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oral and maxillofacial ward of KCD
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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
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
Technique A care full technique ndash based on
knowledge amp Skill Living tissues should be dealt gently Other wise damage amp necrosis can
occur which lead to bacterial growth amp retardation of healing thus causing postoperative complications like pain swelling amp possibly deformity
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 amp cheeks amp further complicated by the movements of tongue amp mandible
Oral cavity communicate with pharynx amp larynx amp is full of saliva which also makes operation difficult
It also lies close to vital centers
Pre surgical Medical AssessmentHistory taking
Biographic Data Name Address Gender Occupation Mental status
Chief complaint Painndash onset etc Fever etc
Medical Hx Present Past
Examination gt Focus on oral cavity lt Focus on Maxillofacial region ltlt GPE
Fear of pain amp Anxiety Verbal LA GA Sedation
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 ndash for FD
INDCATIONS FOR EXTRACTION1 Hopelessly carious tooth2 Teeth with non vital pulps3 Periodontitis or periodontosis where
23rd of bone is lost4 Acute or chronic pulpitis where
endodontic treatment is not indicated5 Mal posed teeth which can not be
treated by orthodontic treatment
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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
Technique A care full technique ndash based on
knowledge amp Skill Living tissues should be dealt gently Other wise damage amp necrosis can
occur which lead to bacterial growth amp retardation of healing thus causing postoperative complications like pain swelling amp possibly deformity
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 amp cheeks amp further complicated by the movements of tongue amp mandible
Oral cavity communicate with pharynx amp larynx amp is full of saliva which also makes operation difficult
It also lies close to vital centers
Pre surgical Medical AssessmentHistory taking
Biographic Data Name Address Gender Occupation Mental status
Chief complaint Painndash onset etc Fever etc
Medical Hx Present Past
Examination gt Focus on oral cavity lt Focus on Maxillofacial region ltlt GPE
Fear of pain amp Anxiety Verbal LA GA Sedation
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 ndash for FD
INDCATIONS FOR EXTRACTION1 Hopelessly carious tooth2 Teeth with non vital pulps3 Periodontitis or periodontosis where
23rd of bone is lost4 Acute or chronic pulpitis where
endodontic treatment is not indicated5 Mal posed teeth which can not be
treated by orthodontic treatment
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Technique A care full technique ndash based on
knowledge amp Skill Living tissues should be dealt gently Other wise damage amp necrosis can
occur which lead to bacterial growth amp retardation of healing thus causing postoperative complications like pain swelling amp possibly deformity
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 amp cheeks amp further complicated by the movements of tongue amp mandible
Oral cavity communicate with pharynx amp larynx amp is full of saliva which also makes operation difficult
It also lies close to vital centers
Pre surgical Medical AssessmentHistory taking
Biographic Data Name Address Gender Occupation Mental status
Chief complaint Painndash onset etc Fever etc
Medical Hx Present Past
Examination gt Focus on oral cavity lt Focus on Maxillofacial region ltlt GPE
Fear of pain amp Anxiety Verbal LA GA Sedation
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 ndash for FD
INDCATIONS FOR EXTRACTION1 Hopelessly carious tooth2 Teeth with non vital pulps3 Periodontitis or periodontosis where
23rd of bone is lost4 Acute or chronic pulpitis where
endodontic treatment is not indicated5 Mal posed teeth which can not be
treated by orthodontic treatment
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 amp cheeks amp further complicated by the movements of tongue amp mandible
Oral cavity communicate with pharynx amp larynx amp is full of saliva which also makes operation difficult
It also lies close to vital centers
Pre surgical Medical AssessmentHistory taking
Biographic Data Name Address Gender Occupation Mental status
Chief complaint Painndash onset etc Fever etc
Medical Hx Present Past
Examination gt Focus on oral cavity lt Focus on Maxillofacial region ltlt GPE
Fear of pain amp Anxiety Verbal LA GA Sedation
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 ndash for FD
INDCATIONS FOR EXTRACTION1 Hopelessly carious tooth2 Teeth with non vital pulps3 Periodontitis or periodontosis where
23rd of bone is lost4 Acute or chronic pulpitis where
endodontic treatment is not indicated5 Mal posed teeth which can not be
treated by orthodontic treatment
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Pre surgical Medical AssessmentHistory taking
Biographic Data Name Address Gender Occupation Mental status
Chief complaint Painndash onset etc Fever etc
Medical Hx Present Past
Examination gt Focus on oral cavity lt Focus on Maxillofacial region ltlt GPE
Fear of pain amp Anxiety Verbal LA GA Sedation
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 ndash for FD
INDCATIONS FOR EXTRACTION1 Hopelessly carious tooth2 Teeth with non vital pulps3 Periodontitis or periodontosis where
23rd of bone is lost4 Acute or chronic pulpitis where
endodontic treatment is not indicated5 Mal posed teeth which can not be
treated by orthodontic treatment
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Biographic Data Name Address Gender Occupation Mental status
Chief complaint Painndash onset etc Fever etc
Medical Hx Present Past
Examination gt Focus on oral cavity lt Focus on Maxillofacial region ltlt GPE
Fear of pain amp Anxiety Verbal LA GA Sedation
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 ndash for FD
INDCATIONS FOR EXTRACTION1 Hopelessly carious tooth2 Teeth with non vital pulps3 Periodontitis or periodontosis where
23rd of bone is lost4 Acute or chronic pulpitis where
endodontic treatment is not indicated5 Mal posed teeth which can not be
treated by orthodontic treatment
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Chief complaint Painndash onset etc Fever etc
Medical Hx Present Past
Examination gt Focus on oral cavity lt Focus on Maxillofacial region ltlt GPE
Fear of pain amp Anxiety Verbal LA GA Sedation
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 ndash for FD
INDCATIONS FOR EXTRACTION1 Hopelessly carious tooth2 Teeth with non vital pulps3 Periodontitis or periodontosis where
23rd of bone is lost4 Acute or chronic pulpitis where
endodontic treatment is not indicated5 Mal posed teeth which can not be
treated by orthodontic treatment
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Medical Hx Present Past
Examination gt Focus on oral cavity lt Focus on Maxillofacial region ltlt GPE
Fear of pain amp Anxiety Verbal LA GA Sedation
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 ndash for FD
INDCATIONS FOR EXTRACTION1 Hopelessly carious tooth2 Teeth with non vital pulps3 Periodontitis or periodontosis where
23rd of bone is lost4 Acute or chronic pulpitis where
endodontic treatment is not indicated5 Mal posed teeth which can not be
treated by orthodontic treatment
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Examination gt Focus on oral cavity lt Focus on Maxillofacial region ltlt GPE
Fear of pain amp Anxiety Verbal LA GA Sedation
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 ndash for FD
INDCATIONS FOR EXTRACTION1 Hopelessly carious tooth2 Teeth with non vital pulps3 Periodontitis or periodontosis where
23rd of bone is lost4 Acute or chronic pulpitis where
endodontic treatment is not indicated5 Mal posed teeth which can not be
treated by orthodontic treatment
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Fear of pain amp Anxiety Verbal LA GA Sedation
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 ndash for FD
INDCATIONS FOR EXTRACTION1 Hopelessly carious tooth2 Teeth with non vital pulps3 Periodontitis or periodontosis where
23rd of bone is lost4 Acute or chronic pulpitis where
endodontic treatment is not indicated5 Mal posed teeth which can not be
treated by orthodontic treatment
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 ndash for FD
INDCATIONS FOR EXTRACTION1 Hopelessly carious tooth2 Teeth with non vital pulps3 Periodontitis or periodontosis where
23rd of bone is lost4 Acute or chronic pulpitis where
endodontic treatment is not indicated5 Mal posed teeth which can not be
treated by orthodontic treatment
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
INDCATIONS FOR EXTRACTION1 Hopelessly carious tooth2 Teeth with non vital pulps3 Periodontitis or periodontosis where
23rd of bone is lost4 Acute or chronic pulpitis where
endodontic treatment is not indicated5 Mal posed teeth which can not be
treated by orthodontic treatment
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
6 Any tooth that lies in field of radiations for some oral malignant lesions
7 Supernumerary teeth8 Any tooth which lies in the line of 9 Non functional tooth or any tooth lying
alone in oral cavity10 Broken down roots or fragments
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
11 Teeth traumatizing soft tissues12 Retained primary teeth when
permanent teeth are present13 Teeth not restorable by operative
dentistry14 Impacted teeth15 Teeth associated with any cyst or
tumour
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
16 Teeth which can not be saved by apiceotomy
17 Teeth mechanically interfering with placement of restorative appliances
18 Foci of infection19 Prosthetic purposes20 Obscure pain21 Infection --- pericoronitis
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
22 Over erupted teeth23 Socioeconomic factors
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Contra indications for the extractions of teeth
A Local contraindications
B Systemic contraindications
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Local contraindications1 Acute inflammation
1 Gingivitis eg 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
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
6 During therapeutic radiations7 Tooth lying in the area of malignant
tumors and suspected haemangioma of jaw
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Systemic contraindication for tooth extractions
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 amp resultant adrenal cortical atrophy
The dose of cortisone must be increased or doubled as we give extra stress to the patient during extraction
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 IM
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Diabetes Mellitus Under production of insulin A resistance of insulin receptors Or both
It is of two types Insulin dependent Non-insulin dependent
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Diabetes Mellitus Characterized by hyperglycemia due
absolute or relative deficiency of insulin Symptoms
Polyuria Increased thrust Excessive appetite
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Loss of weight Skin disturbances Vision disorders Numbness amp tingling Glucosuria Pain especially in lower limbs
Diabetic patients are more prone to infections because
Increased sugar in blood Arteriosclerosis which decreases peripheral
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
circulation General resistance of patient is low ndash
immunity Bacterial growth is favorable as increased
blood sugar level act as a good medium for their growth
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Precautions for diabetic patients3 steps Patient at home before surgery
Put patient on broad spectrum antibiotics 24 Hrs before surgery Amoxicillin 500 mg Erythromycin 250500mg TDS amp BD
respectively Doxycyucllin (vibramycin) 200mg stat
100mg daily Oxytetracycllin 250mg 6 Hrly
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Put the patients on sedatives Diazepam 4-10mg or Phenobarbitone 30 ndash 60 mg frac12 or 5
G=30mgor 05 ndash 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
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Fresh blood sugar level ndash fasting at the day of surgery
Calm amp sympathetic attitude from you Local anaesthesia should be plain ie with out
adrenaline because Increases B Sugar level Vasoconstriction ndash gangrene Not remain there for a longer time
Short appointment Recent ndash HBA1C ndash 60 days picture of diabetic
pt
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 amp plain LA should be used
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Important points Anaesthesia should be complete ndash Ext with
out pain Procedure should not be more than 15 mins Procedure should be a traumatic There should be complete sterilization Ext one tooth at a time Antiseptic mwash before ext After ext pt should remain under
observation for at least 30 minamp should have adult attendant
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 amp abdominal pain Tongue amp skin dry Low BP Low pulse volume but rapid
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 amp abdominal pain Tongue amp skin moist BP Normal
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Extensor planter responses Low glucosuria
Rx 5 Dextrose ampoule (2-4mm IV) if recovers give sugar
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Actual physiological damage to the child On these basis Rx of a pregnant
women is divided in to 3 classes1 Emergency Treatment
1 Severe pain eg pulpitis
2 Non Emergency treatment but essential Rx
1 Chronic periapical abscess Postpone Rx to
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
2nd trimester
2 Elective Rx eg BDRs postpone till delivery
Precautions for a pregnant womenBe very care full because of altered physiology
1 LA more Safebull Comfortably seated to avoid vomiting
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 amp death of baby N2O2 amp O2 mixture can be used Short acting barbiturate like pentothane IV Analgesics
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Consult obstritician Oxygenation ndashavoid hypoxia Antibiotics (like tetracycline group should be
avoided)
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Bleeding Disorders1 Platelet Inadequacy
2 Coagulopathies
3 Therapeutic anticoagulation
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Haemophilia Congenital bleeding disorder due lack of
coagulation factor VIII amp IX designated as Haemophilia A amp B respectively
CT is increased ( Normal CT= 2-5min) Males are sufferers amp females are
carriers
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Precautions LA is absolutely contra indicated because
of continuous bleeding and haemotoma formation
GA is preferred amp pt is hospitalized Fresh blood Plasma Fresh frozen plasma
or cryoprecipitate (deficient factors) Anti hemophilic globulin (AHG) ie fraction
I 400 mg in 20cc of normal saline IV with in frac12 hour the CT is reduced to normal
AHG level should be 20 above normal or normal level
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Factor VIII should be build up to 50-70 Mask anaesthesia to reduced the risk of pricking in
OT amp avoid endotracheal intubation because of danger of bleeding
A traumatic procedures are carried out amp 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 amp when clot is settled no more fraction I or other maintenance is required
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
ASPIRIN amp OTHER PLATELET- INHIBITING DRUGS
Consult physician Defer surgery amp stop platelet inhibiting drug for 5
days Extra measure to control clot formation amp retention Restart drug on the day after surgery
WARFARIN (Coumadin) With physician consultation PT should brought to
15 INR for few days If PT is between 1-15 INR proceed surgery
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
If not stop the drug 2days prior surgery Check PT daily When normal do surgery amp 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
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 ie phenbarbitone 30-60mg or carbamezapine 200mm frac12 or 1 Hr before surgery
2 Instruments must be away from the pt
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
3 Before examination one should place mouth gag or prop in the patients mouth amp remove when the procedure is completed
4 If an attack occurs during surgery phenbarbitone paraldehyde ( anticonvulsant) IV 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 amp is pale and sweaty while in case of epileptic shock pt does not warn you
6 Convulsions in case of epilepsy
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 amp symptoms are sub sternal pain with
dyspnea radiating to the left arm amp lower jaw Following precautions are required while
dealing such pt
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 frac12 an hour amp then sent with an adult fellow
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Management Oral hygiene ndash brought to normal or near
normal eg Povidide MW 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 15G Erythromycin 1 Hr before Rx amp 250500mg tds or bd respectively for 72 hrs
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
PARENTERAL When maximum protection required or If pt can
not take orally or under GA Ampicillin 2G IV or IM plus Gentamycin 15 mgkg
Iv or IM ( not exceeding 80mg) followed by 15 oral amoxicillin 6Hrly ndash where maximum protection is required ( prosthetic Valves)
Ampicillin 2G IV or IM 30 min before procedure 1G Ampicillin IV or IM or 15 G orally 6 Hrly after initial dose
Vancomycin 1G IV administered over one Hr before surgery No repeat dose
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
PEDIATRIC DOSES Half the adult dose or Ampicillin50mgkg or
erythromycin 20mgKg frac12 - 1 hr before Rx then 10mgkg 6 Hrly
In running disease pt should be treated while hospitalized
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Thyrotoxicosis This is the result of hyperthyroidism due
to thyroid disease disease like a multi nodular goiter a thyroid adenoma or Graversquos disease
There is excess circulating triiodothyronine (T3) amp Thyronine (T4)
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
The only absolute contraindication for extraction Extraction can cause crisesSYMPTOMS
Nervousness tremors emotional instability Tachycardia amp palpitation Excessive perspiration Diffuse enlargement of thyroid gland
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Exopthalmos Loss of weight Elevation of BMR Easy fatigue Muscle weakness GIT symptoms like diarrhea amp at times
nausea amp vomiting Pressure symptoms in some instances
such as dyspnea dysphagia etc
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
EFFECTS Thyroid crisis can be precipitated by oral
surgery Pt with thyroid crisis is restless
semiconscious uncontrollable even with heavy sedation
Cyanotic amp at times delirious amp an extremely rapid thready pulse amp a high temperature
So ext is absolutely contraindicated because
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
The trauma can precipitate thyroid crisis with cardiac embarrassment amp heart failure We can not control them Refer pt for Rx before under going any surgical procedure
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Nephritis SYMPTOMS
Reduced urinary output or dysurea Hematuria Fever Albuminuria Chills Xerostomia amp burning in the mouth Generalized Stomatitis Urinous ordour in pts breath
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
EFFECTSExtraction of chronically infected tooth may
precipitate acute nephritis or extraction in a dirty mouth lead to nephritis
These pt must first put on antibiotics
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Jaundice There is impaired liver function due to
alcohol abuse infectious disease or billiary obstruction
The production of Vitamin K dependent coagulation factors (IIVIIIX amp X) may lead to prolonged bleeding
Check PT amp INR or PPT Prophylactic doses of Vit K amp
transamine
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
PRECAUTION amp Rx Tab anaroxyl or Azeptil is given Donrsquot describe any drug that is excreted amp
metabolized by liver such as paracetamol Antibiotics are given Such pts are usually virally infected like
Hepatitis ABC ampD so self and cross contamination be avoided
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Hypertensive Patient Essential hypertension Mild to moderate hypertension (systolic
PB lt200 amp Diastolic PB lt 110 usually not a problem Care
Anxiety reduction protocol amp monitoring of vital signs
LA with epinephrine given carefully After surgery pt advise to seek medical
care
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Severe hypertension (systolic PB gt 200 or more or diastolic PB gt 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
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Local
99 teeth are extracted under LA Infiltration Anaesthesia Inferior dental block
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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)
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Causes of anaesthesia failure
Defect in operator Defect in patient Defect in LA
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Defect in operator
999 due to wrong technique Cartridge is leaked Needle is not accurately inserted
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Defect in patient Infection
There is increased vascularization so immediate absorption occur amp there is no time for LA to work
Medium is acidic but we require alkaline medium for LA
Addiction Extra innervation ndash VV rare
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Defect in LA
Manufacturer hasnrsquot supplied 2 LA LA is expired
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
How to check block anaesthesia
Numbness Prick amp probe PDL
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Other techniques
Peripress Pulpal Intraosseous Intra lesional
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Seating of the patient for extractionLower 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 amp at the shoulder level of operator The head neck amp trunk should be in one level When pt opens mouth occ plane should be bw 450 -
600
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Detailed Examination of TeethBefore extraction the tooth to be
extracted should be examined thoroughly both clinically amp 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 amp max sinus Position of tooth ID canal
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
In detailed examination we also see what type of technique can be used
Forcep only Forcep plus elevator Elevator alone What type of forcep amp 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
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 amp tooth
structure are brittle amp dense Expansion of cortical plate is impossible
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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)
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Technique of extraction
Forcep extraction simple extraction non surgical extraction
Transalveolar extraction odontectomy surgical extraction
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Forcep Extraction99 teeth are extracted by this method It is the best easier method without involving soft tissues
Check anaesthesia ndash tooth amp surrounding buccal lingual mucosa Any loose filling in tooth be removed Ask the pt to rinse with antiseptic mwash Take periosteal elevator amp detach attached gingivae surrounding
crown on buccal amp lingual aspect Hold it in pen grip fashion with concave surface towards tooth Expose neck of tooth take forcep grip tooth amp do extraction
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Selection of forcep
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Upper anterior forcep or straight forcep
Grip the palatal amp 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
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Upper Premolar or Bayonet forcep
The difference bw previous amp 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
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 amp MB)
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Lower forcepsLower anterior forceps
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
The beaks at right angle to the handle Lower BDR are similar
Difference bw ant amp BDR forceps In BDR forceps the beaks should approximate each other
when we press the two handles While in post the beaks dont approximate each other when
we press the handle Difference bw premolar amp 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 amp 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
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Application of forcep
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
1 Select proper forcep2 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 hand4 Hold should be away from the beaks5 Hold the tooth from the cemento enamel
junction amp never from the enamel portion6 Beak should not slip
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Technique amp movements
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
PRINCIPLES OF FORCEP USE1 Expansion of bony socket amp movement
of Tooth
2 Removal of Tooth
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Major motions of forceps1 Apical pressure
1 Dilatation of bone2 Displacing centre of rotation apically
2 Buccal force
3 Lingual pressure
4 Rotational pressure
5 Tractional forces
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
General procedure of forceps extraction1 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 ndash tractional force
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Maxillary teeth
First movement should be apical parallel to long axis of tooth
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
11
Labial movement with Slight palatal pressure Labial pressure Mesial rotation
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
2 2
Only labial movement with Mesial rotation No palatal movement because tip is more
close to palatal plate amp there is a chance of infection over there
Tip is slightly curved rotation may be avoided
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
3 3
As upper one icisorLabial movementPalatal movementLabial amp mesial rotation
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
4 4
Buccal movement Palatal movement (slight) Buccal delivery of tooth No rotation because it has 2 roots
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
5 5
Buccal movement Palatal movement Buccal movement Either palatal delivery of tooth or buccal
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
76 67
Buccal movement Palatal movement Buccal delivery of tooth
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
8 8
No palatal movement Buccal movement with Distal rotation Buccal delivery of tooth
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Mandibular teeth
First pressure applied is the apical force until the beaks of the forceps engage the neck of the tooth
Resting on cementum amp then forces are applied
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
21 12
Labial movement Lingual movement Slight mesio distal rotation amp Labial delivery of teeth
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
3 3
As upper two upper lateral incisorLabial movementMesial rotation amp deliveryNo lingual movement
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
54 45
Having conical roots Rotatory movements Slight buccal movement
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
76 67
Buccal movements Lingual movements Slightly rotatory movements Buccal delivery of tooth
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Primary or deciduous teeth
cba abccba abc Labial movement Mesial rotation
ed deed de Buccal movement Palatallingual
movement Teeth delivered on
lingual side
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Post operative care Immediate post ext measures
See the socket amp 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 amp 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 bc
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
It can cause R cyst Can cause infection
Pack the socket with sterilize gauze It should press directly on wound and shouldnrsquot make a bridge upon the wound
Instructions to the patient Bleeding
Keep the gauze sponge amp hold it firmly bw your jaws amp over the socket for a full or half an hour after extraction
Donrsquot 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
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
If there is some ooze no problem there will be some oozing for 24-48 hrs
Donrsquot 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 amp then yellow amp black to normal Heat in any form applied to the face help in dissipation of discoloration
Pain - put pt on analgesics Antibiotics
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Swelling amp stiffness ndash may be due to bleeding beneath the oral tissues To reduce apply ice cap or towel wring out of ice water on 1st day amp on 2nd day apply heat to your face
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
OPEN SURGICAL EXTRACTIONS
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Odontectomy This is the surgical removal of toothteeth by the reflection of an adequate mucoperiosteal flap amp the removal of overlying bone
Advantages
1 Reduces the chances of tooth during extraction
2 Less danger of creating OAF
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
3 Decreases the possibilities of of maxilla amp mandible4 Reduces the chances of tearing out of alveolar bone
Indications5 Hypercementosis6 Widely divergent roots of molars7 Locked roots8 Teeth with apices at right angles to the long axis of
teeth (curved roots)9 Teeth with post crowns10 Extensively decayed tooth
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
7 Teeth with root canal fillings8 When a thick dense buccal or labial cortical plate or
multi nodular exostosis is present in maxilla or mandible
9 Low antral floor ndash dips bw roots of maxillary molars10 When the maxillary alveolar tuberosity is hollow bc
the antral cavity extends into it11 Thin mandible when excessive forces may fracture it12 Malposed impacted amp supernumary teeth13 When forcep force (pressure) results
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
in dislocation of TMJ despite manual effort to retain it14 Ankylosed roots15 When customary force fails to produce luxation16 Dialaceration 17 BDR
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
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 amp soreness as the alveolar ridge resorbs amp denture strike this prominence
1 Roots are removed to eliminate possible residual infection
2 Remaining roots amp fragments may act as mechanical irritant
3 May give rise to neuralgia or pain of obscure originRetaining of root fragment
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Oral Surgical Incision amp FlapsPrinciples of 1 Incision2 raising of flap
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Incision Proper sizesharp blade Firm continuous stroke Avoid cutting vital
structures Blade perpendicular to
epi- squared wound edges
Incision over attached gingiva amphealthy bone
Extraction ndash incision gingival sulcus
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Oral Surgical flapSection of soft tissue out lined by incision
Mucosal Sub mucosal Full thickness
mucoperiostal
Qualities of proper design
Carry its on blood supply
Access to under lying tissues
Anatomically re approximated back and retained by sutures
Uneventful healing with minimal scaring
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Principles of proper design of flap
Basic Objective is to gain surgical ascess in order to Prevent Flap necrosis Flap dehiscence Flap tearing
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Principlesdesign of Flap Mentally review the nerve amp 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 amp should not be injured otherwise there will be post OP slough of flap pain amp delayed healing
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Angle of the flap ndash 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 amp stitches get solid bony support which means quick amp painless healing other wise stitches will never stay
Never extend the incision on lingual side
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Types of IncisionFlap
1 Envelope incisionflap2 Three corner flap 3 Four corner flap 4 Semi lunar Flap 5 Elliptical Type
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Procedure Knife handle amp blade -- in pen grip fashion Start incision with blade No 12 cut through junction
of periodontal membrane amp mucoperiosteum around the neck of teeth to be exposed
Give incision in one stroke amp be deep enough (touching the bone)
Next with the blade NO 15 start incision bw the two teeth on mesial side of the area to be exposed at the crest of inter dental papilla Dont cut the inter dental papilla ie 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 amp extent in the buccal cavity
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Suturing
principles Close wound
margins Aid in hemostasis Hold soft tissues
over bone Maintaunance of
blood clot
technique Holding of needle
holder Holding of
suturing needle Use of tissue
holding forceps to hold flap margins
surgeonrsquos knot Cutting suturing
material with scissors
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Suturing Return of flap Instruments
Needle holder ndash 15cm Suture needle 38th to frac12 circle reverse cutting edge Non resorbable ndash 20 silk Resorbable
Gut ndash plain amp chromic Vicryl ndash polyglycolic acid polyglactin
technique
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Suture
The word suture describes any strand of material used to ligate (tie) blood vessels or approximate (sew) tissues
Example Suture SelectionAbsorbableNatural
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
Needle anatomySwage BodyPoint
Body of the needle classification by the body of the needle
frac14 circle 38 circle frac12 circle 58 circle
Knots Half Hitch or Single knot Granny Knot Reef Knot Triple Knot Surgeons Knot
