. showed nine (5%) patients in the control group presentedwith IDNI, compared with one (0.06%) in the Coronectomy group. Hantano et al. reported that in the extraction group six patients (5%)suffered IDNI, of which 3 patients were diagnosed with permanentinjury, where as in the Coronectomy group one patient (1%)complained of altered sensation post-operatively which resolved withinone month. The retrospective analysis of O’Riordan consisted of 52 patients thatunderwent Coronectomy. In this study there were 3 cases of transientIDNI which showed resolution one week post operatively. One patientdeveloped permanent IDNI, which was thought to be as a result ofperforation of the canal due to operator error rather than theCoronectomy technique itself.
1, deviation of the canal 2, narrowing of the canal3, periapical radiolucent area 4, narrowing of root;5,darkening of roots 6, curving of root7, loss of lamina dura of canal
Coronectomy: A, cutting crown belowcement-enamel junction (arrow);B, trimming cutting surface to lessthan 3 to 4 mm below alveolar crest.Radiographic imagingshowing pre andpost coronectomy of the rightmandibularthird molar (48)
To avoid traumatizing the surrounding bone during elevation,implant drills were placed in the root canals to thin the root wallsgiving way to extraction with the application of much less force,thereby decreasing the chance of traumatizing the thin buccal bone.
1. FAILURE TO ACHIEVE ANESTHESIA / TOOTHREMOVAL2. FRACTURE OF TOOTH / SURROUNDING STRUCTURES3. DISLOCATION4. DISPLACEMENT OF TOOTH / ROOT5. EXCESSIVE HEMORRHAGE6. DAMAGE TO HARD & SOFT TISSUES7. POSTOPRATIVE PAIN8. POSTOPERATIVE SWELLING9. TRISMUS10. OROANTRAL COMMUNICATION11. SYNCOPE12. RESPIRATORYARREST13. CARDIAC ARREST14. ANESTHETIC EMERGENCIES
Faulty technique Inadequate solution Test the efficacy of anesthesia Tooth could not be removed with intra-alveolar ortrans- alveolar procedure.
Crown / root – Grossly carious Tooth with Endodontic treatment Improper application of forcep One point contact Slip off of forcep Excessive force Hurry Tooth with divergent roots /hypercementosisThen trans-alveolar method is indicated
Remove all the root fragments except –1. 5 mm & requires excessive bone removal – well tolerated.(Simpson 1958)2. Apical 1/3 rd of palatal root of maxillary molars &requires excessive bone removalIf removal is indicated – inform the patientradiographIf root is left in place – pulpectomy should be performed.
Causes – Excessive inclusion of bone within the forcep beaks Extraction of incisors before canine Intact versus torn periosteum Generally during extraction of maxillary 3rd molars Pneumatization of maxillary air cells Gemination
Management – Preoperative radiograph is essential Raise the mucoperiosteal flap Separate the tooth & bone from gingiva Mattress Suture 10 days If tuberosity is excessively mobile –i. Splint the tooth for 6-8 weeksii. Sectioning the crown & pulpectomy.
Heavily restored adjacent teeth –in the line ofwithdrawal Abutment teeth When used as fulcrum Uncontrolled force Under general anesthesia – gauge & props intubation
When used as fulcrum Improper use of elevators Give support to adjacent tooth from other hand Don’t apply the elevator mesial to 1st molarManagement – Place the tooth in socket & splint it
Causes – Excessive / incorrectly applied force Improper use of mouth gauge Senile osteoporosisPrecautions – Take history Exraoral support beneath the angle ofmandibleManagement – Reduce it immediately Reduction technique Instructions to patient
Causes – Abnormal root curvature Carious root Roots of premolars & molars involved by sinus Excessive / incorrectly applied force Inadequate grasping of toothPrecautions – Take past dental history Apply the forcep on sufficient tooth structure Leave uninfected apical 1/3rd of root Never force the root towards sinus Transalveolar method
Causes - Maxillary posterior teeth Involvement of sinus lining by – Periapical pathologyDiagnosis – Increased intra nasal pressure – air coming out frommouth can be heard Amount of blood will be doubled Wisp of cotton wool will be deflected
Management – Mucoperiosteal flap rising Decrease alveolar height Interrupted horizontal suture Protect the clot with – acrylic, denture base, impressionmaterial Give incision in sinus membranePrecautions – Mouth rinsing with antiseptic solution before closure oforoantral communication Passage of instruments from mouth to sinus should beavoided.
Diagnosis – Air bubbles from socket Cotton wool deflection Fluid taken from oral cavity noseManagement – Take radiograph . Blow the air through nose Under general anesthesia – stop the general anesthesiawait till regaining the cough reflex Suction + irrigation ½ inch wide iodoform gauze Sometimes incision in sinus membrane Caldwell-Luc approach
Mostly maxillary third molarsManagement – Extend the incision posteriorly Blunt dissection Grasp the tooth carefully Or wait for several weeks until it becomes somewhatencapsulated.
Reflect the soft tissue flap on lingual aspect of mandible asforward to the premolarsgently dissect the mucoperiosteumDetach the mylohyoid muscle.
If the root is not appearing in the oral cavity/pressure pack Ask the patient to cough & spit Turn the patient towards the operator & position with themouth towards the floor. Radiograph of alveolar socket/ sinus/ chest Re-examine the patient after 3 days Patient is asked to report immediately- fever, cough,chest pain occurs.
Perioperative hemorrhage – Oozing of blood during operationManagement – Wipe Sucker Hot 50 degree celcius for 2 min. Hemostate Local anesthetic solution having vasoconstrictor Gelatine sponge oxidized cellulose After tooth removal – moist pressure pack for 10min.horizontal mattress suture
Postoperative hemorrhage – Instructions to the patients –1. Pressure pack2. Less talk for 2-3 hrs.3. Tea bag4. No smoking for 12 hours5. No staneous exercise Psychological approach Determine site & amount of hemorrhage Remove excess blood clot Provide firm gauze pack with tannic acid
Horizontal mattress suture into mucoperiosteumWait for 5 minutes after placing gauze pressure on sutureGelatin / fibrin foam&All post extraction instructions and avoid frequent aggressivemouth rinsing
Causes – Compression with clot or bone debris Partially or completely tornPrecautions – Preoperative radiograph Elevator should not be forced below tooth Resect 1 root before tooth elevationManagement – Reposition the ends at closeapproximation Decompression Microsurgical reanastomosis Nerve grafting
Causes – Transalveolar extraction of premolarsPrecautions – More Bone reduction mesial to 1st premolar & distalto 2nd premolar Retraction of nerve with mental retractor
Burs Management – drilling the groove around it .
Submucosally & subcutaneously Older patients – increased capillary fragilitydecreased tissue toneweaker inter cellular attachments Onset 2-4 days Resolve within 7 – 10 days
Cause – Suture without adequate bony foundation Suturing the wound under tension Mostly in the region of mandibular 2nd & 3rd molar(internal oblique ridge)Management – Leave the projection – slough out within 2-4 weeks Smooth it with bone file under local anesthesia.
1. Due to traumatized hard tissue – Bruising from bone during intrumentation Excessive heating from bur Sharp bony edges Avoidance of tissue toileting2. Due to traumatized soft tissue – Incision only through mucous membraneragged flap - heals slowly Too small flap – much traumatic retraction Injury from bur.
Postoperative pain in and around the extraction site, whichincreases inseverity at any time between 1 and 3 days after theextractionaccompanied by a partially or totally disintegrated blood clotwithinthe alveolar socket with or without halitosis.I. R. Blum: Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization,etiopathogenesis and management: a critical review. Int. J. Oral Maxillofac. Surg. 2002; 31: 309–317. 2002International Association of Oral and Maxillofacial Surgeons
Mostly 1–3 days after tooth extraction . Within a week - In 95% and 100% of all cases. Unlikely - before the first postoperative day.because the blood clot contains anti-plasmin that must beconsumed by plasmin before clot disintegration can take place. The duration of alveolar osteitis varies to some degree, depending onthe severity of the disease, but it usually ranges from 5–10 days.
1. The denuded alveolar bare bone may be painful and tender.Initially blood clot appears dirty gray disintegratesgrayish yellow bony socket bare of granulation tissue2. Some patients may also complain of intense continuous painirradiating to the ipsilateral ear, temporal region or the eye.3. Regional lymphadenopathy (occasionally).4. unpleasant taste (occasionally).5. Trismus is a rare occurrence in mandibular third molar extractionsprobably due to lengthy and traumatic surgery.
Multifactorial origin Following have been implicated most commonly as etiological,aggravating and precipitating factors:1. Oral micro-organisms - Treponema denticola2. Difficulty and trauma during surgery3. Roots or bone fragments remaining in the wound4. Excessive irrigation or curettage of the alveolus after extraction5. Physical dislodgement of the clot6. Local blood perfusion & anesthesia7. Oral contraceptives - estrogens, like pyrogens will activate thefibrinolytic system indirectly.8. Smoking
1. Previous experience.2. Deeply impacted mandibular third molar (risk factor is directlyproportional to increasing severity of impaction) .3. Poor oral hygiene of patient .4. Active or recent history of acute ulcerative gingivitis or pericoronitis.5. Associated with the tooth to be extracted .6. Smoking (especially >20 cigarettes per day) .7. Use of oral contraceptives .8. Immunocompromised individuals .
BIRN : (BIRN H. Etiology and pathogenesis of fibrinolytic alveolitis (‘dry socket’). Int J OralSurg 1973: 2: 215–263.)
FactorXIIaCLOTTINGSYSTEMKININSYSTEMFIBRINOLYTIC SYSTEMCOMPLEMENTSYSTEMFactor XIICONTACTThis conversion isaccomplished in the presence of tissueorplasma pro-activators and activators.
References in the literature correlating to theprevention of alveolar osteitis can be dividedinto1. Non-pharmacological and2. Pharmacological preventive measures.
Non-pharmacologicalmeasures1. Use of good quality current preoperative radiographs2. Careful planning of the surgery3. Use of good surgical principles4. Extractions should be performed with minimum amount oftrauma and maximum amount of care5. Confirm presence of blood clot subsequent to extraction(if absent, scrape alveolar walls gently)
6. Wherever possible preoperative oral hygienemeasures to reduce plaque levels to a minimumshould be instituted7. Encourage the patient (again) to stop or limit smokingin the immediate postoperative period .8. Advise patient to avoid vigorous mouth rinsing for thefirst 24 h post extraction and to use gentletoothbrushing in the immediate postoperative period .9. For patients taking oral contraceptives extractionsshould ideally be performed during days 23 through28 of the menstrual cycle .10. Comprehensive pre- and postoperative verbalinstructions should be supplemented with writtenadvice to ensure maximum compliance .
1. Remove any sutures to allow adequate exposure of the extraction site.Asthe socket may be exquisitely tender local anaesthesia may be required.2. Irrigate the socket gently with war sterile isotonic saline or local anaestheticsolution, which is followed by careful suctioning of all excess irrigationsolution.3. Do not attempt to curette the socket, as this will increase the level of pain.4. Prescription of potent oral analgesics.5. The patient is given a plastic syringe with a curved tip for home irrigationwith chlorhexidine solution or saline and instructed to keep the socket clean.6. Once the socket no longer collects any debris, home irrigation can bediscontinued.
Under block anesthesia The clot devoided socket is thoroughly curetted, both from thefloor of the socket as well as from the bony walls. The sharp margins were trimmed, rounded. Any foreign bodies if present were thouroghly removed. The detached gingival margins were also scraped. The desired medications as well as precautions . Patient was not only without pain, but was also comfortable bothphysically as well as psychologically from the very next day.S.C.Anand,V. Singh, M. Goel, A.Verma, B. Rai: Dry Socket An ApriasalAnd Surgical Management. The Internet Journal of DentalScience.2006Volume 4 Number 1. DOI: 10.5580/e31
Normal oedemaAfter multiple teeth extractionsurgical tooth extraction Traumatic oedemaBlunt instrumentationExcessive extraction of badly designed flapToo tight sutureManagement – Ice pack application Heat application
Subcutaneous emphysema – Air into connective tissue of intramuscular & fascialspaces Swelling is of sudden onset. Crackles can be felt under finger Resolves within 1-2 daysDue to infection of wound – Preoperative antibiotic Prevention of entry of micro-organism into wound Mild infection – intraoral hot saline mouth wash
It is defined as inability to open the mouth due to musclespasm.Causes – Post operative oedema Hematoma formation Inflammation of soft tissue After mandibular block Traumatic arthritis of TMJ Multiple injections
Transient loss of consciousness and postural tonecharacterized by rapid onset, short duration, and spontaneousrecovery due to global cerebral hypoperfusion that most oftenresults from hypotension.Sign & symptoms – dizziness, weakness, nausea skin is cold,pale & sweating.Management – Position Oxygen administration Blood pressure & pulse measurement 250 mg aminophylline is given slowly.
Skeletal muscle become flaccid pupil dilate widelymanagement – Patient flat on the floor Clean the airway Pull the mandible forward Extend the neck fully Pulmonary resuscitation so that chest is seen to rise every3-4 sec. Brook airway can be inserted over tongue Check carotid pulse & apex beats at regular intervals
Sign & symptoms – Deathly pallor & grayness of skin Cold sweat Pulse & apex beat can be felt Heart sounds can not be audibleChildren - Beginning of heartbeat if the sternum is tapped sharplyAdult –Patient flat on the floorCardiac compression at 1 second interval
Syncope, respiratory arrest & cardiac arrest complicate thegeneral anesthesia. Management –i. Clear the airwayii. Remove all the packs, debris & apparatus from mouth.iii. Pull the mandible forwardiv. Extend the neckv. Head – downward /forward in dental chair- upward if lying on the floorvi. Oxygenvii. Larygotomyviii. Tracheostomy
RESOURCESText books1. The extraction of teeth by – GEOFFREY L HOWE2. Oral & maxillofacial surgery volume 2 , by – DANIEL M. LASKIN3. Oral Surgery by - FRAGISKOS D. FRAGISKOS4. Contemporary Oral & maxillofacial surgery by- HUPP, ELLIS,TUCKER5. Text book of Oral & maxillofacial surgery by – S M BALAJI.