2. DEFINITION
4 A
I A
• The ideal tooth extraction is -
The painless removal
root, with minimal trauma to the
the wound heals uneventfully &
prosthetic problem is created.
of the whole tooth, or
investing tissues, so that
no post-operative
4. The 1°dentist was an EGYPTIAN
- HESI RE (3100-2181BC)
The history of dental extraction forceps is very old and
goes back to the time of Aristotle (384 to 322 BC)
where Aristotle described the mechanics of oral surgery
forceps. This was over 100 years before Archimedes
studied and discussed the principles of the lever.
5. OraAnswers.com
The Martyrdom ofSt. Apollonia,
torturous extraction of teeth
shows the
Dental history arabic
dental
dentist
pulp
cauterizing
Curing a Toothache with FireThe German Traveling Dentist _
fumes from henbane seeds
7. ►until the 16th century, dedicated dentists did not exist and
dentistry 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 de
Chauliac and usuedntilthelate 18th century.
;::.;:c:::::::
9. 228 GEORGE TI E M
A NN 4 CO.8 SURGICAI. INS
T RUMENTS,
DENTAL.
Tooth orcepa.
F u 4 0 4
la in r ig ht .
e . 9 a .
l l € · r o d
•
G
oodwill' lMlp l
u
0
£
The instrument is a combination of the a
t
,.
#
.
attributes of the an extracting forceps
toothkey 1843 to 1863
and a t
E
,.
«
;,-
,. .•
.
a
~
3
..
~
U
'
-
In the 2oth century, the key was replaced
the forceps, which are still in use today
by
11. Allen 1994 caries in 48.8% cases abscess
1.
Periodontal diseases in 40.7% cases to prevent alveolar ridge
resorption
Tooth with necrosed pulp & periapical lesion not responding to
endodontic treatment
2.
3.
Over retained deciduous
Orthodontic purpose
Prosthetic purpose
Unrestorable tooth
Impacted tooth
Supernumerary tooth
tooth but take radiograph first
4.
5.
6.
7.
8.
9.
Grossly decayed 1M/2M make room for 3" molar
HOTZ&SMITH
Tooth in fracture line
Teeth directly involved by cyst & tumor
10.
11.
12.
12. 13. Teeth in the area of therapeutic irradiation
14. Teeth acting as foci of infection
ex. bacterial endocarditis
- rheumatic fever
RICHARDS (1932) bacteremia after infected tooth extraction
OKELL & ELLIOTT (1935) STREPTOCOCCUS VIRIDANS
blood stream (75% of 40 patient)
Use oflocal anesthetic solution (vasoconstrictor) - !
in
rate of spread of
infection
14. ►
It may be judicious to delay the extraction until certain
local or systemic condition corrected or modified.
►
In the era of antibiotics acute infection of odontogenic
origin are not considered as absolute contraindication of
immediate extraction.
►
NUG / HERPETIC GINGIVOSTOMATITIS -- spread of
infection & greater degree of systemic reaction.
►
Previously irradiated area (within 1 year) less trauma+
pre & post-op antibiotic prophylaxis
15. Other relative systemic contraindications -
>
►
►
►
Acute blood dyscrasias - acute leukemia , agranulocytosis,
Untreated coagulopathies - congenital or acquired
Adrenal insufficiencies
Within 6 months of myocardial infarction
16. CONTRAINDICATIONS :
A. Absolute: Central Haemangioma. May cause
A-V malformation.
uncontrolled bleeding.
8. 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-1yr].
•
19. THi
i E L - i
M
i
E
- E L
CH
d i i w
A
e i r
NIi
CAL
E H
P
i
i i i L - E L
Expansion of bony socket
specially for forcep extraction
sufficient tooth structure
elastic bone (children) e
multiple small fractures of buccal cortical bone
Use of a lever &fulcrum
remove the tooth/root along the path of least resistance
basic factor governing the use of elevators
RINCIPLES
E
20.
21.
22.
23.
24.
25.
26. THE MECHANICAL PRINCIPLES
2. The insertion of wedge or
wedges between tooth-root
& bony socket wall
z#tee
$
..
.'. ''
+
I[
27. Wheel & axle principle
3.
F
IGURE 7-41 T
riangular elevator in role of wheel-and-axle m
a ch
used to retrieve root from socket.
28.
29.
30.
31. Forces applied during
extraction of tooth
(
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A
I
t.,
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I
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I
I
E 7-42 Extraction forceps should be seated with strong apical
to expand crestal bone and to displace center of rotation
ly as possible
y
< (
34. ►Take history of-
1. general disease
2 . nervousness
3.
4.
resistance to inhalational anesthesia
previous difficulty with extraction
►Oral hygiene status of the patient
oral prophylaxis
antiseptic mouth rinse
►
►
Clinical examination of the tooth
Clinical examination of the oral cavity- any prosthesis
35. ►
PREOPERATIVE RADIOGRAPHS-
Indications
H/0 difficult & attempted extractions
Resistance to forcep extraction
Planning to remove the tooth by dissection
Close approximation with important anatomical structures Abnormal
root pattern - third molars, in standing premolars, misplaced canine Tooth having
periodontal problem & some sclerosis - hypercementosis Trauma to
tooth -fracture of tooth, roots & alveolar bone
Isolated & Unopposed maxillary molars
Partially erupted, unerupted tooth & retained roots
Delayed erupting or having abnormal crown
Condition indicating dental or dentoalveolar deformities -
osteitis deformans - hypercementosis
cleido-cranial dysosteosis - hooked root
therapeutic irradiation
]osteopetrosis
1.
11.
111.
iv.
36. General factors
LOCAL ANESTHESIA
GENERAL ANESTHESIA
•
•
•
•
30-45min.
No pre-op preparation
Respiratory tract disease
Cardiovascular diseases
•
•
5-10mm.
uncooperative patients
38. GENi
e
Ea
R.
A«
L Ai
Ri
RAi
NGEMi
Ea
N«
T
Position
-
-
-
-
-
-
of the operator -
Stand erect, equal distribution of weight
, Force delivery- w it h arm & shoulder not wit h
1.
on both feet
hand
application of force without stress to shoulders & back
generally on right hand side
for Right posteriors - back side
operating box
39. Position of the patient -
make the patient comfortable on dental chair
2.
Height Of Dental Chair -
maxillary teeth- 8 cm/ 3 inch below the shoulder level
of operator
mandibular teeth -16 cm/ 6 inch below the elbow of
operator
40. Angulation of the chair•
maxillary teeth -45-60 degree
4.
mandibular teeth - parallel or 10 degree
Light•
good illumination
s.
41. Role of opposite hand
A
c
$
6
6.
.2>7
-
"•D
-
►
►
►
►
Reflection of soft tissue
Protection of other teeth
Stablization of patient's head
7
£ F
Supporting & stablizing the mandible
Supports alveolar bone
Tactile information
Compress socket
Deliver the whole tooth, root, dislodged filling
42. Role of assistant
7.
►
►
Helps the surgeon to gain access & visualize the
Suction
Protect the teeth of opposite arch
Support the head
Support the mandible
field
Psychological & emotional support
43. PRINCIi
PLES
OF
T
,., OOT
_ 11
H
9' ,_, .R
,.._ E
. 1M
19'. ~
OV
- A
.... L
. . _
►
Clear access to & vision of the surgical field.
►Use of controlled force
►Unimpeded path of removal
45. What we doin extraction
of a tooth ????
►
Separation of tooth from alveolar bone
crestal & principal periodontal fibers.
with
►
Alveolar expansion
►
Bleeding is arrested by pressure pack.
49. 1. Forcep Technique
►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 orifice
so promotes healing
=
50. Basic principles for forcep technique
Beaks should seated as far apically as possible
1.
Beaks should be parallel to the long axis of tooth
2.
Excess force should be avoided.
3.
HOWTO HOLDTHE FORCEP
Thumb- just below the joint
Handle in palm
Little finger- inside the handle
A B
Fig. 39.-Correct grip of forceps. A, During application of the forceps to the tooth.
B, During the extraction of the tooth
51. ?
•
'
t
Fig. 34.-Sharpening forceps blades.
.
@
.
C
A 8
Fig. 35.- Cross-sections of root with forceps blades applied to it . A, Ideal f t.
B,'Two-point contact'. C, 'One-point contact'.
52. Adaptation of blade
►
►
►
Buccally & lingual parallel to long axis of tooth.
Forced through periodontal membrane, towards apex.
Firm pressure.
1 apply on less accessible side of tooth under direct vision
2""ly on other side
Cervical caries- 1 movement towards carious part
53. IT IS SAID THAT -
Time spent in careful application offorcep
bladesto the radicular portion
never wasted.
of tooth is
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54. Displacement of tooth from socket
►Pressure applied by the operator by moving his trunk
from hips not from elbow.
►Movements - linguobuccal & buccolingual
& controlled
loose
- firm, smooth
FRONT
- > > removal
rotatory/ figure of 8
BACK
55. ►Maxillary buccal bone is thinner- buccally removal of teeth
►Mandibular buccal bone till molar is thinner - buccally removal
teeth
of
►Mandibular buccal bone in molar region is thicker - lingually
removal of teeth
►Socket compression
►Avoid soft tissue laceration
57. Maxillary canine
►In multiple extraction cases canine should be extracted
prior to extraction of incisors, as prior extraction of
incisors weakens the labial cortex.
65. So use fine blades
Factors-
Permanent successors Warwickjames
1.
elevators can be used
Limited access
2.
..
.'.¢
.
.
.-
$
: '
,
Extraction of deciduous molar with forceps.
Forceps are positioned mesially or distally
on the crown and not the center of the tooth
66. 2. Elevator technique
► on lever &fulcrum principle
Works
►It forces the tooth/ root along the line of withdrawal R/G
►Fulcrum - bone or adjacent tooth
►Elevator grasping
67. ►Applicat ion -
in periodontal space
450 to long axis of tooth
Fig.56. Elevator correctly applicd
ur face f
to the
molar.
mesial mandibular
Placement of gauze between finger and
lingual side, for protection from injury in
case the elevator slips
69. Movement-
rotate the elevator along its long axis
FIGURE 7-51 Handle of sm all, stra ight eleva tor, turned so th at
occlusal side of elevator blade is tu rned to ward too th . The handle is
also moved apically to help elevate the tooth.
70. '•
d
'5j,
- $
d
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a
'';
s
_'
s
:
3
w
. . . . . z
st"; , i n 4 £ I
2 i· " " . s ,
------------
.. ' £ 3
7 ' ~ a
------------ b
a
a During luxation of a tooth, the
alveolar ridge is used as a fulcrum,
the adjacent tooth.
b Incorrect
placement of the instrument.
c
Photoelastic model showing
extraction of the third
mandibular molar using a
straight elevator. Using the adjacent
tooth ( second molar) as
not
I
a fulcrum creates great tension around
the tooth, with a risk
of injury to tissues surrounding the root
75. Extraction of Multi-Rooted Teeth
with Destroyed Crown
Roots of mandibular first molar.
Extract ion is accomplished by sect ioning
roots using a straight elevator
76. a
Positioning of the elevator and the fingers of the left hand for separation of molar roots
b
77. I
a
Using an elevator with T-shaped handles to remove intraradicular bone
·
r
,
·, 'i
'!,·
b
78. Extraction of Root Tips
b UV
Diagrammatic illustrations showing luxation of the root tip of the
mandibular second premolar, using
double-angled elevators
79. MESIAL ROOT OF A MANDIBULAR
MOLAR
a
b
Technique for removing the tip of a mesial
root of a mandibular molar. Removal of int raradicular bone
and luxation of the root tip using a double-angled elevator
81. REMOVAL OF ROOT TIP
7 G e·-"
6»
a '
b
Removal of the root tip using an endodontic
file. After the endodontic file enters the root canal, the root
tip is drawn upwards by hand (a), or with a needle holder (b)
82. AFTER CARE
►
►
►
►
►
►
►
Irrigation of the socket
Squeezing of the socket
Mout h rinsing wit h warm
Suturing if require
Moist gauze pack
Medication
bland water for once
Post extraction instructions -verbal & written
84. INDICATIONS•
Intra-alveolar attempt is failed
Ret ained root s in proxim it y wit h maxillary sinus & not accessible
to forcep
History of difficult or attempted extraction
Heavily restored tooth
Geminated / di lacerated tooth
1.
2.
3.
4.
5.
89. Deciduous mandibular molar, whose roots
embrace the crown of the succedaneous
premolar. Risk of concurrent luxation with
the simple extraction technique.
I
II
I
I
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I
I
I
I
I
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I
I
90. Main components of transalveolar extraction -
Design of mucoperiosteal flap
1.
Method to be used to deliver the tooth/ root from socket
2.
Bone removal used to facilitate tooth/ root removal
3.
91.
92. Design of
Base-broad
mucoperiosteal flap
A
Raise to render the operative
visible & accessible
site clearly
Suture should not be placed over blood clot
A
l Obliteration of buccal sulcus should be avoided a.a.a .
93. INCISION
Sharp scalpel
Firm pressure
Mucousa + periosteum
Avoid Button hole formation in case
►
►
►
of sinus
Incision of sufficient length at once
A
I
I
B Blood supply Blood supply
Blood supply
Area ol compromised bloo
d
upply as a result of a button
t ole' in fla p
96. Bone removal
►
►
►
►
To expose root/tooth
Facilitated by large flaps
Provides point of application
After tooth/root removal
prominences
- remove all sharp edges & bone
n
Instruments used -
a
97. dental burs
►
►
►
►
►
►
Round/ rose head provides - less clogging,
It doesn1
t cut the tooth that easily
Should not contact soft tissue
Avoid overheating
Postage stemp method
better control.
then join with chisel
t
•. • 8
Fig. 89.--The extraction by dissection of a mandibular frst perm""",',
the roots of which have conflicting lines of withdrawal. N.B. Granulom
to root apices in f. See textfor description.
98. TOOTH DIVISION
►
►
►
►
Different line of removal for different roots
Divide the root from furcation area
Make space for application of forcep / elevator
Osteotome / burs
99. REMOVAL OF TOOTH OR ROOT
►
►
Engage the elevator in a notch on side of root
450
If notch is not present then create it with round bur directed at
angle to the long axis of root.
~)
L ;:
e.
+ f
·:
.... ..
'+
.
pl a
te I
of a bu r te I
100. AFTER CARE
►Irrigat ion of t he socket
►
►
►
►
Suturing
Moist gauze pack
Medication
Post extraction instructions
Recall after z48 hours
-verbal & written
SUTURE REMOVAL
►
►
►
Normally 7 days
Within 2 days - if it was for control of hemorrhage
OAC repair-10 days
101. of maxillary molar
Removal
b
Steps in the surgical extraction of an intact
maxillary first molar. Reflection of the envelope flap,
sectioning of two buccal roots from the crown (a), removal
of the crown together with the palatal root, and then finally
removal of the mesial and distal roots (b)
102. hypercementosis at the root tip
b
An L-shaped incision is made and the flap is reflected.
The buccal plate covering the surface of the root is
removed, and the tooth is extracted using forceps
- - "
103. Hypercementosis at the
root tip
distal
I
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l
r s
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I I
I
I I
t
I /
7 l
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a, b. Surgical extraction of a mandibular
molar
with hypercementosis at the distal root tip.
The envelope
flap is reflected, part of the buccal plate is
removed, and the
tooth is sectioned buccolingually at the crown
as far as the
intraradicular bone
104. Extraction of the mesial portion of the tooth,
which includes the crown and root
Widening of the alveolus with a round bur, so
that removal of the root is possible without
fracturing the bulbous root tip
113. RUBBER BAND EXTRACTION
INDICATIONS-
Patient Under Coverage of BISPHOSPHONATE
1.
Hemophilic patients
2.
PROCEDURE-
Dentin bulge (arrows)
preventing elastics from sliding
apically.
nal treated and split mandibular molar during
on process. Note extrusion of mesial root.
114. Specific consideration for extraction
under general anesthesia
►Take careful history
►Take care of- airway, support ofmandible &
patient's head
position of
.
115. PREPARATION FOR ANESTHESIA
Accompanying person
No driving
6hrs of NPO
Emptying the bladder Loose
the tight clothing Patient
Comfortable in dental
Head slightly extended
1.
2.
3.
4.
5.
6. chair
7.
a.
9.
1o.
Mandible should be parallel to floor
Arm & leg position of patient
Waterproof apron
Hearing of patient's each breath
1 .
116. Preoperative consideration
Identify the tooth
All prosthesis are removed
All instruments should be keep ready
Larger the anesthesia-increase risk of anoxia &
aspiration
Ideal time-5-10 min.
1.
2.
3.
4.
s.
117. Modification of extraction
technique
Tooth priorities
1.
2. Avoid excess force to mandible
Soft tissue injury should be avoided
Postpone -remove pulp if it is exposed
Fractured root v/s resorbed root
3.
4.
5.
119. 5 Stages -
Hemorrhage & clot formation -1-2 days
1.
Organization of clot by granulation tissue - 3-7 days
2.
Replacement of granulation tissue by connective
tissue & epithilialization of wound - 4-35 days
3.
Replacement of connective tissue by coarse fibrillar
bone - 6-8 weeks
4.
Reconstruction of alveolar process & replacement of 2
5.
immature bone by mature bone tissue _
120.
121. Factors influencing the healing
Infection
Size of wound
Blood supply
1.
2.
3.
I
I
I
II
II
II
[l Resting
Foreign
General
of part
bodies
condition
4.
~..
' 5.
I
I
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I
of the patient
I
6.
'
I
II
I
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124. Powered periotome
Powertome® Assisted
Atraumatic Tooth Extraction
The Journal of Implant &Advanced
Clinical Dentistry
Jason White, Dan Holtzclaw, Nicholas Toscano
September 2oo9 Volume 1 , No. 6
125. Powered periotome
e m .
= M e
►
►
Precise extraction of tooth
Preserves bone & gingival architecture
Option for immediate implant placement
►
►
►
Mechanism of "WEDGINNG" & "SEVERING"
Severs the periodontal ligament
Multirooted teeth requires sectioning.
127. Physicsforceps
The Physics Forceps uses first-class level mechanics to atraumatically
extract a tooth from its socket.
►
►One handle of the device is connected to a "bumper," which acts as a
fulcrum during the extraction.
►Together the "beak and bumper" design acts as a simple first-class
lever.
►A squeezing motion should not used with these forceps. By contrast,
handles are actually rotated as one unit using a steady yet gentle
rotational force with wrist movement only.
the
►Once the tooth is loosened, it may be removed with traditional
instruments such as a conventional forceps
128. GMX-1 00A - Upper Anterior - Extracts Teeth 6 to 11
GMX-1 00R - Upper Right - Extracts Teeth 2 to 5
GMX-200 -
Lower Universal -
Extracts Teeth 18
to 31
GMX-l00L - Upper Left -
Extracts Teeth 12 to 15
130. FAILURE TO ACHIEVE ANESTHESIA/ TOOTH
REMOVAL
1.
FRACTURE OF TOOTH/ SURROUNDING
DISLOCATION
DISPLACEMENT OF TOOTH / ROOT
EXCESSIVE HEMORRHAGE
DAMAGE TO HARD & SOFT TISSUES
POSTOPRATIVE PAIN
POSTOPERATIVE SWELLING
TRISMUS
OROANTRAL COMMUNICATION
SYNCOPE
RESPIRATORY ARREST
STRUCTURES
2.
3.
4.
s.
6.
7.
8.
9.
10.
11.
12.
CARDIAC ARREST
13.
14. ANESTHETIC
--
E
-
M
-•
ERGENCIES
I
a
131. FAILURE TO ACHIEVE ANESTHESIA/
TOOTH REMOVAL
Faulty technique
Inadequate solution
Test the efficacy of anesthesia
Tooth could not be removed with
trans- alveolar procedure.
intra-alveolar or
132. FRACTURE OF TOOTH
Crown / root
►
►
►
►
►
►
►
►
Grossly carious
Tooth with Endodontic treatment
Improper application
One point contact
Slip off of forcep
Excessive force
Hurry
Tooth with divergent
Of forcep
roots /hypercementosis
Then trans-alveolar method is indicated
133. Remove all the root fragments except
1. 5 mm & requires excessive bone removal -
(Simpson 1958)
well tolerated.
2. Apical 1/3 rd of palatal root of maxillary molars &
requires excessive bone removal
If removal is indicated inform the patient
radiograph
134. FRACTURE
Causes-
OF ALVEOLAR BONE
►
►
►
Excessive inclusion of bone within the forcep
Extraction of incisors before canine
Intact versus torn periosteum
beaks
FRACTURE OF MAXILLARYTUBEROSITY
Generally during extraction of maxillary 3" molars
Pneumatization of maxillary air cells
Gemination
►
►
135. Management-
►
►
►
►
►
Preoperative radiograph is essential
Raise the mucoperiosteal flap
Separate the tooth & bone from gingiva
Mattress Suture
10 days
►
i.
If tuberosity is excessively mobile
Splint the tooth for 6-8 weeks
Sectioning the crown & pulpectomy.
ii.
136. FRACTURE OF ADJACENT TEETH
►
►
►
Heavily restored adjacent teeth -in the
withdrawal
Abutment teeth
When used as fulcrum
line of
FRACTURE OF OPPOSITE TEETH
►
►
►
Uncontrolled force
Under general anesthesia-
intubation
gauge & props
137. FRACTURE OF MANDIBLE
Causes-
►
►
►
Excessive / incorrectly applied force
Pathologic fracture
Senile osteoporosis
management
Precautions
►
►
Inform the patient
Reduce the fractured
►
►
►
Peroperative radiograph
Splint febrication
Exraoral support
segment
138. DISLOCATION OF ADJACENT TOOTH
►
►
►
When used as fulcrum
Improper use of elevators
Give support to adjacent tooth from other hand
Management
►
Place the tooth in socket & splint it
139. DISLOCATION OF
TEMPOROMANDIBULAR JOINT
Causes-
►
►
►
Excessive / incorrectly applied
Improper use of mouth gauge
Senile osteoporosis
force
Management
►Reduce it immediately
►Reduction technique
►Instructions to patient
Precautions
►
►
Take history
Exraoral support beneath
mandible
the angle of
140. DISPLACEMENT OF ROOT INTO
MAXILLARY SINUS
Causes-
►Abnormal root curvature
►Carious root
►
►
►
Roots of premolars & molars involved by sinus
Excessive / incorrectly applied force
Inadequate grasping of tooth
Precautions •
►Take past dental history
►
>
►
►
Apply the forcep on sufficient tooth structure
Leave uninfected apical 1/3of root
Never force the root towards sinus
Transalveolar method
141. OROANTRAL COMMUNICATION
Causes -
►
►
Maxillary posterior teeth
Involvement of sinus lining by Periapical pathology
Diagnosis
►
►
►
Increased intra nasal pressure - air coming out from
mouth can be heard
Amount of blood will be doubled
Wisp of cotton wool will be deflected
142. Management -
►
Mucoperiosteal flap rising
►
►
►
►
Decrease alveolar height
Interrupted horizontal suture
Protect the clot with acrylic, denture
material
Give incision in sinus membrane
base, impression
Precautions -
►
Mouth rinsing with antiseptic solution before closure of
oroantral communication
Passage of instruments from mouth to
avoided.
► sinus should be
143. Diagnosis •
►
►
►
Air bubbles from socket
Cotton wool deflection
Fluid taken from oral cavity >
>nose
Management
►Take radiograph .
►Blow the air through nose
►Under general anesthesia - stop the general anesthesia
i
wait till regaining the cough reflex
►Suction + irrigation
½ inch wide iodoform gauze
Sometimes incision in sinus membrane
Caldwell-Luc approach
144. DISPLACEMENT OF ROOT INTO
INFRATEMPORALFOSSA
►
Mostly maxillary third molars
Management
►
►
►
►
Extend the incision posteriorly
Blunt dissection
Grasp the tooth carefully
Or wait for several weeks until
encapsulated.
it becomes somewhat
145. DISPLACEMENT OF ROOT INTO
SUBMANDIBULAR SPACE
Reflect the soft tissue flap on lingual aspect of mandible
forward to the premolars
!
as
gently dissect the mucoperiosteum
Detach the mylohyoid muscle.
146. DISPLACEMENT
PHARYNGEAL
OF ROOT INTO
SPACE
If the root is not appearing in the oral cavity/pressure pack
►
►
►
►
►
Ask the patient to cough & spit
Tum the patient towards the operator & position with
mouth 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.
the
147. EXCESSIVE HEMORRHAGE
Perioperative hemorrhage
►
Oozing of blood
Management
during operation
►
Wipe
►
Sucker
Hot 50 degree
Hemostate
► celcius for 2 min.
►
►
Local anesthetic solution having
Gelatine sponge
oxidized cellulose
vasoconstrictor
►
►
►
After tooth removal - moist pressure pack for 1 0min.
+
horizontal mattress suture
148. Postoperative hemorrhage
►
1.
Instructions to the patients
Pressure pack
•
Less talk for
Tea bag
No smoking
No staneous
2-3 hrs.
2.
3.
for 12 hours
exercise
4.
5.
►
►
►
►
Psychological approach
Determine site & amount of hemorrhage
Remove excess blood clot
Provide firm gauze pack with tannic acid
149.
150. Horizontal mattress suture into mucoperiosteum
l
Wait for 5 minutes after placing gauze pressure on suture
Gelatin / fibrin foam
&
All post extraction instructions and avoid frequent aggressive
mouth rinsing
151.
152.
153.
154.
155.
156. DAMAGE TO SOFT TISSUES
Gingiva
Lower lip mechanical & thermal injury
Tongue & floor of mouth
157. Injury to the inferior alveolar nerve
Causes-
►
►
Compression with clot or bone debris
Partially or completely tom
Precautions •
►
►
►
Preoperative radiograph
Elevator should not be forced below tooth
Resect 1 root before tooth elevation
Management
►Reposition the ends at close
approximation
►Decompression
►Microsurgical reanastomosis
►Nerve grafting
158. Injury to the mental nerve
Causes-
►
Transalveolar extraction of premolars
Precautions -
More Bone reduction mesial to I° premolar
to 2"" premolar
& distal
►
Retraction of nerve with mental retractor
159. Injury due to breakage ofinstrument
►
►
Burs
Management- drilling the groove around it.
161. WOUND DEHISCENCE
Cause-
►
►
Suture without adequate bony foundation
Suturing the wound under tension
Mostly in the region of mandibular 20 & 3" molar
(internal oblique ridge)
Management
►
►
Leave the projection - slough out within 2-4 weeks
Smooth it with bone file under local anesthesia.
162. POSTOPRATIVE PAIN
Due to traumatized hard tissue -
Bruising from bone during intrumentation
Excessive heating from bur
Sharp bony edges
Avoidance of tissue toileting
1.
•
•
•
Due to traumatized soft tissue -
Incision only through mucous membrane
ragged flap - heals slowly
Too small flap much traumatic retraction
Injury from bur.
2.
•
•
164. Definition -
Postoperative pain in and around the extraction site, which
. .
Increases in
severity at any time between 1 and 3 days after the
extraction
accompanied by a partially or totally disintegrated blood
within
the alveolar socket with or without halitosis.
clot
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.
International Association of Oral and Maxillofacial Surgeons
2002
I
I
I
I
I
I
I
I
I
I
I
I
165. ONSET AND DURATION
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-plasm in that must be
consumed by plasm in before clot disintegration can take place.
►The duration of alveolar osteitis varies to some degree, depending on
the severity of the disease, but it usually ranges from 5-10 day5.
166. SIGN & SYMPTOMS
The denuded alveolar bare bone may be painful and tender.
1.
Initially blood clot appears dirty gray ) disintegrates
!
grayish yellow bony socket bare of granulation tissue
Some pat ient s may also complain of int ense cont inuous pain
irradiat ing to the ipsilat eral ear, temporal region or the eye.
2.
Regional lymphadenopathy (occasionally).
3.
unpleasant taste (occasionally).
4.
Trismus is a rare occurrence in mandibular third molar extractions
probably due to lengthy and traumatic surgery.
5.
167. ETIOLOGY
►Multifactorial origin
►Following have been implicated most commonly as etiological,
aggravating and precipitating factors:
Oral micro-organisms - Treponema denticola
Difficulty and trauma during surgery
Roots or bone fragments remaining in the wound
Excessive irrigation or curettage of the alveolus after extraction
Physical dislodgement of the clot
Local blood perfusion & anesthesia
Oral contraceptives - estrogens, like pyrogens will activate the
fibrinolytic system indirectly.
Smoking
1.
2.
3.
4.
s.
6.
7.
8.
168. RISK FACTORS
Previous experience.
1
.
Deeply impacted mandibular third molar (risk factor is direct ly
proportional to increasing severity of impact ion) .
2.
Poor oral hygiene of patient.
3.
Active or recent history of acute ulcerative gingivitis or pericoronitis
4.
Associated with the tooth to be extracted .
5.
Smoking (especially >2o cigarettes per day).
6.
Use of oral contraceptives .
7.
Immunocompromised individuals.
8.
169. ►BlRN pathogenesis of fibrinolytic alveolitis ('dry socket'). Int J Oral
Surg 1973: 2: 215-263.)
(BIRNH. Etiology and
I
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Il
II
II
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~
',
,
II
',
e i e a se o f
tissue
activators
o> e» o
ra ma and+or
c
inflammation
of bone rnarrow
inte. tion
I
I
',
Converted
to
'I
'
I
I
I
I
I
I
I
I
I
I Lysis of fibrin
I
I
I
I
I
Formation of kinins
I
0
0
o p
D o
.
Dis s olu ti on o f
blood clot
Pain
170. PROPHYLACTIC
MANAGEMENT
References in the literature correlating to the
prevention of alveolar osteitis can be divided
into
Non-pharmacological and
1.
Pharmacological preventive measures.
2.
171. Non-pharmacological
measures
Use of good quality current preoperative radiographs
1.
Careful planning of the surgery
2.
Use of good surgical principles
3.
Extractions should be performed
trauma and maximum amount of
with minimum amount
care
of
4.
Confirm presence of blood clot subsequent to extraction
(if absent, scrape alveolar walls gently)
5.
172. Wherever possible preoperative oral
measures to reduce plaque levels to
should be instituted
hygiene
a minimum
6.
Encourage the patient (again) to stop or
in the immediate postoperative period .
limit smoking
7.
Advise patient to avoid vigorous mouth rinsing for the
first 24 h post extraction and to use gentle
toothbrushing in the immediate postoperative period .
8.
For patients taking oral contraceptives extractions
should ideally be performed during days 23 through
28 of the menstrual cycle .
9.
10. Comprehensive pre- and postoperative verbal
instructions should be supplemented with written
advice to ensure maximum compliance .
173. PHARMACOLOGICAL MEASURES-
Antibacterial agents -
Antiseptic agents and lavage Chlorhexidine (CHX)
Ant ifibrinolyt ic agent s - para-h
y droxybenzoic acid (PHBA),
Steroid anti-inflammatory agents - polylactic acid (PLA)
Obtundent dressings
Clot supporting agents
1.
2.
3.
4.
5.
6.
174. NON-DRESSING INTERVENTIONS
TO MANAGE ALVEOLAR OSTEITIS
Remove any sutures to allow adequate exposure of the extraction site. As
the socket may be exquisitely tender local anaesthesia may be required.
1.
Irrigate the socket gently with warm sterile isotonic saline or local
anaesthetic
solution, which is followed by careful suctioning of all excess irrigation
solution.
2.
Do not attempt to curette the socket, as this will increase the level of pain.
3.
Prescription of potent oral analgesics.
4.
The patient is given a plastic syringe with a curved tip for home irrigation
with chlorhexidine solution or saline and instructed to keep the socket clean.
5.
Once the socket no longer collects any debris, home irrigation can be
discontinued.
6.
175. SURGICAL MANAGEMENT OF
"DRY SOCKET" S.C.Anand, V. Singh, M. Goel, A. Verma, B. Rai: DrySocketAnApriasal
And Surgical Management. The Internet JournalofDental Science.
2006 Volume 4 Number 1. DOE: 10.5580/e31
►
►
►
►
Under block anesthesia
The clot devoided socket is thoroughly curetted, both from
floor 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
►
►
►
The detached gingival margins were also scraped.
The desired medications as well as precautions.
Patient was not only without pain, but was also comfortable
physically as well as psychologically from the very next day.
both
176. POSTOPERATIVE SWELLING
►
Normal oedema Management
►
►
After multiple teeth extraction
surgical tooth extraction
Ice pack application
Heat application
►
Traumatic oedema
Blunt instrumentation
Excessive extraction of badly
Too tight suture
designed flap
177. Subcutaneous emphysema -
►
►
►
►
Air into connective tissue of intramuscular
spaces
Swelling is of sudden onset.
Crackles can be felt under finger
Resolves within 1-2 days
& fascial
Due to infection of wound -
►
►
►
Preoperative antibiotic
Prevention of entry of micro-organism into wound
Mild infection intraoral hot saline mouth wash
178. TRISMUS
►
It is defined as inability
spasm.
to open the mouth due to muscle
Causes
►
►
►
►
►
►
Post operative oedema
Hematoma formation
Inflammation of soft tissue
After mandibular block
Traumatic arthritis of TMJ
Multiple injections
180. SYNCOPE
►
Transient loss of consciousness and postural tone
characterized by rapid onset, short duration, and spontaneous
recovery due to global cerebral hypoperfusion that
results from hypotension.
most often
Sign & symptoms dizziness,
pale & sweating.
weakness, nausea skin is cold,
Management
►
►
►
Position
Oxygen administration
Blood pressure & pulse measurement
250 mg aminophylline is given slowly.
181. RESPIRATORY ARREST
►
►
Skeletal muscle become
pupil dilate widely
flaccid
management -
►
Patient flat on the floor
►
►
►
►
►
►
Clean the airway
Pull the mandible forward
Extend the neck fully
Pulmonary resuscitation so
3-4 sec.
that chest is seen to rise every
Brook airway can be inserted over tongue
Check carotid pulse & apex beats at regular intervals
182. CARDIAC ARREST
Sign & symptoms
►
►
►
►
Deathly pallor & grayness of skin
Cold sweat
Pulse & apex beat can be felt
Heart sounds can not be audible
Children -
►Beginning of heartbeat if the sternum is tapped sharply
Adult-
Patient flat on the floor
Cardiac compression at 1 second interval
183. ANESTHETIC EMERGENCIES
arrest & cardiac arrest complicate
►Syncope, respiratory
general anesthesia.
the
►
1.
Management
Clear the airway
Remove all the packs, debris & apparatus from
Pull the mandible forward
Extend the neck
Head downward /forward in dental chair
- upward if lying on the floor
Oxygen
Larygotomy
Tracheostomy
mouth.
ii.
iii.
iv.
V.
Vl.
vii.
...
V .
lll
