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Page 1: Exodonia
Page 2: Exodonia

DEFINATION

The branch of Dentistry which deals with the surgical treatment of tooth and surrounding area or in other words the extraction of teeth is called exodontia.

Page 3: Exodonia

Exodontia

• Uncomplicated --- simple or forcep tooth extraction.

• Complicated --- surgical extraction, flap raising and bone removal or tooth sectioning is required.

• Modified --- whether simple or complicated extraction, some systemic condition require modification, pre; during or intra operative.

Page 4: Exodonia

Technique

• A care full technique – based on knowledge & Skill.

• Living tissues should be dealt gently.

• Other wise damage & necrosis can occur which lead to bacterial growth & retardation of healing, thus causing postoperative complications like pain, swelling & possibly deformity.

Page 5: Exodonia

Before going for extraction1

• You should know this is the only branch of dentistry where the bleeding is experienced by the patient.

• Access to the teeth and other oral structures becomes difficult by lips & cheeks & further complicated by the movements of tongue & mandible.

• Oral cavity communicate with pharynx & larynx & is full of saliva which also makes operation difficult.

• It also lies close to vital centers.

Page 6: Exodonia

Pre surgical Medical Assessment

History taking

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Biographic Data

• Name.

• Address.

• Gender.

• Occupation.

• Mental status

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Chief complaint

– Pain– onset etc.– Fever etc

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Medical Hx.

– Present– Past

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Examination

• > Focus on oral cavity.

• < Focus on Maxillofacial region.

• << GPE

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Fear of pain & Anxiety

• Verbal.

• LA

• GA

• Sedation.

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Three main indications

• Pain– Dialometry

» Labor 10 dm, rheumatic/ G surgery 4dm dental 2dm» Pain up to thalamus non narcotic beyond up to

cerebral cortex narcotic» Dental pain can be relieved by LA but short duration

unless open pulp or extraction

• Infection» Peri coronitis / dentoalveolar abscess

• Functionless tooth» Malposed» Lower 3rd molar ext upper supra occ» Solitary maxillary last molar – for F/D

Page 14: Exodonia

INDCATIONS FOR EXTRACTION

1. Hopelessly carious tooth.

2. Teeth with non vital pulps.

3. Periodontitis or periodontosis where 2/3rd of bone is lost.

4. Acute or chronic pulpitis where endodontic treatment is not indicated.

5. Mal posed teeth which can not be treated by orthodontic treatment.

Page 15: Exodonia

6. Any tooth that lies in field of radiations for some oral malignant lesions.

7. Supernumerary teeth.

8. Any tooth which lies in the line of #.

9. Non functional tooth or any tooth lying alone in oral cavity.

10.Broken down roots or fragments.

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11.Teeth traumatizing soft tissues.

12.Retained primary teeth, when permanent teeth are present.

13.Teeth not restorable by operative dentistry.

14. Impacted teeth.

15.Teeth associated with any cyst or tumour.

Page 17: Exodonia

16.Teeth which can not be saved by apiceotomy.

17.Teeth mechanically interfering with placement of restorative appliances.

18.Foci of infection.

19.Prosthetic purposes.

20.Obscure pain.

21. Infection --- pericoronitis.

Page 18: Exodonia

22.Over erupted teeth.

23.Socioeconomic factors

24.Esthetics.(severely malposed/stained).

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Contra indications for the extractions of teeth

A. Local contraindications.

B. Systemic contraindications.

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Local contraindications

1. Acute inflammation.1. Gingivitis e.g. fusospirochetal or

streptococcal infection.

2. Stomatitis.

2. Acute peri coronal infection -- 3rd molars.

3. Acute alveolar abscess.(3 Reasons)

4. Maxillary sinusitis. (OAF)

5. Tooth lying in area of alveolar nerve.

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6. During therapeutic radiations.

7. Tooth lying in the area of malignant tumors and suspected haemangioma of jaw.

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Systemic contraindication for tooth extractions

Page 23: Exodonia

Patients on steroid therapy

• Cortisone is a life saving drug. It acts as a shock absorber.

• Patients on steroid therapy have a suppression of secretions of their own & resultant adrenal cortical atrophy.

• The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction.

Page 24: Exodonia

• If the patient is under going oral surgery or extraction under GA,– 50-100 mg orally 2 Hrs preoperatively.– 100mg + 500cc of 5% Dextrose during

operation.– 50mg 12 Hrs orally or 100mg I/M.

Page 25: Exodonia

Diabetes Mellitus

• Under production of insulin.

• A resistance of insulin receptors.

• Or both.It is of two types;– Insulin dependent.– Non-insulin dependent

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Diabetes Mellitus

• Characterized by hyperglycemia due absolute or relative deficiency of insulin.– Symptoms:

• Polyuria.• Increased thrust.• Excessive appetite.

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• Loss of weight.• Skin disturbances.• Vision disorders.• Numbness & tingling.• Glucosuria.• Pain especially in lower limbs.

• Diabetic patients are more prone to infections because;

• Increased sugar in blood.• Arteriosclerosis which decreases peripheral

Page 28: Exodonia

circulation• General resistance of patient is low – immunity.• Bacterial growth is favorable as increased blood

sugar level act as a good medium for their growth.

Page 29: Exodonia

Precautions for diabetic patients

3 steps

• Patient at home before surgery:– Put patient on broad spectrum antibiotics 24

Hrs before surgery;• Amoxicillin 500 mg• Erythromycin 250/500mg TDS & BD respectively.• Doxycyucllin (vibramycin) 200mg stat, 100mg

daily.• Oxytetracycllin 250mg 6 Hrly.

Page 30: Exodonia

– Put the patients on sedatives;• Diazepam 4-10mg or• Phenobarbitone 30 – 60 mg ½ or .5 G=30mg.or

0.5 – 1 G.

24 Hrs before operation, which relieve anxiety because anxiety increases adrenaline level which in turn increase blood sugar level.

• Patient in clinic or surgery:– Early morning appointment, break fast +

insulin.

Page 31: Exodonia

– Fresh blood sugar level – fasting at the day of surgery.

– Calm & sympathetic attitude from you.– Local anaesthesia should be plain i.e. with out

adrenaline because;• Increases B. Sugar level.• Vasoconstriction – gangrene.• Not remain there for a longer time.

– Short appointment.– Recent – HBA1C – 60 days picture of diabetic pt

Page 32: Exodonia

Various school of thoughts about LA with or without adrenaline

• Adrenaline should be given, as bleeding is severe in such patients.

• Should not be given because it increase sugar level.

• Use it because adrenaline which is given is less than secreted by patients ( endogenous).

• Broadly speaking Adrenaline should not be given because such patient are very sensitive it & plain LA should be used.

Page 33: Exodonia

Important points

• Anaesthesia should be complete – Ext with out pain.

• Antiseptic m/wash before ext• There should be complete sterilization.• . Procedure should be atraumatic• Ext one tooth at a time.• . Procedure should not be more than 15 mins.• After ext pt should remain under observation for

at least 30 min& should have adult attendant.

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• Patient at home after extraction:– Antibiotic for 1 week duration.

• In case of emergency at chair:– Pt has taken break fast but no insulin;

• Hyperglycemic Coma– Signs:-

» Pt is ill looking before extraction.» Vomiting & abdominal pain.» Tongue & skin dry.» Low BP, Low pulse volume but rapid.

Page 35: Exodonia

» Flexer planter response.» High glucosuria.

• Rx: Inj. Insulin

• Hypoglycemic coma (More Common);– Pt has not taken his break fast but has taken insulin or

has done unnecessary exercise.

• Signs:-» Pt is healthy looking before ext.» Not vomiting & abdominal pain.» Tongue & skin moist.» B.P Normal.

Page 36: Exodonia

» Extensor planter responses.» Low glucosuria

• Rx. 5% Dextrose ampoule (2-4mm IV), if recovers give sugar.

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Pregnancy

• Pregnancy is a physiological phenomenon, but care has to be taken while dealing such pt.

• One school of thought that care should be extended to prophylaxis and restorations and surgery be deferred till birth of the baby, because;

• Abortion.• Premature labor.

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• Actual physiological damage to the child.

• On these basis Rx of a pregnant women is divided in to 3 classes.

1. Emergency Treatment.1. Severe pain e.g. pulpitis

2. Non Emergency treatment but essential Rx.

1. Chronic periapical abscess. Postpone Rx to

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2nd trimester.

2. Elective Rx. e.g. BDRs postpone till delivery.

Precautions for a pregnant women.

Be very care full because of altered physiology.

1. LA more Safe.• Comfortably seated, to avoid vomiting.

Page 40: Exodonia

• No x-ray. If emergency Lead cover.• Certain sympathomimetic drugs (vasoconstrictors)

can diminish uterine blood flow, so as minimum as possible.

• GA better done in middle trimester• Volatile anaesthetic like halothane should be

avoided as it crosses placenta & death of baby.

• N2O2 & O2 mixture can be used.

• Short acting barbiturate like pentothane I/V .• Analgesics .

Page 41: Exodonia

• Consult obstritician• Oxygenation –avoid hypoxia.• Antibiotics (like tetracycline group should be

avoided).

Page 42: Exodonia

Bleeding Disorders

1. Platelet Inadequacy

2. Coagulopathies

3. Therapeutic anticoagulation

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Haemophilia

• Congenital bleeding disorder due lack of coagulation factor VIII & IX designated as Haemophilia A & B respectively.

• CT is increased ( Normal CT= 2-5min)

• Males are sufferers & females are carriers.

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Precautions

• LA is absolutely contra indicated because of continuous bleeding and haemotoma formation.

• GA is preferred & pt is hospitalized.• Fresh blood, Plasma, Fresh frozen plasma or

cryoprecipitate (deficient factors).• Anti hemophilic globulin (AHG) i.e. fraction I 400

mg in 20cc of normal saline I/V with in ½ hour, the CT is reduced to normal.

• AHG level should be 20 % above normal or normal level

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• Factor VIII should be build up to 50-70 %• Mask anaesthesia to reduced the risk of

pricking in OT & avoid endotracheal intubation because of danger of bleeding.

• A traumatic procedures are carried out & no stitching.

• After extraction one should pack the socket with gauze or with spongostan cubes 12 Hrs afterwards.

• If bleeding occurs after 4-5 hours fraction I can be given & when clot is settled no more fraction I or other maintenance is required.

Page 46: Exodonia

Patient on anticoagulants

• Patients on anticoagulant therapy face two problems;– Profuse bleeding after surgery.– Thromboembolic accident.

• We should stop anticoagulant therapy un till PT is in normal limits;

• Adjust the dose to bring PT OR INR in normal limits.

Page 47: Exodonia

• ASPIRIN & OTHER PLATELET- INHIBITING DRUGS

• Consult physician.• Defer surgery & stop platelet inhibiting drug for 5 days.• Extra measure to control clot formation & retention.• Restart drug on the day after surgery.

• WARFARIN (Coumadin)• With physician consultation PT should brought to 1.5

INR for few days.• If PT is between 1-1.5 INR proceed surgery.

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• If not, stop the drug 2days prior surgery.• Check PT daily.• When normal do surgery & restart this drug on the day

of surgery.• If in physician opinion is that it is unsafe for the pt to

stop this drug the admit pt with his consent stop warfarin give Heparin during peri operative period.

• HEPARIN• Consult physician.• Stop it 6 Hrs prior to surgery or reverse with protamine.• Restart drug when a good clot is formed

Page 49: Exodonia

Epilepsy

Precautions must be taken when treating an epileptic pt, because attack can occur in the dental chair.

1. Pt must have taken medicine early before coming for Rx, i.e. phenbarbitone 30-60mg or carbamezapine 200mm ½ or 1 Hr before surgery.

2. Instruments must be away from the pt.

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3. Before examination one should place mouth gag or prop in the patients mouth & remove when the procedure is completed.

4. If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) I/V can be given to control convulsion.

5. When attack occurs, it must be differentiated from an anaphylactoid shock or syncopy where patient warns you that he or she does not feel well & is pale and sweaty while in case of epileptic shock pt does not warn you.

6. Convulsions in case of epilepsy.

Page 51: Exodonia

Angina pectoris

• This disease occurs due obstruction of coronary blood supply to the myocardium of heart.

• This due to narrowing of one or both coronary artery leading to increased demand of oxygen.

• This further increases in stress.• Sign & symptoms are sub sternal pain with

dyspnea, radiating to the left arm & lower jaw.• Following precautions are required while dealing

such pt;

Page 52: Exodonia

• Sedation.• Nitroglycerin tablet sublingually when pt sits in

the dental chair prophylactically.• Anaesthesia should be plain (Controversial).• If pt feels uncomfortable during operation,

another tab should be given.• After extraction pt should stay in the clinic for ½

an hour & then sent with an adult fellow.

Page 53: Exodonia

Rheumatic Heart Disease

• Pt with a history of rheumatic fever, or rheumatic or congenital valvular heart disease or synthetic vascular graft or prosthesis or a cardiac pacemaker implanted require special care.

• Colonies of circulating organisms may settle on scared endothelium to form vegetations ,the condition SABE.

• This disease has high mortality or morbidity.• Bacteraemia must be avoided in such pts.

Page 54: Exodonia

• Management– Oral hygiene – brought to normal or near

normal e.g. Povidide M/W.– Antibiotic cover– ORAL

– Amoxycillin 3G 1 Hr before ant dental treatment in front of dental surgeon. Post treatment 250 or 500mg 6 Hrly for 72 hours.

– If sensitive to penicillin then, 1.5G Erythromycin 1 Hr before Rx & 250/500mg tds or bd respectively for 72 hrs.

Page 55: Exodonia

– PARENTERAL – When maximum protection required or If pt can not take

orally or under GA» Ampicillin 2G I/V or I/M plus Gentamycin 1.5 mg/kg

I/v or I/M ( not exceeding 80mg) followed by 1.5 oral amoxicillin 6Hrly – where maximum protection is required. ( prosthetic Valves).

» Ampicillin 2G I/V or IM 30 min before procedure, 1G Ampicillin IV or IM or 1.5 G orally 6 Hrly after initial dose.

» Vancomycin 1G I/V administered over one Hr before surgery. No repeat dose.

Page 56: Exodonia

– PEDIATRIC DOSES– Half the adult dose or Ampicillin50mg/kg or erythromycin

20mg/Kg ½ - 1 hr before Rx then 10mg/kg 6 Hrly.

• In running disease pt should be treated while hospitalized.

Page 57: Exodonia

Thyrotoxicosis

• This is the result of hyperthyroidism due to thyroid disease disease like a multi nodular goiter, a thyroid adenoma or Grave’s disease.

• There is excess circulating triiodothyronine (T3) & Thyronine (T4).

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• The only absolute contraindication for extraction.

• Extraction can cause crises.

SYMPTOMS:– Nervousness, tremors, emotional instability.– Tachycardia & palpitation.– Excessive perspiration.– Diffuse enlargement of thyroid gland.

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– Exopthalmos.– Loss of weight.– Elevation of BMR.– Easy fatigue.– Muscle weakness.– GIT symptoms like diarrhea & at times nausea

& vomiting.– Pressure symptoms in some instances such

as dyspnea, dysphagia etc.

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EFFECTS:– Thyroid crisis can be precipitated by oral

surgery.– Pt with thyroid crisis is restless,

semiconscious, uncontrollable even with heavy sedation

– Cyanotic & at times delirious & an extremely rapid thready pulse & a high temperature.

So ext is absolutely contraindicated because

Page 61: Exodonia

The trauma can precipitate thyroid crisis with cardiac embarrassment & heart failure. We can not control them. Refer pt for Rx before under going any surgical procedure.

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Nephritis

SYMPTOMS:– Reduced urinary output or dysurea,– Hematuria.– Fever.– Albuminuria– Chills.– Xerostomia & burning in the mouth.– Generalized Stomatitis.– Urinous ordour in pts breath.

Page 63: Exodonia

EFFECTS:Extraction of chronically infected tooth may

precipitate acute nephritis or extraction in a dirty mouth lead to nephritis.

These pt must first put on antibiotics.

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Jaundice

• There is impaired liver function due to alcohol abuse, infectious disease or billiary obstruction.

• The production of Vitamin K dependent coagulation factors (II,VII,IX & X) may lead to prolonged bleeding.

• Check PT & INR or PPT.

• Prophylactic doses of Vit K & transamine.

Page 65: Exodonia

• PRECAUTION & Rx.– Tab anaroxyl or Azeptil is given.– Don’t describe any drug that is excreted &

metabolized by liver such as paracetamol.– Antibiotics are given.– Such pts are usually virally infected like

Hepatitis A,B,C &D. so, self and cross contamination be avoided.

Page 66: Exodonia

Hypertensive Patient

• Essential hypertension.

• Mild to moderate hypertension (systolic PB <200 & Diastolic PB < 110 usually not a problem.– Care;

• Anxiety reduction protocol & monitoring of vital signs.

• LA with epinephrine given carefully.• After surgery pt advise to seek medical care.

Page 67: Exodonia

• Severe hypertension (systolic PB > 200 or more or diastolic PB > 110 or more.

• Should be postponed until PB is well controlled.• Refer pt or emergency dental TT carried out in well

controlled environment in a hospital.

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Page 69: Exodonia

Local

• 99% teeth are extracted under LA.• Infiltration Anaesthesia• Inferior dental block

Page 70: Exodonia

How to minimize pain while giving LA

• 4% surface anaesthesia is given

• Needle must be sharp

• Solution must be isotonic

• Deposition should be slow

( inj directly into blood vessel increases the toxicity by 16 times)

Page 71: Exodonia

Causes of anaesthesia failure

• Defect in operator

• Defect in patient

• Defect in LA

Page 72: Exodonia

Defect in operator

• 99.9% due to wrong technique.

• Cartridge is leaked.

• Needle is not accurately inserted.

Page 73: Exodonia

Defect in patient

• Infection;– There is increased vascularization so immediate

absorption occur & there is no time for LA to work– Medium is acidic but we require alkaline medium for

LA

• Addiction

• Extra innervation – VV rare

Page 74: Exodonia

Defect in LA

• Manufacturer hasn’t supplied 2% LA

• LA is expired

Page 75: Exodonia

How to check block anaesthesia

• Numbness

• Prick & probe PDL

Page 76: Exodonia

Other techniques

• Peripress

• Pulpal

• Intraosseous

• Intra lesional

Page 77: Exodonia

Seating of the patient for extraction

Lower jaw:• The occlusion plane of pt should be at elbow joint

of operator.• When the pt opens the mouth the occlusal plane

be parallel to the floor.

Upper jaw:• The occlusion plane of patient should be above the

elbow & at the shoulder level of operator• The head, neck & trunk should be in one level• When pt opens mouth occ: plane should be b/w

450 - 600 .

Page 78: Exodonia

Detailed Examination of Teeth

Before extraction the tooth to be extracted should be examined thoroughly both clinically & radiographically.

» Any filling in the crown» Any pathology especially caries» Is the tooth abraded» Root canal filling» Position of roots» Position of tooth to surrounding & max sinus» Position of tooth ID canal

Page 79: Exodonia

In detailed examination, we also see what type of technique can be used;

» Forcep only

» Forcep plus elevator

» Elevator alone

» What type of forcep & elevator

» Odontectomy is require or not

» Possibilities of # of roots

Dental radiographs are very valuable in preventing un wanted accidents like;

» Fracture of mandible

» Tearing of the floor of max sinus

Page 80: Exodonia

Examination of supporting Hard tissues

• See the thickness of labial, buccal and lingual cortical plates

• Are there any nodular area of exostosis overlying the roots of the tooth

• Estimate the density of bone

• In old age, osseous tissue & tooth structure are brittle & dense. Expansion of cortical plate is impossible.

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Principles of tooth extraction

• Selection of forcep

• Application of forcep

• Dilate the socket

• Cut the periodontal ligaments

• Take the tooth out of the socket to the least resistant way.

( usually the path of eruption is the path of extraction provided there is no change in the roots)

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Technique of extraction

• Forcep extraction/ simple extraction/ non surgical extraction

• Transalveolar extraction/ odontectomy/ surgical extraction

Page 83: Exodonia

Forcep Extraction

99% teeth are extracted by this method. It is the best easier method without involving soft tissues

» Check anaesthesia – tooth & surrounding buccal/ lingual mucosa

» Any loose filling in tooth be removed.» Ask the pt to rinse with antiseptic m/wash» Take periosteal elevator & detach attached gingivae

surrounding crown on buccal & lingual aspect» Hold it in pen grip fashion with concave surface

towards tooth» Expose neck of tooth, take forcep, grip tooth & do

extraction

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Selection of forcep

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Upper anterior forcep or straight forcep

• Grip the palatal & labial side• Beak should be maximally at root

portion• Beak must be parallel to the long

axis of tooth• Apply force apically to hold the

deepest part

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Upper Premolar or Bayonet forcep

• The difference b/w previous & upper premolar forcep is that it is slightly curved

• As it is a posterior one there must be some angle to make the grip easy

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Upper molar forcep

• Rounded beak on the palatal side• Nobed beak on the buccal side• This nob should be at bifurcation point,

as there are 2 roots on this side (DB & MB)

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Lower forceps

Lower anterior forceps

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• The beaks at right angle to the handle.

• Lower BDR are similar– Difference b/w ant & BDR forceps

• In BDR forceps the beaks should approximate each other when we press the two handles.

• While in post the beaks don't approximate each other when we press the handle.

– Difference b/w premolar & molar forceps• In case of premolar forceps both beaks are rounded while

there are knobs on both the sides in case of molar forceps because there are two roots mesial & distal.

– As the grip should be at right angles to the long axis, which is impossible in last lower molars so, we use cow horn forceps.

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Application of forcep

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1. Select proper forcep

2. Hold the tooth with the forcep, so that the beak applied to the long axis of the tooth to be extracted

3. Hold the forcep firmly in hand

4. Hold should be away from the beaks

5. Hold the tooth from the cemento enamel junction & never from the enamel portion

6. Beak should not slip

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Technique & movements

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PRINCIPLES OF FORCEP USE

1. Expansion of bony socket & movement of Tooth

2. Removal of Tooth

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Major motions of forceps

1. Apical pressure1. Dilatation of bone2. Displacing centre of rotation apically

2. Buccal force

3. Lingual pressure

4. Rotational pressure

5. Tractional forces

Page 96: Exodonia

General procedure of forceps extraction

1. Loosening of soft tissue around tooth

2. Luxation of tooth

3. Adaptation of forcep

4. Luxation of tooth with forcep

5. Removal of tooth from socket – tractional force

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Maxillary teeth

First movement should be apical, parallel to long axis of tooth

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11

• Labial movement with

• Slight palatal pressure

• Labial pressure

• Mesial rotation

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2 2

• Only labial movement with • Mesial rotation ?• No palatal movement because tip is more close

to palatal plate & there is a chance of infection over there

• Tip is slightly curved rotation may be avoided.

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3 3

• As upper one/ icisor• Labial movement• Palatal movement• Labial & mesial rotation

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4 4

• Buccal movement

• Palatal movement (slight)

• Buccal delivery of tooth

• No rotation because it has 2 roots

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5 5

• Buccal movement

• Palatal movement

• Buccal movement

• Either palatal delivery of tooth or buccal

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76 67

• Buccal movement

• Palatal movement

• Buccal delivery of tooth

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8 8

• No palatal movement

• Buccal movement with

• Distal rotation

• Buccal delivery of tooth

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Mandibular teeth

• First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth,

• Resting on cementum

• & then forces are applied

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21 12

• Labial movement

• Lingual movement

• Slight mesio distal rotation &

• Labial delivery of teeth

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3 3

• As upper two/ upper lateral incisor• Labial movement• Mesial rotation & delivery• No lingual movement

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54 45

• Having conical roots

• Rotatory movements

• Slight buccal movement

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76 67

• Buccal movements

• Lingual movements

• Slightly rotatory movements

• Buccal delivery of tooth

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8 8

• All teeth are embedded in spongy alveolar bone except 8 8 which are embedded in external oblique ridge

• Buccal pressure

• Lingual or buccal delivery

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Primary or deciduous teeth

cba abc

cba abc• Labial movement• Mesial rotation

ed de

ed de• Buccal movement• Palatal/lingual

movement• Teeth delivered on

lingual side

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Which tooth is most difficult to extract

• 8 8 is most difficult to extract buccal plate is supported by external oblique ridge

• Buccal plate may # but usually green stick type

• Remains there, not seen by operator

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Post operative care:

• Immediate post ext measures:– See the socket & position of alveolar bone.– Buccal plate is usually fractured in green stick

fashion so;• Press the socket to reduce the #• Approximate the socket for quick healing & clot formation

– See the position of inter radicular bone, if its level above the mucoperiosteum or gingival level, it should be trimmed. Also inter dental septum if ext of adjacent tooth.

– If there is granuloma at the root tip it should be curetted, gently remove or scope the granuloma out b/c,

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• It can cause R cyst• Can cause infection

– Pack the socket with sterilize gauze. It should press directly on wound and shouldn’t make a bridge upon the wound

Instructions to the patient:

• Bleeding;– Keep the gauze sponge & hold it firmly b/w your

jaws & over the socket for a full or half an hour after extraction

– Don’t rinse or use a mouth wash for 6 hrs after extraction. Frequent mouth washing disturbs the clot. After 24 hrs nothing can enter the clot.

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– If there is some ooze no problem, there will be some oozing for 24-48 hrs.

– Don’t talk 2 hrs.– If there is more bleeding, then patient should use

tea leaves wrapped in a piece of gauze or cotton soaked.

– Discoloration some swelling of the soft tissues of face is followed by discoloration. This is a normal post operative event. The purplish black discoloration fades in to greenish yellow & then yellow & black to normal. Heat in any form applied to the face help in dissipation of discoloration.

– Pain - put pt on analgesics.– Antibiotics

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– Swelling & stiffness – may be due to bleeding beneath the oral tissues. To reduce apply ice cap or towel wring out of ice water on 1st day & on 2nd day apply heat to your face.

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Odontectomy

This is the surgical removal of tooth/teeth by the reflection of an adequate mucoperiosteal flap & the removal of overlying bone.

Advantages:

1. Reduces the chances of tooth# during extraction

2. Less danger of creating OAF.

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3. Decreases the possibilities of # of maxilla & mandible

4. Reduces the chances of tearing out of alveolar bone

Indications:1. Hypercementosis

2. Widely divergent roots of molars

3. Locked roots

4. Teeth with apices at right angles to the long axis of teeth (curved roots)

5. Teeth with post crowns

6. Extensively decayed tooth

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7. Teeth with root canal fillings

8. When a thick, dense buccal or labial cortical plate or multi nodular exostosis is present in maxilla or mandible

9. Low antral floor – dips b/w roots of maxillary molars

10.When the maxillary alveolar tuberosity is hollow b/c the antral cavity extends into it

11.Thin mandible when excessive forces may fracture it

12.Malposed, impacted & supernumary teeth

13.When forcep force (pressure) results

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in dislocation of TMJ, despite manual effort to retain it

14.Ankylosed roots

15.When customary force fails to produce luxation

16.Dialaceration

17.BDR

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Reasons for removal of roots:

Fractured roots should be removed at the time of extraction. Large roots left will be a localized source of inflammation & soreness as the alveolar ridge resorbs & denture strike this prominence;

1. Roots are removed to eliminate possible residual infection

2. Remaining roots & fragments may act as mechanical irritant

3. May give rise to neuralgia or pain of obscure origin

Retaining of root fragment

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Mucoperiosteal Flap / Flap Operation

Types of Incision/Flap1. Envelope incision/flap:2. Three corner flap: 3. Four corner flap: 4. Semi lunar Flap: 5. Elliptical Type:

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Principles/design of Flap

• Mentally review the nerve & blood supply of the soft tissues to be included in the flap

• Design a flap so that maximum area is exposed

• Base of the flap reflected should be broader than apex so that it may have a good blood supply

• During reflection of flap the periosteum should be reflected intact & should not be injured, otherwise there will be post OP slough of flap, pain & delayed healing.

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• Angle of the flap – should not be acute but rounded

• Always have the flap wider than bone cavity which will be present at the end of operation so that stitches does not come on the bony cavity & stitches get solid bony support which means quick & painless healing, other wise stitches will never stay.

• Always use sharp blade excise through the soft tissue at the starting point until bone is contacted. Then with the knife edge hold firmly in contact & bone, make the incision with one cut.

• Never extend the incision on lingual side.

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• Procedure:– Knife handle & blade -- in pen grip fashion.– Start incision with blade No. 12, cut through junction of

periodontal membrane & mucoperiosteum around the neck of teeth to be exposed

– Give incision in one stroke & be deep enough (touching the bone)

– Next with the blade NO. 15 start incision b/w the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla. Don't cut the inter dental papilla i.e. its morphology should not be disturbed.

– Make the incision through the mucoperiosteum towards the mucobuccal fold mesially at an angle of 45o to the long axis of tooth.

– If adequate exposure is not obtained when mucoperiosteum is reflected then make a second incision at the distal side in the same manner & extent in the buccal cavity.

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Suturing

• Return of flap.

• Instruments– Needle holder – 15cm– Suture needle 3/8th to ½ circle reverse cutting edge– Non resorbable – 2/0 silk– Resorbable

• Gut – plain & chromic• Vicryl – polyglycolic acid / polyglactin

• technique

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SutureThe word "suture" describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues.

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Example Suture Selection

AbsorbableNatural

Synthetic

Non AbsorbableNatural

Synthetic

Fast Absorbing Gut

Chromic gut

Plain Gut

VICRYL*

VICRYLRapide*

PDS II*

MONOCRYL*

(polyglactin 910) suture

( polyglacin 910) suture

(polyglecaprone 25) suture

(polydioxanone) suture

Stainless steel

Silk

PROLENE*

ETHIBOND*

MERSILENE*

NOROLON*

Ethilon*(nylon) suture

(nylon) suture

(polyester) suture

(polyester) suture

(polypropylene) suture

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Needle anatomy

• Swage • Body• Point

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Body of the needle

• classification by the body of the needle:

¼ circle 3/8 circle ½ circle 5/8 circle

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Knots

• Half Hitch or Single knot

• Granny Knot

• Reef Knot

• Triple Knot

• Surgeons Knot

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Teeth resist to forcep extraction

• Maxillary teeth

• Mandibular

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Removal of broken down roots

1. Closed procedure:

2. Open procedure:

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1. Gingival third:

• Wedge principle.• Apply straight elevator – concave surface

towards root in the periodontal space.• With rotatory & labial movements

(pressure), enlarge the space.• Both for mesial & distal roots• Repeat for several times till a depth of 5-

6mm is gained.• If enlargement is not possible make a

groove with bur and apply elevator.

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2. Half way to the apexReflection of flap & removal of buccal and labial plates of alveolar bone (open or flap operation).

2. Enable the operator to see clearly the field of operation. Never work in the pool of blood otherwise you may;

1) Displace root into maxillary sinus

2) Into mandibular canal

3) Into submandibular space

3. To remove the alveolar plate, so that apexo elevator can function in the same way as the fracture root in the gingival line.

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3. Apical third:

• Here root ejectors are used.

• Examine the root of # tooth to determine how much the root is left.

• Place the point of apical root fragment ejector into the alveolus keeping it against the alveolar wall.

• With the help of ejector move the root tip flanges from the alveolar wall towards the centre of the socket using only slight pressure forcing the tip of instrument between the flanges of root & the wall of alveolar bone.

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• Now use the apical fragment forcep grasp the flange of the root tip and then gently rock the tip back & forth from the socket.

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Individual Roots

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Upper Incisors

• Root broken at apical level use root ejector.

• Take the flap & expose bone.

• Put ejector on distal side & push it towards the mesial side.

• Then put it on the mesial side and push towards the distal side.

• Dislodge root & remove with an artery forcep

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Upper Premolars

• If the buccal root of the first premolar has broken while the palatal is removed.

• Take a flap & remove the inter radicular bone with the help of William's fragment elevator.

• Approach is made from palatal socket & root is pushed down ward with same elevator but if it can not be engaged by hook then use apical fragment forcep

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Upper molars

• Prepare a grove b/w MB & DB roots.

• Extend the groove to separate them from palatal root i.e. distal & palatal aspect of palatal root with bone

• Put straight apexo elevator in b/w the groove of 3 roots & rotate.

• If one root is left &is above the gingival margin then raise the flap, remove the buccal plate& apply root ejector.

• If palatal root left take flap & take it out.

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Lower Incisors, Canine & Premolars

• By wedge principle– Gingival 3rd – take a straight apexo elevator,

the concave surface towards the root. If the engagement of the root is not possible, then make a groove with a bur & then apply elevator.

– Apical 3rd – 1st apply root ejector. If not possible, then take a flap.

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Lower molars• 1st of all cut the inter radicular septum with

cross bar elevator.

• Now put the cross bar elevator in the clear socket with concavity in the root & push it out wards.

• If not possible the put a root ejector on one side & push the root on the other side. Then put the ejector on opposite side & repeat same procedure & dislodge the root.

• If still not possible, take flap, use wedge principle & remove the root.

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Removal of roots from healed ridges of jaw bone

• If teeth are present localization is simple.

• Exposure & removal is carried out with out damaging the roots of adjacent teeth.

• Localization of roots in the edentulous ridge:• A care full study of osteological land marks.• Shift sketch technique

• Roots located close to Max sinus or inferior alveolar canal may be forced into these structures so, a care full examination is required.

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COMPLICATIONS OF TOOTH EXTRACTION

1. Immediate complication:During operation / after an operation:1. Syncope:

• Also called fainting. It is the important complication at dental chair. It is the earliest form of shock. It is transient cerebral ischemia. It is due to fear & apprehension associated with tooth extraction. The blood is pulled down in splanchnic vessels of abdomen & thus blood supply to brain is restricted.

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• Clinical features:• Ashy grey color of skin• Cold Perspiration• Low Rerspiration• Dizziness• Nausea• Light headedness• Pt warn u that he is not feeling well

• Treatment :• Head down position but not the way that it

interfere with breathing• Supporting O2 & cortisone Inj for PB, if pain

morphine or pethadine• Loose the tight button & clothing• Respiratory stimulant button & clothing• Saline drip increase the circulatory volume

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2.Shock:Shock is a clinical state, which shows the response of the body towards its existence threat. It is a circulatory deficiency when the blood is not available for the vital structures and is characterized by decreased cardiac out put & haemoconcentration.

when the blood supply to vital structures is limited patient goes into primary shock (Syncope)

if it is not immediately fatal, other mechanisms comes into play like;

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1. Baroreceptors:So, in shock pulse rate is increased but volume is

decreased (Hypovolumea)

2. Chemoreceptors:increased Co2 stimulates the chemoreceptors which

again stimulate respiratory centre & respiratory rate is increased. That is why respiration is shallow but with increased rate.

Now the pt needs help b/c this mechanism works for a little time & if not helped, then secondary shock appears

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• Clinical features:1. Cold and pale skin2. Clammy from sweat3. Mucous membrane is pale4. Lips, nails & tip of fingers are greyish blue5. Face is expression less6. Pupils dilated7. Weak rapid pulse8. Irregular rapid but shallow respiration9. Temperature is below normal

• Treatment :Shock can be more easily prevented than

treated.

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First determine the cause & treat.1. Supportive O22. Head down position3. Blood transfusion ( if from haemmorrage)4. Normal saline / glucose infusion5. Morphine / pethadine (Neurogenic stress

due to pain)6. Maintain body heat7. Cortisone to maintain BP8. Adrenaline in Anaphylactic shock

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3. Damage to soft Tissues:• This is due to faulty & careless

instrumentation• The elevators may slip & plug into deep

structures, creating a serious injury & haemorrage

• Catching the lips b/w the handles of forceps may also damage the soft tissues of lip

• Finger guards should always be used with elevators

4. Damage to the nerves:• Neuroprexia• Axonotmesis• Neurotemesis

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Commonly endanger nerves are;1. Inferior dental nerve2. Lingual nerve3. Naso palatine nerve4. Infra orbital nerve

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5. Haemorrhage:The escape of blood from CVS is called

haemorrhage1. Mechanical – from severed vessels of any

size2. Chemical / Biochemical – abnormality of

blood elements or vascular system which prevents normal clot formation & organization. This is typical in Haemophilia , hepatic & blood disorders.

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Mechanical Haemorrhage

1. Primary haemorrhage

2. Reactionary haemorrhage

3. Secondary haemorrhage

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Management • If the suture has become loosed , anesthetize the area & insert

a mat suture.

• Apply the direct pressure by having the pt bite firmly on the gauze pressure pads over the bleeding area.

• Apply a vasoconstrictor (Epinephrine) to the bleeding area & apply thrombin or fibrinogen (like spongaston) locally to speed up blood coagulation. ( adrenaline few drops in a cup of water,& a soaked cotton packed in cavity). Some times Tannic acid powder is useful.

• If not possible then crush the alveolar socket to block the blood vessels.

• If again not working then ligate the external carotid artery.

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6. Dislocation of TMJ:

1. Local

2. Under GA

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6. Pain Pain may be due to anaesthesia i.e. prick of needle but the pain may be due to extraction and can be prevented by the following measures;

1. Atraumatic extraction2. Don’t leave any piece of root3. Remove sharp bony specules4. Put the pt on analgesics &

antibiotics.

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8. Dry socket/ alveolgia / Localized osteotis

It is a condition in which the particular socket after tooth extraction is not filled with blood clot or the clot is disintegrated due to infection of socket.

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Aetiology:

1.Exact cause not known.2.Traumatic extraction.3.Local anesthesia

( vasoconstriction) Excessive.4.Pt has not followed the instructions

of the surgeon.5.Use of repeated sponging during

or after ext ( arterioles become blocked)

6.Tooth was already infected

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8. Instruments were not sterilized9. Use of excessive mouth washes.10.Excessive curettage.11.Entrance of saliva into sterile socket.12.Systemic diseases

1. Diabetes mellitus

2. Pt on oral contraceptives.

3. Radiotherapy

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Clinical features

1. Pt will come with pain in socket or may be referred after 2-3 days of ext or in some cases about 7 days after ext. pain is severe.

2. There is foul smelling from the mouth.3. Bone surrounding the socket is greenish in

colour.4. Pus is present in the socket.5. If a curette is passed through the semi tough

blood clot there will be musty semi fluid clot beneath the surfaces.

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6. The mucous membrane surrounding the socket is red & tender.

7. Pain is deep seated, severe aching & throbbing in character.

8. There is no clot in socket, which contains instead saliva & food debris.

9. When debris is passed away whitish dead bone is seen.

10.Some times the socket becomes concealed by granulation tissue growing in the form of edge, which hinder the drainage of pus.

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DRY SOCKET MORE IN LOWER JAW AS COMPARED TO UPPER JAW

• Because;1.Blood supply to lower jaw is less.2.Extraction of lower jaw is usually

traumatic.3.Saliva can go easily go in to socket

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Treatment:1. Take an x-ray of that area to see any foreign

body or retained root.2. Give anesthesia & irrigate the socket with the

antiseptic solution gently or normal saline.3. Scoop out any necrotic tissue, but don't scrap.4. Dry the socket gently & isolate it with sponge.5. Iodoform gauze saturated with eugenol is

inserted into the socket. Now cover the socket with a doughy mixture of zinc oxide eugenol. It will prevent the entrance of food & saliva & promote healing 1-10 days.

6. A moist sponge

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Osteomyelitis

Bone

• Cortex – its inflammation is called osteitis.

• Medulla – its inflammation is called osteomyelitis.

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Osteomyelitis is an inflammatory condition of bone involving primarily the soft parts i.e. medullary portion

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Bacteriology:• It is the result of an acute pyogenic

inflammation of the bone marrow. The most common organism found in decreasing order are;• Haemolytic staphylococcus aureus• Staphylococcus Albus• Streptococci• pneumococci

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• Aetiology:• Direct extension from the source of

infection (teeth, sinuses, nasal cavity, socket & soft tissues) into the healthy bone

• Hematogenous dessimination of an infection (chicken pox) into healthy bone

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pathogenesisInfection - direct ext or hematogenic dessiminatin

Bone(devitalized by,1. Radionecrosis2. Chemical necrosis3. External trauma4. Surgical trauma5. Tuberculosis6. Syphilis7. Actinomycosis8. Poor resistence of Pt

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• Osteomyelitis starts in acute form & if not treated by massive dozes of penicillin – turn to be the chronic one

• Osteomyelitis (chronic or acute), according to the area of bone involved may be;• Localized – confined to small area• Diffused – destruction spreads to large area• Diffuse fulminating – acute osteomyelitis of

sudden & severe onset destroying large areas

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• Clinical features:1. Raised temp2. Swelling3. General malaise4. Toxic appearance5. Leucocytosis (signs of acute infection)6. Known site of infection in early stages7. Parasthesia of lower lip8. Swelling can be felt9. Teeth tender to percussion10.Teeth become loose- one after the other11.Gingivae – dark, red & edematous

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Radiological features:

• Sequestrum.

• Involcurum

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Treatment:1. Broad spectrum antibiotics. If antibiotic is

proper & stage is initial we can stop the whole process. Antibiotics are continued at least for 4 weeks – heavy doses of penicillin

2. Complete bed rest & adequate fluid intake3. Soft diet with multivitamins4. High proteins, high calories IV fluids5. Surgical drainage is established, as soon as

pus is localized

But if second stage has started;

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& sequestrum is formed we have to do sequestrectomy (but it should not be done in the initial stages & wait). When the sequestrum itself start coming through the sinus, but if it is formed & attached to the involcurum, don’t remove it at this time. But when it is detached from its place then gently remove it

SAUCERIZATION:The medullary portion of the bone has been dissolved due to osteomyelitis due to which a portion of the cortex has been left without support. Now this cortex can’t survive, cut the cortex with Rongeurs’s forcep & make it smooth saucer – shaped. This process is called saucerization.

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• DECORTICATION:• If osteomyelitis has started & is in initial

stages & also parasthesia is present another way of treatment is as follows;• Give incision in the & reflect the flap& then

make holes in the cortex of the bone upto the medullary region & drain the exudate in the initial stage. Now bring the flap in place & bring the soft tissue in close contact with the medullary portion of the so it gets good blood supply from this soft tissue.

• Here cortex is intact

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