EXODONTIA

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy...
ORAL AND MAXILLOFACIAL
SURGERY
IS THE SPECIALITY OF DENTISTRY
THAT INCLUDES THE DIAGNOSIS ,
SURGICAL AND ADJUNCTIVE
TREATM...
EXODONTIA
EXTRACTION:THE IDEAL TOOTH
EXTRACTION IS THE PAINLESS
REMOVAL OF THE WHOLE TOOTH OR
TOOTH-ROOT,WITH MINIMAL TRAU...
BASIC REQUIREMENTS
 A GOOD RADIOGRAPH
 ADEQUATE ANESTHESIA
 PROPER INSTRUMENTS
 ADEQUATE ILLUMINATION
 EFFICIENT ASSI...
PREPARATION
PAIN AND ANXIETY:
1.ANESTHESIA
2.SEDATION
PRE SURGICAL MEDICAL ASSESSMENT:
1.SYSTEMIC
2.LOCAL

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INDICATIONS









periodontal disturbances
severe caries
pulpal necrosis/pathology
peri apical pathology
orthodo...
INDICATIONS
 SUPERNUMERARY TEETH
 TOOTH IN THE LINE OF FRACTURE
 ROOT FRAGMENTS
 PRE RADIATION THERAPY
 ESTHETIC PURP...
CONTRA INDICATIONS
1. SYSTEMIC
2. LOCAL

systemic: absolute
un controlled metabolic diseases
-diabetes
-end stage renal di...
infection:non functioning white cells
bleeding:inadequate number of platelets
un controlled cardiac diseases
-angina
-isch...
LOCAL CONTRAINDICATIONS
-HISTORY OF RADIATION
-SITE OF MALIGNANT TUMORHASTENS METASTASIS
-SEVERE PERICORONITIS
-ACUTE DENT...
RELATIVE CONTRAINDICATIONS:
PREGNANCY-1ST AND 3RD TRIMESTERSUNSAFE
2ND TRIMESTER-SAFE
DEFER-IF COMPLICATED
PATIENTS ON DRU...
PATIENT AND SURGEON
1.hand gloves
2.mouth mask
3.head cap
4.wash
5.mouth rinses
6.gauze-to prevent aspiration
no finger ri...
TYPES OF EXTRACTION
1.CLOSED EXTRACTIONintra alveolar
regular conventional method
2.OPEN METHODtrans alveolar extraction
i...
Elevators in oral surgery
 Indications:
 Removal

of teeth: impactions,
malposed teeth, decayed , tilted.

 Removal

of...
Complications in the use of
elevators
 Damaging or even extracting adjacent

teeth
 Fracturing the maxilla or mandible
...
 Penetrating into the maxillary antrum


forcing a root or apical third of the root of
the lower third molar into the ma...
Rules when using elevators
 Never use an adjacent tooth as a fulcrum

unless that tooth is to be extracted also.
 Never ...
 Always

use finger guards to protect the
patient in case the elevator slips.

 Be certain that the forces applied by th...
Parts of elevator
 Handle

: this may be a continuation of the
shank or at right angles to it

 Shank
 Blade

or root

...
Classification of elevators






According to the use:
Elevators designed to remove the entire tooth
Elevators desig...
 Elevators designed to reflect the

mucoperiosteum (periosteal elevators)
before forceps or extracting elevators are
used...
 According

to the form:
 Straight: wedge type (straight apex)
 Angular: right &left
 Cross bar (handle at right angle...
Work principles in use of
elevators
 Lever principle
 Wedge principle
 Wheel &axle principle

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PRE EXTRACTION
EVALUATION
1.access to the tooth
2.mobility of the tooth
3.condition of crown
4.radiographic examination
-p...
ORDER OF EXTRACTION
FIRST-MAXILLA
NEXT-MANDIBLE
THIRD MOLAR
SECOND MOLAR
SECOND PRE MOLAR
FIRST MOLAR
FIRST PRE MOLAR
LATE...
CHAIR POSITIONS
POSITION:
MAXILLA




tipped backward
45 degrees to the floor
should be 3 inches below shoulder level.
...
MANDIBLE
 parallel to the floor on opening.

 should be 6 inches below elbow level

operator left quadrant

- right fro...
Position of the dentist
1. Posture
2. Relation to the patient
3. Dentist left hand:
A. during forceps application:
1. retr...
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2.Guiding the beaks of the forceps onto the
tooth to be extracted.
3.Stabilizing the patients head during
operations on th...
B. During tooth luxation.
1.Supporting the buccal and lingual cortical
plates.
2.Estimating the amount of pressure
applied...
3.Counteracting the pressure applied. Unless the
mandible is supported, the forces exerted
through the forceps to the toot...
4. Prevention and protection against slipping
of forceps and elevators.
5. Removal of broken fillings, tooth
fragments or ...
C. After tooth extraction.
1.Compressing the buccal and lingual
cortical plates back into position.
2.Examination of the s...
FUNDAMENTALS
OF A GOOD EXTRACTION:
1.adequate access and visualization
2.an unimpeded pathway for the
removal
3.the use of...
PRINCIPLES OF FORCEPS
EXTRACTION
1.expansion of bony socket
2.removal of the tooth

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5 MAJOR MOTIONS TO LUXATE AND
EXPAND
1. apical pressure
2. buccal pressure
3. lingual pressure
4. rotational pressure
5. t...
GENERAL STEPS OF EXTRACTION


STEP 1:
loosening of soft tissue attachment from the
tooth



STEP 2:
luxation of tooth wi...
 STEP 4:

luxation of the tooth with forceps
 STEP 5:

removal of the tooth from the socket

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REASONS OF ROOT BREAKAGE
 a. improper application of beaks of forceps

1. beaks placed on enamel instead of
on cementum
2...
 d. brittleness due to age or nonvitality of

tooth ,root canal filling indicate the
possibility of root fracture

 e. p...
 f. excessive density of surrounding bone

due to:
1.condensing osteitis
2.osteopetrosis(marble bone,albersschonberg dise...
 5.bridge abutments ,fixed or removable





subjected to great stress
6. a coarse diet stimulating osteoblastic
activ...
 G. incorrect application of force in

extraction of teeth
 1. wrong direction
 2. jerking a tooth (sudden violent
appl...
ODENTECTOMY & TOOTH DIVISION
Is the surgical removal of a tooth or teeth by
reflection of an adequate mucoperiosteal
flap ...
Indications for odontectomy and tooth
division
 hypercementosis of the roots

 widely divergent roots of mandible

maxil...





Extensively decayed teeth ,particularly those
with deep gingival cavities
Teeth with root canal fillings
When a t...
 Thin mandibles in which excessive force is

required to luxate the teeth .this excessive
force may result in the fractur...
 When the forces used to remove the

mandibular teeth results in dislocation of
condyles
 When the customary force fails...
Steps in odontectomy









Pre operative assessment
Administration of local anesthesia
Incision
Elevation of mu...
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Principles of mucosal incisions
 1.should not be placed on the operative

site but on the undisturbed area.
 2.incisions...
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 5.incise to have broader base
 6.no incision on thinned mucosa
 7.around the teeth in the gingival crevice
 8.integre...
 9.releasing incisions should be made if

necessary (should be in smooth curve
with primary incision)
 10. single stock ...
THE TERM LOCAL FLAP INDICATES:
A SECTION OF SOFT TISSUE THAT
1.IS OUT LINED BY A SURGICAL INCISION
2.CARRIES ITS OWN BLOOD...
DESIGN PARAMETERS FOR
FLAPS
1.
2.

3.

4.

BASE- BRODER THAN FREE MARGIN
SUFFICIENT SOFT TISSUE
REFLECTION –TO PROVIDE
NEC...
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FLAP DESIGN CONTD
6.FULL THICKNESS FLAP
- MUCOSA
- SUB MUCOSA
- PERIOSTEUM
7.INCISION ON INTACT BONE ONLY
8.TO AVOID VITAL...
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Needles
According to the shape :
1/4circle,3/8circle,1/2circle,3/4circle,straight with curved
end, straight
 According to...
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Principles of suturing
 1.needle holder should be grasped ¾ from

the point
 2.needle should enter perpendicular
 3.nee...
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 5.needle should be passed from free to

fixed.
 6.thinner to thicker
 7.Deeeper to superficial
 8.distance of penetra...
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 9.tension free closure

 10.suture should be tied for approximation

not blanched.
 11.knot should not be placed over ...
SUTURE MATERIALS
A SUTURE IS A STRAND OF MATERIAL
USED TO LIGATE BLOOD VESSELS
AND TO APPROXIMATE TISSUES
TOGETHER
AIM IS ...
 Ideal suture material should have :











adequate strength
good handling properties
knot tying characteri...
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Classification of suture material:



Biologically derived materials :




1.absorbable:eg:plain catgut, chromic catgut...








Different types of suturing methods :
1.interrupted suture
2.continous suture
3.locking continuous suture
4...
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










Catgut: derived from sheep intestinal sub mucosa or bovine
intestinal serosa
Kit gut-string of dancin...









2.Collagen: grinding the native collagen of deep flexor
tendons of cattle ,increase absorption-not widely...
 Have

to wet with saline
 suggested knot of polyglacolic acid
&polyglactin 910 is first row- 3 throws,2
&3 rows-two tie...
Non absorbable sutures


1. silk: organic substance, resorbs after 2 years, most popular for
intraoral use
Braided ,moder...
KNOT TYING
BASICALLY: instrument tie and one or two hand tie
TYPES OF KNOTS:
1.square knot:two knots-opposite directions.....
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POST OPERATIVE CARE
DEBRIDEMENT
COMPRESSION OF THE EXPANDED
SOCKET
SUTURE IF NEEDED
PRESSURE PACK
PROPER INSTRUCTIONS
ANAL...
Operative complications
 Fracture
 Causes:

of the tooth:

 Teeth that has been devitalized

 Mechanical obstruction :...
 Injuries

to the adjacent teeth:
 Loosening of teeth
 Avulsion of an adjacent tooth
 Fracture of the crown
 Extracti...
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 Maxillary sinus perforation
 Root displaced into the sinus
 Root displaced into the submandibular

space

 Gingival a...
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 Hemorrhage
 Subcutaneous emphysema
 Temporomandibular joint trauma

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Postoperative complications
 Hemorrhage
 Primary hemorrhage
 Secondary hemorrhage
 Ecchymosis and hematoma
 Swelling
...
 Septic

periostitis

 Alveolar

osteitis(dry socket)

 Prevention

of postoperative pain

 infection

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Healing of extraction wounds






Hemorrhage and clot formation
Organization of the clot by granulation tissue
Repla...
HEMOSTATIC BIOMATERIALS
 GEL FOAM-GELATIN FOAM
 OXYCEL-OXIDIZED CELLULOSE
 SURGICEL-OXIDIZED REGENERATED

CELLULOSE
 B...
OXYCEL AND SURGICEL-WILL REACT
CHEMICALLY WITH BLOOD TO FORM
AN ARTIFICIAL CLOT
-SHOULD BE APPLIED DRY
BONE WAX-ONLY TO AR...
MECHANICAL WOUND
CLOSURE
LIGATING CLIPS
2. SURGICAL STAPLE
TISSUE ADHESIVES: N-BUTYL CYANO
ACRYLATE
-EPOXY RESINS
-POLY UR...
Electro surgery
cusel, cushing & bovie
 1.medical diathermy: two electrodes are used


Heat is produced when current is ...
Its effects:
 1.dehydration
 2.warming

of the tissues

 3.coagulation
 5.tissue

destruction
www.indiandentalacademy....
2.Electrodessication
(electrofuluguration):
 Oscillations

of the current used

 When

electrode is in contact with the
...
3. ELECTROCOAGULATION:
 Heat causes coagulation
 Promotes coagulation &burns &seals the
edges of the blood vessels
4. El...
Techniques
 1.The

active electrode should passed
through the tissues as quickly as possible
in a brush stroke movement w...
 4.Active

electrode should not come into
contact with the periosteum or bone

 5.When

used as a coagulation device it ...
Complications of electrocautery
 Explosion

of volatile anesthetic gases
 Burns at sites remote from the surgery
 Ignit...
Cryosurgery
 Involves application of cold to the tissue to

freeze &destroy

 Decrease of temperature causes necrosis in...
Factors effecting damage
 1.rate
 2.

of cooling

final temperature

 3.time

spent at the frozen site

 4.rate

of th...
Effects of freezing
 1.formation

of extra cellular ice
 2.concentration of extra cellular solutes
 3.decrease in intra...
Clinical applications:
 1.cancer

growth
 2.brain tumors
 3.vascular anomalies including
heamangiomas
 4.caracts
 5.p...
 Cryosurgery
 Most

units:

expensive –liquid nitrogen
 Carbon dioxide ,nitrous oxide, Freon
 For tissue necrosis:-20 ...
Thank you
www.indiandentalacademy.com
Leader in continuing dental education

www.indiandentalacademy.com
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Exodontia /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

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Exodontia /certified fixed orthodontic courses by Indian dental academy

  1. 1. EXODONTIA INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. ORAL AND MAXILLOFACIAL SURGERY IS THE SPECIALITY OF DENTISTRY THAT INCLUDES THE DIAGNOSIS , SURGICAL AND ADJUNCTIVE TREATMENT OF DISEASES,INJURIES,DEFECTS, INCLUDING BOTH THE FUNCTIONAL AND ESTHETIC ASPECTS OF THE HARD AND SOFT TISSUES OF THE ORAL AND MAXILLOFACIAL REGION. www.indiandentalacademy.com
  3. 3. EXODONTIA EXTRACTION:THE IDEAL TOOTH EXTRACTION IS THE PAINLESS REMOVAL OF THE WHOLE TOOTH OR TOOTH-ROOT,WITH MINIMAL TRAUMA TO THE INVESTING TISSUES,SO THAT THE WOUND HEALS UNEVENTFULLY AND NO POST OPERATIVE PROSTHETIC PROBLEM IS CREATED. www.indiandentalacademy.com
  4. 4. BASIC REQUIREMENTS  A GOOD RADIOGRAPH  ADEQUATE ANESTHESIA  PROPER INSTRUMENTS  ADEQUATE ILLUMINATION  EFFICIENT ASSISTANCE  GOOD SUCTION APPARATUS www.indiandentalacademy.com
  5. 5. PREPARATION PAIN AND ANXIETY: 1.ANESTHESIA 2.SEDATION PRE SURGICAL MEDICAL ASSESSMENT: 1.SYSTEMIC 2.LOCAL www.indiandentalacademy.com
  6. 6. INDICATIONS        periodontal disturbances severe caries pulpal necrosis/pathology peri apical pathology orthodontic reasons -therapeutic -malposed -serial extractions prosthetic extractions impactions www.indiandentalacademy.com
  7. 7. INDICATIONS  SUPERNUMERARY TEETH  TOOTH IN THE LINE OF FRACTURE  ROOT FRAGMENTS  PRE RADIATION THERAPY  ESTHETIC PURPOSE  ECONOMICS www.indiandentalacademy.com
  8. 8. CONTRA INDICATIONS 1. SYSTEMIC 2. LOCAL systemic: absolute un controlled metabolic diseases -diabetes -end stage renal disease with severe uremia un controlled leukemias and lymphomas www.indiandentalacademy.com
  9. 9. infection:non functioning white cells bleeding:inadequate number of platelets un controlled cardiac diseases -angina -ischemia -mi cirrhosis of liver www.indiandentalacademy.com
  10. 10. LOCAL CONTRAINDICATIONS -HISTORY OF RADIATION -SITE OF MALIGNANT TUMORHASTENS METASTASIS -SEVERE PERICORONITIS -ACUTE DENTO ALVEOLAR ABSCESS www.indiandentalacademy.com
  11. 11. RELATIVE CONTRAINDICATIONS: PREGNANCY-1ST AND 3RD TRIMESTERSUNSAFE 2ND TRIMESTER-SAFE DEFER-IF COMPLICATED PATIENTS ON DRUGS-WITH CAUTION -CORTICOSTEROIDS -IMMUNOSUPPRESIVES -CHEMOTHERAPEUTIC AGENTS www.indiandentalacademy.com
  12. 12. PATIENT AND SURGEON 1.hand gloves 2.mouth mask 3.head cap 4.wash 5.mouth rinses 6.gauze-to prevent aspiration no finger rings,no watches,no bracelets…. www.indiandentalacademy.com
  13. 13. TYPES OF EXTRACTION 1.CLOSED EXTRACTIONintra alveolar regular conventional method 2.OPEN METHODtrans alveolar extraction if the crown fractures, retained root stumps. www.indiandentalacademy.com
  14. 14. Elevators in oral surgery  Indications:  Removal of teeth: impactions, malposed teeth, decayed , tilted.  Removal of roots : roots fractured at the gingival line, roots left in the alveolus from previous extractions www.indiandentalacademy.com
  15. 15. Complications in the use of elevators  Damaging or even extracting adjacent teeth  Fracturing the maxilla or mandible  Fracture of alveolar process  Slipping and plunging the point of the instrument into the soft tissue, with possible perforation of great blood vessels and nerves www.indiandentalacademy.com
  16. 16.  Penetrating into the maxillary antrum  forcing a root or apical third of the root of the lower third molar into the mandibular canal or through the lingual plate of the mandible into the sub maxillary or pterygomandibular space www.indiandentalacademy.com
  17. 17. Rules when using elevators  Never use an adjacent tooth as a fulcrum unless that tooth is to be extracted also.  Never use the buccal plate at the gingival line as a fulcrum ,except where odontectomy is performed or in the third molar areas.  Never use the lingual plate at the gingival margin as fulcrum www.indiandentalacademy.com
  18. 18.  Always use finger guards to protect the patient in case the elevator slips.  Be certain that the forces applied by the elevator are under control and that the elevator tip is exerting pressure in the correct direction. www.indiandentalacademy.com
  19. 19. Parts of elevator  Handle : this may be a continuation of the shank or at right angles to it  Shank  Blade or root : the part which engages the crown www.indiandentalacademy.com
  20. 20. Classification of elevators      According to the use: Elevators designed to remove the entire tooth Elevators designed to remove roots broken at the gingival margin Elevators designed to remove roots broken off half way to the apex Elevators designed to remove the apical third of the root www.indiandentalacademy.com
  21. 21.  Elevators designed to reflect the mucoperiosteum (periosteal elevators) before forceps or extracting elevators are used www.indiandentalacademy.com
  22. 22.  According to the form:  Straight: wedge type (straight apex)  Angular: right &left  Cross bar (handle at right angles to the shank) www.indiandentalacademy.com
  23. 23. Work principles in use of elevators  Lever principle  Wedge principle  Wheel &axle principle www.indiandentalacademy.com
  24. 24. www.indiandentalacademy.com
  25. 25. www.indiandentalacademy.com
  26. 26. www.indiandentalacademy.com
  27. 27. PRE EXTRACTION EVALUATION 1.access to the tooth 2.mobility of the tooth 3.condition of crown 4.radiographic examination -proximity of associated vital structures -configuration roots -condition of surrounding bone www.indiandentalacademy.com
  28. 28. ORDER OF EXTRACTION FIRST-MAXILLA NEXT-MANDIBLE THIRD MOLAR SECOND MOLAR SECOND PRE MOLAR FIRST MOLAR FIRST PRE MOLAR LATERAL INCISORS CANINE www.indiandentalacademy.com
  29. 29. CHAIR POSITIONS POSITION: MAXILLA    tipped backward 45 degrees to the floor should be 3 inches below shoulder level. operatorright front of the patient www.indiandentalacademy.com
  30. 30. MANDIBLE  parallel to the floor on opening.  should be 6 inches below elbow level operator left quadrant - right front  right quadrant - right back www.indiandentalacademy.com
  31. 31. Position of the dentist 1. Posture 2. Relation to the patient 3. Dentist left hand: A. during forceps application: 1. retraction of lips ,cheeks and tongue www.indiandentalacademy.com
  32. 32. www.indiandentalacademy.com
  33. 33. www.indiandentalacademy.com
  34. 34. www.indiandentalacademy.com
  35. 35. 2.Guiding the beaks of the forceps onto the tooth to be extracted. 3.Stabilizing the patients head during operations on the maxillary teeth and stabilizing the mandible during operations on the lower teeth. www.indiandentalacademy.com
  36. 36. B. During tooth luxation. 1.Supporting the buccal and lingual cortical plates. 2.Estimating the amount of pressure applied and the amount of alveolar bone dilatation. www.indiandentalacademy.com
  37. 37. 3.Counteracting the pressure applied. Unless the mandible is supported, the forces exerted through the forceps to the tooth and hence to the mandible will result in sublaxation of the temporomandibular joint, tearing of the intercapsular fibers and in many cases result in chronic painful dysarthrosis of the temporomandibular joint. www.indiandentalacademy.com
  38. 38. 4. Prevention and protection against slipping of forceps and elevators. 5. Removal of broken fillings, tooth fragments or a whole tooth before it reaches the oropharynx. www.indiandentalacademy.com
  39. 39. C. After tooth extraction. 1.Compressing the buccal and lingual cortical plates back into position. 2.Examination of the surgical field and detection of sharp, bony edges, bony undercuts or loose bone fragments. www.indiandentalacademy.com
  40. 40. FUNDAMENTALS OF A GOOD EXTRACTION: 1.adequate access and visualization 2.an unimpeded pathway for the removal 3.the use of controlled force to luxate and remove. www.indiandentalacademy.com
  41. 41. PRINCIPLES OF FORCEPS EXTRACTION 1.expansion of bony socket 2.removal of the tooth www.indiandentalacademy.com
  42. 42. 5 MAJOR MOTIONS TO LUXATE AND EXPAND 1. apical pressure 2. buccal pressure 3. lingual pressure 4. rotational pressure 5. tractional forces www.indiandentalacademy.com
  43. 43. GENERAL STEPS OF EXTRACTION  STEP 1: loosening of soft tissue attachment from the tooth  STEP 2: luxation of tooth with a dental elevator  STEP 3: adaptation the forceps to the tooth www.indiandentalacademy.com
  44. 44.  STEP 4: luxation of the tooth with forceps  STEP 5: removal of the tooth from the socket www.indiandentalacademy.com
  45. 45. REASONS OF ROOT BREAKAGE  a. improper application of beaks of forceps 1. beaks placed on enamel instead of on cementum 2.beaks not parallel to long axis of tooth  b. wrong type of forceps  c. extensive caries www.indiandentalacademy.com
  46. 46.  d. brittleness due to age or nonvitality of tooth ,root canal filling indicate the possibility of root fracture  e. peculiar root formation 1. curved roots 2.hypercementosis 3.supernumerery roots www.indiandentalacademy.com
  47. 47.  f. excessive density of surrounding bone due to: 1.condensing osteitis 2.osteopetrosis(marble bone,albersschonberg disease) 3.defensive osteitis 4.isolated tooth, because of extraction of adjacent teeth some years previously www.indiandentalacademy.com
  48. 48.  5.bridge abutments ,fixed or removable    subjected to great stress 6. a coarse diet stimulating osteoblastic activity 7. chewing of tobacco 8.low-grade chronic gingivitis, giving rise to periostitis ,with resultant exostosis of labial cortical plate www.indiandentalacademy.com
  49. 49.  G. incorrect application of force in extraction of teeth  1. wrong direction  2. jerking a tooth (sudden violent application of force in one direction)  4. use of twisting motion when not indicated  5. pulling a tooth www.indiandentalacademy.com
  50. 50. ODENTECTOMY & TOOTH DIVISION Is the surgical removal of a tooth or teeth by reflection of an adequate mucoperiosteal flap and the removal of overlying bone from between the buccal roots of molars by means of chisels ,burs and or roungers www.indiandentalacademy.com
  51. 51. Indications for odontectomy and tooth division  hypercementosis of the roots  widely divergent roots of mandible maxillary molars  Locked roots  Teeth with apices at right angles to the long axis of the teeth  Teeth with post crowns www.indiandentalacademy.com
  52. 52.     Extensively decayed teeth ,particularly those with deep gingival cavities Teeth with root canal fillings When a thick ,dense buccal or labial cortical plate or multinodular exostosis is present When the maxillary alveolar Tuberosity is hollow because the antral cavity extends into this area www.indiandentalacademy.com
  53. 53.  Thin mandibles in which excessive force is required to luxate the teeth .this excessive force may result in the fracture of the mandible  Malposed teeth ,impactions,unerupted teeth and supernumerary teeth  Ankylosed roots found only in elderly patients) www.indiandentalacademy.com
  54. 54.  When the forces used to remove the mandibular teeth results in dislocation of condyles  When the customary force fails to produce any luxation. www.indiandentalacademy.com
  55. 55. Steps in odontectomy         Pre operative assessment Administration of local anesthesia Incision Elevation of mucoperiosteal flap Bone removal Delivery of the tooth or root Toileting or debridement of surgical site Suturing or wound closure www.indiandentalacademy.com
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  57. 57. Principles of mucosal incisions  1.should not be placed on the operative site but on the undisturbed area.  2.incisions should avoid blood vessels  3.maintain good blood supply to the flapso give incisions parallel to major vessels  4.minimize number of side cuts www.indiandentalacademy.com
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  60. 60.  5.incise to have broader base  6.no incision on thinned mucosa  7.around the teeth in the gingival crevice  8.integrety of the interdental papillae should be maintained (avoid interdental papillae) www.indiandentalacademy.com
  61. 61.  9.releasing incisions should be made if necessary (should be in smooth curve with primary incision)  10. single stock (to elevate both mucosa & periosteum for mucoperiosteal flaps) www.indiandentalacademy.com
  62. 62. THE TERM LOCAL FLAP INDICATES: A SECTION OF SOFT TISSUE THAT 1.IS OUT LINED BY A SURGICAL INCISION 2.CARRIES ITS OWN BLOOD SUPPLY 3.ALLOWS SURGICAL ACCESS TO UNDERLYING TISSUES 4.CAN BE REPLACED IN THE ORIGINAL POSITION 5.CAN BE MAINTAINED WITH SUTURES AND IS EXPECTED TO HEAL WITHOUT ANY PROBLEM. www.indiandentalacademy.com
  63. 63. DESIGN PARAMETERS FOR FLAPS 1. 2. 3. 4. BASE- BRODER THAN FREE MARGIN SUFFICIENT SOFT TISSUE REFLECTION –TO PROVIDE NECESSARY VISUALIZATION ENOUGH FLAP REFLECTION TO PERMIT THE RETRACTOR TO HOLD THE FLAP WITHOUT TENSION LONG,STRAIGHT INCISION-BETTER THAN-TORN,SHORT INCISION www.indiandentalacademy.com
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  65. 65. FLAP DESIGN CONTD 6.FULL THICKNESS FLAP - MUCOSA - SUB MUCOSA - PERIOSTEUM 7.INCISION ON INTACT BONE ONLY 8.TO AVOID VITAL STRUCTURES MANDIBLE: LINGUAL AND MENTAL N. MAXILLA: NASOPALATINE AND GREATER PALATINE A www.indiandentalacademy.com
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  74. 74. Needles According to the shape : 1/4circle,3/8circle,1/2circle,3/4circle,straight with curved end, straight  According to the shape of the cutting edge : Tapered, cutting, reverse cutting.  According to the material : Carbon steel, stainless steel  According to presence or absence of eye: Swaged, eyed, spilt eyed.  www.indiandentalacademy.com
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  78. 78. Principles of suturing  1.needle holder should be grasped ¾ from the point  2.needle should enter perpendicular  3.needle should be passed following the curve.  4.suture should be placed at equal distance (2-3mm) from the incision &at equal depth. www.indiandentalacademy.com
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  83. 83.  5.needle should be passed from free to fixed.  6.thinner to thicker  7.Deeeper to superficial  8.distance of penetration > distance from the tissue edge. www.indiandentalacademy.com
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  85. 85.  9.tension free closure  10.suture should be tied for approximation not blanched.  11.knot should not be placed over the incision line.  12.sutures should be placed 3-4mm apart.  13.avoid dog ear. www.indiandentalacademy.com
  86. 86. SUTURE MATERIALS A SUTURE IS A STRAND OF MATERIAL USED TO LIGATE BLOOD VESSELS AND TO APPROXIMATE TISSUES TOGETHER AIM IS TO BRING TISSUES TOGETHER AND HOLD THEM IN POSITION UNTIL HEALING HAS TAKEN PLACE. www.indiandentalacademy.com
  87. 87.  Ideal suture material should have :          adequate strength good handling properties knot tying characteristics should be sterilized evoke little tissue reaction. 3-0 to 7-0 ,more number of zeroes –smaller diameter of the strain 5-0&6-0: skin closure in head &neck 3-0&4-0:for intraoral mucosal incisions Sutures can be:monofilament,braided,gut. www.indiandentalacademy.com
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  89. 89. Classification of suture material:  Biologically derived materials :   1.absorbable:eg:plain catgut, chromic catgut 2.non absorbable:eg:silk ,cotton  Synthetic materials:  1.Absorbable;eg;polyglycolic acid,polyglactic 910(vicryl) 2.non absorbable:eg;nylon,dacron,polypropylene stainless steel,tantalum,titanium.  www.indiandentalacademy.com
  90. 90.        Different types of suturing methods : 1.interrupted suture 2.continous suture 3.locking continuous suture 4.mattress suture 5.figure of 8 suture 6.sub cuticular suture. www.indiandentalacademy.com
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  94. 94.           Catgut: derived from sheep intestinal sub mucosa or bovine intestinal serosa Kit gut-string of dancing master’s fiddle Least tensile strength Packed in isopropyl alcohol –to prevent enzymatic degradation(organic material) Quick rinse before use in saline Absorbed by proteolytic degradation &phagocytosis-considerable inflammation 40-6- days –complete absorption intraorally remove- 3-5 days Chromic catgut-chromic salts are added before spunning, grounding& polishing They increase tensile strength ,resistance to absorption &knot retaining capacity, decrease tissue reaction www.indiandentalacademy.com
  95. 95.         2.Collagen: grinding the native collagen of deep flexor tendons of cattle ,increase absorption-not widely used 3.polyglycolic acid&glycolactin 910:resorbed by hydrolysis, synthetic polymer decreases reaction Polylgycolic acid: is hydroxyacetic acid in presence of heat &catalyst forms linear chain polymer Polyglactin 910:a copolymer of glycolide &lactide derived from hydroxyacetic acid &lactic acid respectively Strongest absorbable suture Degradation products-decrease tissue reaction Can be used as non absorbable sutures intraorally (5-7 days) Difficult in tying the knot www.indiandentalacademy.com
  96. 96.  Have to wet with saline  suggested knot of polyglacolic acid &polyglactin 910 is first row- 3 throws,2 &3 rows-two ties in opposite direction  Subcuticular area-general usage www.indiandentalacademy.com
  97. 97. Non absorbable sutures  1. silk: organic substance, resorbs after 2 years, most popular for intraoral use Braided ,moderate tissue reaction ,does not imitate adjacent tissues, excellent handling properties Lowest rank in knot holding cpacvity,2nd –tensile strength  2.nylon:braide ,monofilamentous(skin suture) has memory  3.cotton &linen : fibers twisted into piles  4.metal : stainless steel or titanium, monofilamentous or braided www.indiandentalacademy.com
  98. 98. KNOT TYING BASICALLY: instrument tie and one or two hand tie TYPES OF KNOTS: 1.square knot:two knots-opposite directions..ex;nylon,poly propelene,pga and gut. 2.surgeon’s knot:two throws in one direction for first knot and one throw for second knot in opposite direction.ex; synthetic and pga 3.granny knot: two knots in the same direction and third in the opposite direction www.indiandentalacademy.com
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  102. 102. POST OPERATIVE CARE DEBRIDEMENT COMPRESSION OF THE EXPANDED SOCKET SUTURE IF NEEDED PRESSURE PACK PROPER INSTRUCTIONS ANALGESICS AND ANTI INFLAMMATORY DRUGS ANTIBIOTICS FOR 5 TO 7 DAYS PERIODICAL REVIEW IF NEEDED www.indiandentalacademy.com
  103. 103. Operative complications  Fracture  Causes: of the tooth:  Teeth that has been devitalized  Mechanical obstruction :hypercementosis, curvature of the root  Decision to leave or remove broken root pieces www.indiandentalacademy.com
  104. 104.  Injuries to the adjacent teeth:  Loosening of teeth  Avulsion of an adjacent tooth  Fracture of the crown  Extraction of wrong tooth  Fracture of alveolar bone  Fracture of tuberosity www.indiandentalacademy.com
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  106. 106.  Maxillary sinus perforation  Root displaced into the sinus  Root displaced into the submandibular space  Gingival and mucosal lacerations  Injury to the inferior alveolar nerve www.indiandentalacademy.com
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  108. 108.  Hemorrhage  Subcutaneous emphysema  Temporomandibular joint trauma www.indiandentalacademy.com
  109. 109. Postoperative complications  Hemorrhage  Primary hemorrhage  Secondary hemorrhage  Ecchymosis and hematoma  Swelling www.indiandentalacademy.com
  110. 110.  Septic periostitis  Alveolar osteitis(dry socket)  Prevention of postoperative pain  infection www.indiandentalacademy.com
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  112. 112. Healing of extraction wounds      Hemorrhage and clot formation Organization of the clot by granulation tissue Replacement of granulation by connective tissue and epithelialization of the wound Replacement of the connective tissue by coarse fibrillar bone Reconstruction of the alveolar process and replacement of the immature bone by mature bone tissue www.indiandentalacademy.com
  113. 113. HEMOSTATIC BIOMATERIALS  GEL FOAM-GELATIN FOAM  OXYCEL-OXIDIZED CELLULOSE  SURGICEL-OXIDIZED REGENERATED CELLULOSE  BONE WAX-BEES WAX,OLIVE OIL,PHENOL GELFOAM-MANUFACTURED FROM DENATURED ANIMAL SKIN COLLAGENMECHANICAL SCAFFOLD www.indiandentalacademy.com
  114. 114. OXYCEL AND SURGICEL-WILL REACT CHEMICALLY WITH BLOOD TO FORM AN ARTIFICIAL CLOT -SHOULD BE APPLIED DRY BONE WAX-ONLY TO ARREST BONE BLEEDERS -MECHANICAL OBSTRUCTION www.indiandentalacademy.com
  115. 115. MECHANICAL WOUND CLOSURE LIGATING CLIPS 2. SURGICAL STAPLE TISSUE ADHESIVES: N-BUTYL CYANO ACRYLATE -EPOXY RESINS -POLY URETHANES 1. www.indiandentalacademy.com
  116. 116. Electro surgery cusel, cushing & bovie  1.medical diathermy: two electrodes are used  Heat is produced when current is passed through the tissues  Large electrodes-dispersive  Small electrode-active (heat is generated at the smaller electrode as the current is uneven) www.indiandentalacademy.com
  117. 117. Its effects:  1.dehydration  2.warming of the tissues  3.coagulation  5.tissue destruction www.indiandentalacademy.com
  118. 118. 2.Electrodessication (electrofuluguration):  Oscillations of the current used  When electrode is in contact with the tissue- desiccation occurs)  When away –sparkle causes superficial burn or carbonization www.indiandentalacademy.com
  119. 119. 3. ELECTROCOAGULATION:  Heat causes coagulation  Promotes coagulation &burns &seals the edges of the blood vessels 4. Electrocautery:  high current wire passes heat causes burn  Tissue effects: no significant difference between the scalpel www.indiandentalacademy.com
  120. 120. Techniques  1.The active electrode should passed through the tissues as quickly as possible in a brush stroke movement with no pressure  2.A continuous rapid movement is important because delay in one area will cause tissue burning  3.Allowing time between the strokes will allow heat to dissipate7produce less damage www.indiandentalacademy.com
  121. 121.  4.Active electrode should not come into contact with the periosteum or bone  5.When used as a coagulation device it is better to adjust ht machine at low current to avoid necrosis &slough  6.Electrode may be applied directly or indirectly (via a hemostat or forceps) to the bleeding tissue www.indiandentalacademy.com
  122. 122. Complications of electrocautery  Explosion of volatile anesthetic gases  Burns at sites remote from the surgery  Ignition of dry sponges in the mouth  Burning of the endotracheal tube  Ventricular fibrillation  electrocution www.indiandentalacademy.com
  123. 123. Cryosurgery  Involves application of cold to the tissue to freeze &destroy  Decrease of temperature causes necrosis in vascular &connective tissues  Less cellular –less susceptible to freezing www.indiandentalacademy.com
  124. 124. Factors effecting damage  1.rate  2. of cooling final temperature  3.time spent at the frozen site  4.rate of thawing  5. the medium it takes place www.indiandentalacademy.com
  125. 125. Effects of freezing  1.formation of extra cellular ice  2.concentration of extra cellular solutes  3.decrease in intracellular water  4.cell shrinkage  5.concentration of intracellular solutes  6.cell membrane damage  7.formation of intracellular ice www.indiandentalacademy.com
  126. 126. Clinical applications:  1.cancer growth  2.brain tumors  3.vascular anomalies including heamangiomas  4.caracts  5.premalignant lesions  6.mucous membrane tumors  7.intaosseous tumors  8.ameloblastoma 9.aneurysmal bone cyst. www.indiandentalacademy.com
  127. 127.  Cryosurgery  Most units: expensive –liquid nitrogen  Carbon dioxide ,nitrous oxide, Freon  For tissue necrosis:-20 for 4-5 min.-80 for 4-5 min (intramucosal)  Disadvantage:  no specimen for histological examination www.indiandentalacademy.com
  128. 128. Thank you www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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