Oral and maxillofacial surgery Exodontia ppt.pptx

Huhj

1. EXODONTIA Principles, techniques & complications By- ROHAN SRIVASTAVA FINAL YEAR BDS

2. INTRODUCTI O N Science the earliest period of history of the extraction of the tooth has been considered a very formidable procedure by the layman, & it is because of the horrifying experiences associated with the tooth extraction in the past that even today the removal of a tooth is dreaded by a patient almost more than any other surgical procedure. Many patients suffer from extractionfobia & are often difficult to care for, despite modern methods of anesthesia. Many dentists still believe that speed is essential when extracting the teeth.

3. DEFIN I TION The ideal tooth extraction is – The painless removal of the whole tooth, or root, with minimal trauma to the investing tissues, so that the wound heals uneventfully & no post-operative prosthetic problem is created. (Geoffray L Howe)

4. Allen 1994 – caries in 48.8% cases – abscess Periodontal diseases – in 40.7% cases – to prevent alveolar ridge resorption Tooth with necrosed pulp & periapical lesion – not responding to endodontic treatment Over retained deciduous tooth – but take radiograph first Orthodontic purpose Prosthetic purpose Unrestorable tooth Impacted tooth Supernumerary tooth Grossly decayed 1M / 2M – make room for 3 rd molar HOTZ & SMITH Tooth in fracture line Teeth directly involved by cyst & tumor

5. 13. Teeth in the area of therapeutic irradiation 14. Teeth acting as foci of infection – ex. – bacterial endocarditis - rheumatic fever RICHARDS (1932) – bacteremia after infected tooth extraction OKELL & ELLIOTT (1935) – STREPTOCOCCUS VIRIDANS in blood stream (75% of 40 patient) Use of local anesthetic solution (vasoconstrictor) - rate of spread of infection

6. Absolute : Central Haemangioma. May cause uncontrolled bleeding. A-V malformation. Relative : When some precautions have to be taken. 1. Local Acute cellulitis. ANUG. 2. Systemic Uncontrolled Diabetes Mellitus, Hypertension. Bleeding disorders. Cardiovascular diseases. Liver disorders. Patients on long-term steroid therapy. Teeth that have undergone radiation [6 months – 1 yr ].

7. Order of extraction Lower teeth are removed before the upper teeth are removed to prevent bleeding from socket obscuring field of operation ( prof.J.Moore ) 12

8. Order of Multiple teeth extraction Maxillary Posterior teeth except 1 st Molar Maxillary anterior teeth except the canines Maxillary 1 st Molar Maxillary canines Mandibular Posterior teeth except 1 st Molar Mandibular anterior teeth except the canines Mandibular 1 st Molar Mandibular canines

9. 1. Position of the operator – - Stand erect , equal distribution of weight on both feet Force delivery – with arm & shoulder not with hand application of force without stress to shoulders & back generally on right hand side for Right posteriors – back side operating box

10. 2. Position of the patient – make the patient comfortable on dental chair 3. Height Of Dental Chair – maxillary teeth – 8 cm / 3 inch below the shoulder level of operator mandibular teeth – 16 cm / 6 inch below the elbow of operator

11. 4. Angulation of the chair – maxillary teeth – 45-60 degree mandibular teeth – parallel or 10 degree 5. Light – good illumination

12. 6. Role of opposite hand Reflection of soft tissue Protection of other teeth Stablization of patient’s head Supporting & stablizing the mandible Supports alveolar bone Tactile information Compress socket Deliver the whole tooth, root, dislodged filling

13. 7. Role of assistant Helps the surgeon to gain access & visualize the field Suction Protect the teeth of opposite arch Support the head Support the mandible Psychological & emotional support Avoid casual , offhand comments – increase patient’s anxiety - decrease patient’s cooperation

14. A. Intra-alveolar extraction (closed technique) B. Transalveolar extraction (open method) Types/Methods Of Exodontia

15. INTRA ALVEOLAR EXTRACTION It means direct access is gained on the tooth to be extracted. It is carried out with the help of dental forceps and elevators.

16. Types- 1.Forcep Technique 2. Elevator Technique

17. Forceps Technique Indications Fairly mobile teeth, Extraction of single tooth, Extraction of multiple teeth which are scattered. Contraindications In complicated extractions, Deformed roots, Hard tissue pathology of roots like hyper-cementosis etc. Badly destroyed teeth.

18. Advantages – It causes the least amount of trauma. Promotes retention of a satisfactory blood clot. Favours rapid healing.

19. Various movement for extraction of individual tooth Upper central, lateral, canine , second pre-molar First apical slight labial/buccal slight palatal rotation with traction Upper molars F i rst a p i cal buccal p a l a tal deliver the tooth buccaly Lower central, lateral, canine, first pre-molar, second pre-molar First apical slight labial/buccal slight lingual rotation with traction Lower molars F i rst a p i cal buccal l i ng u al deliver the tooth buccaly Maxillary 1 st Premolar- apical,buccal,palatal

20. Elevator technique Indications To luxate teeth which cannot be engaged by beaks of forceps eg: impacted, malposed or grossly destructed teeth. To remove roots

21. DI S A D V ANTAGES- Fracture of maxilla or mandible. Fracture of the alveolar process. Injuring the soft tissue if proper care is not taken. Penetrating into the maxillary sinus, during extraction of maxillary posterior teeth. Forcing a maxillary root into the maxillary sinus or forcing the apical third of the root of the lower third molar into the mandibular canal or into submaxillary or pterygomandibular space depending upon the position of the impacted third molar .

22. Rules to be followed when using an Elevator – Never use an adjacent tooth as a fulcrum unless that tooth is also to be removed. Never use the buccal plate at the gingival line as fulcrum except in third molars. Always use finger guards to protect the patient in case the elevator slips. Use interseptal bone as fulcrum. Avoid using an elevator to luxate a tooth which has a tooth distal to it.

23. APPLICATION OF FORCEP BLADES

24. M a x i l l a r y f o r c e p s

25. M a x i l l a r y f o r c e p s

26. M a n d i b u l a r f o r c e p s

27. E l e v a t o r s

28. E l e v a t o r s

29. OPEN METHOD/ TRANS-ALVEOLAR EXTRACTION Consists of dissecting the tooth or root from bony attachments by removal of some bone investing the tooth/roots, which are then delivered by use of elevators and/or forceps

30. I n d i c a t i o n s : - Root # during forcep extraction Need for excessive force that may lead to # root, bone or both Dilacerated roots Ankylosed tooth Impacted/submerged tooth Endanger to anatomical structures

31. A d v a ntages: Removal of teeth lying in difficult position without damaging the neuro-vascular bundle. Fracture of bone avoided. Less danger of creating an oro-antral fistula. Less chance of tearing of soft tissues & fracture of large pieces of alveolar bone.

32. Steps in Trans-alveolar extraction : Local anesthesia. Incision and reflection of mucoperiosteal flap. Removal of bone/ bone cutting. Sectioning of tooth, if required. Elevation of the tooth.

33. Smoothening of sharp edges of bone. Control of bleeding. Debridement of the socket. Suturing the flap. Suture removal & post-operative follow up.

34. I n c i s i o n : -

35. B o n e r e m o v a l : -

36. T o o t h S e c t i o n i n g : -

37. Stobie technique – extraction of multiple mandibular anteriors by using elevators b/w teeth

38. Postage stamp method In this technique, rows of small holes is made with a small round bur & then they are joined together with either bur or chisel cuts. This simple procedure will minimize the risk of damage to the surrounding tissues & limits the cutting. Disadv : - post operative pain & edema - delayed wound healing

39. INDICATIONS – Patient Under Coverage of BISPHOSPHONATE Hemophilic patients PROCEDURE – Dentin bulge ( arrows) preventing elastics from sliding apically. Root canal treated and split mandibular molar during exfoliation process. Note extrusion of mesial root.

40. Expansion of bony socket specially for forcep extraction sufficient tooth structure elastic bone (children) multiple small fractures of buccal cortical bone 1. Use of a lever & fulcrum remove the tooth/root along the path of least resistance basic factor governing the use of elevators

41. 2. The insertion of wedge or wedges between tooth-root & bony socket wall

42. 3. Wheel & axle principle

43. Take history of – general disease nervousness resistance to inhalational anesthesia previous difficulty with extraction Oral hygiene status of the patient oral prophylaxis antiseptic mouth rinse Clinical examination of the tooth Clinical examination of the oral cavity- any prosthesis

44. PREOPERATIVE RADIOGRAPHS – Indications H/O difficult & attempted extractions Resistance to forcep extraction Planning to remove the tooth by dissection Close approximation with important anatomical structures Abnormal root pattern – third molars, in standing premolars, misplaced canine Tooth having periodontal problem & some sclerosis – hypercementosis Trauma to tooth – fracture of tooth, roots & alveolar bone Isolated & Unopposed maxillary molars Partially erupted, unerupted tooth & retained roots Delayed erupting or having abnormal crown Condition indicating dental or dentoalveolar deformities – osteitis deformans - hypercementosis cleido-cranial dysosteosis - hooked root therapeutic irradiation osteopetrosis

45. GENERAL ANESTHESIA 5-10 min. uncooperative patients 30-45 min. No pre-op preparation Respiratory tract disease Cardiovascular diseases LOCAL ANESTHESIA General factors

46. Local factors Acute infection at the site of injection Hemangioma

47. Is defined as – removal of all micro-organisms from a given object. Hands of operator Instruments Operation area Engines, lights & chairs are inevitably sources of cross-infection. Use the sterile gauze /cloth – to change the position of light.

48. Clear access to & vision of the surgical field. Use of controlled force Unimpeded path of removal

49. Separation of tooth from alveolar bone with crestal & principal periodontal fibers. Alveolar expansion Bleeding is arrested by pressure pack.

50. Severing Soft Tissue Attachment The straight and curved desmotomes

51. Chompret elevators; a straight, and b curved

52. A. Intra-alveolar extraction (closed technique) B. Transalveolar extraction (open method)

53. forcep Technique elevator Technique

54. Commonly used Not used in – hypercementosis root deformities grossly decayed crown grossly decayed root brittle root Advantages - least trauma gingival fibers reduces the size of extraction orifice so promotes healing

55. 1. Beaks should seated as far apically as possible Beaks should be parallel to the long axis of tooth Excess force should be avoided. HOW TO HOLD THE FORCEP Thumb – just below the joint Handle in palm Little finger – inside the handle

56. Buccally & lingual parallel to long axis of tooth. Forced through periodontal membrane, towards apex. Firm pressure. 1 st apply on less accessible side of tooth under direct vision 2 nd ly on other side Cervical caries - 1 st movement towards carious part

57. In multiple extraction cases canine should be extracted prior to extraction of incisors, as prior extraction of incisors weakens the labial cortex.

58. Heavy bladed forceps are used.

59. Works on lever & fulcrum principle It forces the tooth / root along the line of withdrawal R / G Fulcrum – bone or adjacent tooth Elevator grasping

60. Application – in periodontal space 450 to long axis of tooth Placement of gauze between finger and lingual side, for protection from injury in case the elevator slips

61. Application of elevator – Buccally Mes i a lly distally

62. Movement – rotate the elevator along its long axis

63. a During luxation of a tooth, the alveolar ridge is used as a fulcrum, not the adjacent tooth. b Incorrect placement of the instrument. c Photoelastic model showing extraction of the third mandibular molar using a straight elevator. Using the adjacent tooth (second molar) as a fulcrum creates great tension around the tooth, with a risk of injury to tissues surrounding the root

64. Positioning of straight elevator on the distal surface of the root, either perpendicular to, or at an angle to the root

65. Removal of the root of mandibular premolar with the special instrument (endodontic file-based action) for root extraction

66. Separation of roots of the mandibular first molar with fissure bur

67. Roots of mandibular first molar. Extraction is accomplished by sectioning roots using a straight elevator

68. Positioning of the elevator and the fingers of the left hand for separation of molar roots

69. Using an elevator with T-shaped handles to remove intraradicular bone

70. Diagrammatic illustrations showing luxation of the root tip of the mandibular second premolar, using double-angled elevators

71. Technique for removing the tip of a mesial root of a mandibular molar. Removal of intraradicular bone and luxation of the root tip using a double-angled elevator

72. Removal of the tip of the distal root of a maxillary molar

73. Removal of the root tip using an endodontic file. After the endodontic file enters the root canal, the root tip is drawn upwards by hand (a), or with a needle holder (b)

74. Irrigation of the socket Squeezing of the socket Mouth rinsing with warm bland water for once Suturing if require Moist gauze pack Medication Post extraction instructions – verbal & written

75. Intra-alveolar attempt is failed Retained roots in proximity with maxillary sinus & not accessible to forcep History of difficult or attempted extraction Heavily restored tooth Geminated / dilacerated tooth

76. Dens in dente of maxillary left canine Fusion of teeth

77. Deciduous mandibular molar, whose roots embrace the crown of the succedaneous premolar. Risk of concurrent luxation with the simple extraction technique.

78. Main components of transalveolar extraction – Design of mucoperiosteal flap Method to be used to deliver the tooth / root from socket Bone removal used to facilitate tooth / root removal

79. Raise to render the operative site clearly visible & accessible Suture should not be placed over blood clot Obliteration of buccal sulcus should be avoided Base – broad

80. Sharp scalpel Firm pressure Mucousa + periosteum Avoid Button hole formation in case of sinus Incision of sufficient length at once

81. Minnesota retractors for retraction of the cheek and tongue Austin’s retractor

82. To expose root/tooth Facilitated by large flaps Provides point of application After tooth/root removal – remove all sharp edges & bone prominences Instruments used -

83. Round / rose head provides – less clogging, better control. It doesn't cut the tooth that easily Should not contact soft tissue Avoid overheating Postage stemp method then join with chisel

84. Different line of removal for different roots Divide the root from furcation area Make space for application of forcep / elevator Osteotome / burs

85. Engage the elevator in a notch on side of root If notch is not present then create it with round bur directed at 450 angle to the long axis of root.

86. Irrigation of the socket Suturing Moist gauze pack Medication Post extraction instructions – verbal & written Recall after 48 hours Normally 7 days Within 2 days – if it was for control of hemorrhage OAC repair – 10 days

87. COMPLICATIONS OF EXODONTIA

88. FAILURE TO ACHIEVE ANESTHESIA / TOOTH REMOVAL FRACTURE OF TOOTH / SURROUNDING STRUCTURES DISLOCATION DISPLACEMENT OF TOOTH / ROOT EXCESSIVE HEMORRHAGE DAMAGE TO HARD & SOFT TISSUES POSTOPRATIVE PAIN POSTOPERATIVE SWELLING TRISMUS OROANTRAL COMMUNICATION SYNCOPE RESPIRATORY ARREST CARDIAC ARREST ANESTHETIC EMERGENCIES

89. Faulty technique Inadequate solution Test the efficacy of anesthesia Tooth could not be removed with intra-alveolar or trans- alveolar procedure.

90. Crown / root – Grossly carious Tooth with Endodontic treatment Improper application of forcep One point contact Slip off of forcep Excessive force Hurry Tooth with divergent roots /hypercementosis Then trans-alveolar method is indicated

91. Remove all the root fragments except – 5 mm & requires excessive bone removal – well tolerated. (Simpson 1958) Apical 1/3 rd of palatal root of maxillary molars & requires excessive bone removal If removal is indicated – inform the patient radiograph If root is left in place – pulpectomy should be performed.

92. Causes – Excessive inclusion of bone within the forcep beaks Extraction of incisors before canine Intact versus torn periosteum Generally during extraction of maxillary 3 rd molars Pneumatization of maxillary air cells Gemination

93. Management – Preoperative radiograph is essential Raise the mucoperiosteal flap Separate the tooth & bone from gingiva Mattress Suture 10 days If tuberosity is excessively mobile – Splint the tooth for 6-8 weeks Sectioning the crown & pulpectomy.

94. Heavily restored adjacent teeth –in the line of withdrawal Abutment teeth When used as fulcrum Uncontrolled force Under general anesthesia – gauge & props intubation

95. Causes – Excessive / incorrectly applied force Pathologic fracture Senile osteoporosis Precautions – Peroperative radiograph Splint febrication Exraoral support management – Inform the patient Reduce the fractured segment

96. When used as fulcrum Improper use of elevators Give support to adjacent tooth from other hand Don’t apply the elevator mesial to 1 st molar Management – Place the tooth in socket & splint it

97. Causes – Excessive / incorrectly applied force Improper use of mouth gauge Senile osteoporosis Precautions – Take history Exraoral support beneath the angle of mandible Management – Reduce it immediately Reduction technique Instructions to patient

98. Causes – Abnormal root curvature Carious root Roots of premolars & molars involved by sinus Excessive / incorrectly applied force Inadequate grasping of tooth Precautions – Take past dental history Apply the forcep on sufficient tooth structure Leave uninfected apical 1/3 rd of root Never force the root towards sinus Transalveolar method

99. Causes - Maxillary posterior teeth Involvement of sinus lining by – Periapical pathology Diagnosis – Increased intra nasal pressure – air coming out from mouth can be heard Amount of blood will be doubled Wisp of cotton wool will be deflected

100. Management – Mucoperiosteal flap rising Decrease alveolar height Interrupted horizontal suture Protect the clot with – acrylic, denture base, impression material Give incision in sinus membrane Precautions – Mouth rinsing with antiseptic solution before closure of oroantral communication Passage of instruments from mouth to sinus should be avoided.

101. Diagnosis – Air bubbles from socket Cotton wool deflection Fluid taken from oral cavity n ose Management – Take radiograph . Blow the air through nose Under general anesthesia – stop the general anesthesia wait till regaining the cough reflex Suction + irrigation ½ inch wide iodoform gauze Sometimes incision in sinus membrane Caldwell-Luc approach

102. Mostly maxillary third molars Management – Extend the incision posteriorly Blunt dissection Grasp the tooth carefully Or wait for several weeks until it becomes somewhat encapsulated.

103. Reflect the soft tissue flap on lingual aspect of mandible as forward to the premolars gently dissect the mucoperiosteum Detach the mylohyoid muscle.

104. If the root is not appearing in the oral cavity/pressure pack Ask the patient to cough & spit Turn the patient towards the operator & position with the mouth towards the floor. Radiograph of alveolar socket/ sinus/ chest Re-examine the patient after 3 days Patient is asked to report immediately- fever, cough, chest pain occurs.

105. Perioperative hemorrhage – Oozing of blood during operation Management – Wipe Sucker Hot 50 degree celcius for 2 min. Hemostate Local anesthetic solution having vasoconstrictor Gelatine sponge oxidized cellulose After tooth removal – moist pressure pack for 10min. horizontal mattress suture

106. Postoperative hemorrhage – Instructions to the patients – Pressure pack Less talk for 2-3 hrs. Tea bag No smoking for 12 hours No staneous exercise Psychological approach Determine site & amount of hemorrhage Remove excess blood clot Provide firm gauze pack with tannic acid

107. Horizontal mattress suture into mucoperiosteum Wait for 5 minutes after placing gauze pressure on suture Gelatin / fibrin foam & All post extraction instructions and avoid frequent aggressive mouth rinsing

108. Gingiva Lower lip – mechanical & thermal injury Tongue & floor of mouth

109. Causes – Compression with clot or bone debris Partially or completely torn Precautions – Preoperative radiograph Elevator should not be forced below tooth Resect 1 root before tooth elevation Management – Reposition the ends at close approximation Decompression Microsurgical reanastomosis Nerve grafting

110. Causes – Transalveolar extraction of premolars Precautions – More Bone reduction mesial to 1 st premolar & distal to 2 nd premolar Retraction of nerve with mental retractor

111. Burs Management – drilling the groove around it .

112. Submucosally & subcutaneously Older patients – increased capillary fragility decreased tissue tone weaker inter cellular attachments Onset 2-4 days Resolve within 7 – 10 days

113. Cause – Suture without adequate bony foundation Suturing the wound under tension Mostly in the region of mandibular 2 nd & 3 rd molar (internal oblique ridge) Management – Leave the projection – slough out within 2-4 weeks Smooth it with bone file under local anesthesia.

114. 1. Due to traumatized hard tissue – Bruising from bone during intrumentation Excessive heating from bur Sharp bony edges Avoidance of tissue toileting 2. Due to traumatized soft tissue – Incision only through mucous membrane ragged flap - heals slowly Too small flap – much traumatic retraction Injury from bur.

115. Synonyms : alveolar osteitis (AO), localized osteitis, postoperative alveolitis, alveolalgia, alveolitis sicca dolorosa, septic socket, necrotic socket, localized osteomyelitis, fibrinolytic alveolitis

116. Postoperative pain in and around the extraction site, which increases in severity at any time between 1 and 3 days after the extraction accompanied by a partially or totally disintegrated blood clot within the alveolar socket with or without halitosis. I. R. Blum : Contemporary views on dry socket (alveolar osteitis): a clinical appraisal of standardization, etiopathogenesis and management: a critical review. Int. J. Oral Maxillofac. Surg. 2002; 31: 309–317. 2002 International Association of Oral and Maxillofacial Surgeons

117. Mostly 1–3 days after tooth extraction . Within a week - In 95% and 100% of all cases. Unlikely - before the first postoperative day. because the blood clot contains anti-plasmin that must be consumed by plasmin before clot disintegration can take place. The duration of alveolar osteitis varies to some degree, depending on the severity of the disease, but it usually ranges from 5–10 days.

118. The denuded alveolar bare bone may be painful and tender. Initially blood clot appears dirty gray disintegrates grayish yellow bony socket bare of granulation tissue Some patients may also complain of intense continuous pain irradiating to the ipsilateral ear, temporal region or the eye. Regional lymphadenopathy (occasionally). unpleasant taste (occasionally). Trismus is a rare occurrence in mandibular third molar extractions probably due to lengthy and traumatic surgery.

119. Multifactorial origin Following have been implicated most commonly as etiological, aggravating and precipitating factors: Oral micro-organisms - Treponema denticola Difficulty and trauma during surgery Roots or bone fragments remaining in the wound Excessive irrigation or curettage of the alveolus after extraction Physical dislodgement of the clot Local blood perfusion & anesthesia Oral contraceptives - estrogens, like pyrogens will activate the fibrinolytic system indirectly. Smoking

120. 1. Previous experience. 2. Deeply impacted mandibular third molar (risk factor is directly proportional to increasing severity of impaction) . 3. Poor oral hygiene of patient . 4. Active or recent history of acute ulcerative gingivitis or pericoronitis . 5. Associated with the tooth to be extracted . 6. Smoking (especially >20 cigarettes per day) . 7. Use of oral contraceptives . 8. Immunocompromised individuals .

121. Antibacterial agents - Antiseptic agents and lavage Chlorhexidine (CHX) Antifibrinolytic agents - para-hydroxybenzoic acid (PHBA), Steroid anti-inflammatory agents - polylactic acid (PLA) Obtundent dressings Clot supporting agents

122. Remove any sutures to allow adequate exposure of the extraction site. As the socket may be exquisitely tender local anaesthesia may be required. Irrigate the socket gently with war sterile isotonic saline or local anaesthetic solution, which is followed by careful suctioning of all excess irrigation solution. Do not attempt to curette the socket , as this will increase the level of pain. Prescription of potent oral analgesics . The patient is given a plastic syringe with a curved tip for home irrigation with chlorhexidine solution or saline and instructed to keep the socket clean. Once the socket no longer collects any debris, home irrigation can be discontinued.

123. S.C. Anand, V. Singh, M. Goel, A. Verma, B. Rai: Dry Socket An Apriasal And Surgical Management. The Internet Journal of Dental Science . 2006 Volume 4 Number 1. DOI: 10.5580/e31 Under block anesthesia The clot devoided socket is thoroughly curetted, both from the floor of the socket as well as from the bony walls. The sharp margins were trimmed, rounded. Any foreign bodies if present were thouroghly removed. The detached gingival margins were also scraped. The desired medications as well as precautions . Patient was not only without pain, but was also comfortable both physically as well as psychologically from the very next day.

124. Normal oedema After multiple teeth extraction surgical tooth extraction Traumatic oedema Blunt instrumentation Excessive extraction of badly designed flap Too tight suture Management – Ice pack application Heat application

125. Subcutaneous emphysema – Air into connective tissue of intramuscular & fascial spaces Swelling is of sudden onset. Crackles can be felt under finger Resolves within 1-2 days Due to infection of wound – Preoperative antibiotic Prevention of entry of micro-organism into wound Mild infection – intraoral hot saline mouth wash

126. It is defined as inability to open the mouth due to muscle spasm. Causes – Post operative oedema Hematoma formation Inflammation of soft tissue After mandibular block Traumatic arthritis of TMJ Multiple injections

127. Management – Treat underlying cause Intraoral heat application Antibiotics & specialist treatment.

128. Transient loss of consciousness and postural tone characterized by rapid onset, short duration, and spontaneous recovery due to global cerebral hypoperfusion that most often results from hypotension. Sign & symptoms – dizziness, weakness, nausea skin is cold, pale & sweating. Management – Position Oxygen administration Blood pressure & pulse measurement 250 mg aminophylline is given slowly.

129. Skeletal muscle become flaccid pupil dilate widely management – Patient flat on the floor Clean the airway Pull the mandible forward Extend the neck fully Pulmonary resuscitation so that chest is seen to rise every 3-4 sec. Brook airway can be inserted over tongue Check carotid pulse & apex beats at regular intervals

130. Sign & symptoms – Deathly pallor & grayness of skin Cold sweat Pulse & apex beat can be felt Heart sounds can not be audible Children - Beginning of heartbeat if the sternum is tapped sharply Adult – Patient flat on the floor Cardiac compression at 1 second interval

131. Syncope, respiratory arrest & cardiac arrest complicate the general anesthesia. Management – Clear the airway Remove all the packs, debris & apparatus from mouth. Pull the mandible forward Extend the neck Head – downward /forward in dental chair - upward if lying on the floor Oxygen Larygotomy Tracheostomy

132. Technological Advances in Extraction Techniques and Outpatient Oral Surgery Adam Weiss, DDS*, Avichai Stern, DDS, Harry Dym, DDS Department of Dentistry and Oral and Maxillofacial Surgery, The Brooklyn Hospital Center, 121 Dekalb Avenue, Brooklyn, NY 11201, USA * Corresponding author. E-mail address: [email protected] KEYWORDS Powered periotome Polyurethane foam Piezosurgery Immediate implants Orthodontic extrusion Bone grafting Physics forceps Dent Clin N Am 55 (2011) 501–513 doi: 10.1016/j.cden.2011.02.008 dental.theclinics.com 0011-8532/11/$ – see front matter 2011 Elsevier Inc. All rights reserved.

133. 1. 2. 3. 4. 5. 6.

134. Powertome® Assisted Atraumatic Tooth Extraction The Journal of Implant & Advanced Clinical Dentistry Jason White, Dan Holtzclaw, Nicholas Toscano September 2009 Volume 1, No. 6

135. Precise extraction of tooth Preserves bone & gingival architecture Option for immediate implant placement Mechanism of “WEDGINNG” & “SEVERING” Severs the periodontal ligament Multirooted teeth requires sectioning.

136. Presurgical radiograph of Case 1. Powertome® blade advanced in a ”sweeping” fashion. Rotational movement of root with forceps Atraumatic removal of the tooth

137. Presurgical clinical presentation Powertome® blade advanced down PDL Extracted segments of maxillary canine

138. Presurgical radiograph Presurgical clinical presentation

139. Piezosurgery is an innovative bone surgery technique that produces a modulated ultrasonic frequency of 24 to 29 kHz , and a microvibration amplitude between 60 and 200 mm/s . The amplitude of the vibrations created allows a very clean and precise surgical cut. It works selectively, without harming soft tissues such as nerves and blood vessels even with accidental contact with the cutting tip. The surgical control of the device is effortless compared with rotational burs or oscillating saws because there is no need for an additional force to oppose rotation or oscillation of the instrument.

140. Despite the longer time of the procedure , the investigators also noted that the piezoelectric osteotomy reduced postoperative facial swelling and trismus. Uses of piezosurgery device to cut and elevate a precisely defined bone lid on the lateral cortex of the mandible to provide access to the teeth needing extraction or even a lesion that needs to be excised. The bone window is then elevated with the help of a curved osteotome. After the visual confirmation of an undamaged IAN and adjacent tissues, the bone lid is placed back into its original position and fixated with absorbable miniplates.

141. For the surgical extraction of the teeth, the covering bone was first ablated, layer by layer, using the Er:YAG laser. In the case of the fiber-optic Er:YAG [erbium:yttrium-aluminum garnet ], laser the fiber is closely guided around the teeth, creating a narrow gap with minimal bone loss. The benefits of laser therapy include the creation of a bloodless surgical field and thus improved visualization during surgery, decreased postoperative pain, and limited scarring and contraction. Time consuming, sound and smell , significantly inhibition the laser cutting because of the overall volume of irrigation and blood covering the bone surface.

142. Third molars in close proximity to the IAN have a significant negative impact on recovery for pain and oral function. The advantage of this technique is that the risk of direct trauma to the nerve is eliminated , due to both the increased distance between the roots and the mandibular canal and the decreased need for surgical manipulation during the extraction.

143. A potential problem with this technique is soft tissue damage from impingement on the mucosa of the cheek and the gingiva. In addition, working in this area of the mouth presents great difficulty, and the action of the masseter muscle leads to cheek compression against the orthodontic appliances. This technique will be of no value for a tooth that cannot move because of ankylosis . This technique should be used only in carefully selected cases in conjunction with an orthodontist, being certainly difficult, time consuming, and not always successful.

144. © 2010 American Association of Oral and Maxillofacial Surgeons 0278-2391/10/6802-0032$36.00/0 doi:10.1016/j.joms.2009.07.038 J Oral Maxillofac Surg 68:442-446, 2010

145. Panoramic radiograph at initial consultation. The mandibular third molars are mesially impacted with the roots close to the alveolar canal.

146. Postoperative radiograph after second sectioning of the right mandibular third molar. A pulpotomy has been performed. More space was created distal to the right mandibular second molar to allow further migration Postoperative radiograph after the right mandibular third molar was surgically sectioned. The space distal to the second molar would allow mesial migration of the impacted tooth.

147. 3 months after odontectomy. The third molar moved mesially. However, the mesial root was still in contact with the alveolar canal. A second sectioning was required. Periapical radiograph obtained 2 months after second sectioning. At that time, the roots were away from the alveolar canal, and a riskless extraction could be scheduled.

148. The Physics Forceps uses first-class level mechanics to atraumatically extract a tooth from its socket. One handle of the device is connected to a “bumper,” which acts as a fulcrum during the extraction. Together the “beak and bumper” design acts as a simple first-class lever. A squeezing motion should not used with these forceps. By contrast, the handles are actually rotated as one unit using a steady yet gentle rotational force with wrist movement only. Once the tooth is loosened, it may be removed with traditional instruments such as a conventional forceps

149. GMX-100R - Upper Right - Extracts Teeth 2 to 5 GMX-100L - Upper Left - Extracts Teeth 12 to 15 GMX-100A - Upper Anterior - Extracts Teeth 6 to 11 GMX-200 - Lower Universal - Extracts Teeth 18 to 31

150. 1*,3Oral and Maxillofacial Surgery, Oral and Maxillofacial Department, Guys Hospital, Floor 23, Great Maze Pond, London, SE1 9RT; 2Restorative Dentistry, Guys Hospital, Floor 26, Great Maze Pond, London, SE1 9RT *Correspondence to: Dr Vinod Patel Email: [email protected] Refereed Paper Accepted 29 April 2010 DOI: 10.1038/sj.bdj.2010.673 © British Dental Journal 2010; 209: 111 – 114 BRITISH DENTAL JOURNAL VOLUME 209 NO. 3 AUG 14 2010 Coronectomy is a technique that should be considered for mandibular third molars when it is felt there is an increased risk of injury to the inferior dental nerve. Coronectomy is oral surgery’s approach to minimal interventional dentistry.

151. Coronectomy can be beneficial but success requires both good patient selection and operator technique. Renton et al .reported no IDNI in 58 successful Coronectomy patients and a 19% IDNI rate in those having traditional extractions. Leung et al. showed nine (5%) patients in the control group presented with IDNI, compared with one (0.06%) in the Coronectomy group. Hantano et al. reported that in the extraction group six patients (5%) suffered IDNI, of which 3 patients were diagnosed with permanent injury, where as in the Coronectomy group one patient (1%) complained of altered sensation post-operatively which resolved within one month. The retrospective analysis of O’Riordan consisted of 52 patients that underwent Coronectomy. In this study there were 3 cases of transient IDNI which showed resolution one week post operatively. One patient developed permanent IDNI, which was thought to be as a result of perforation of the canal due to operator error rather than the Coronectomy technique itself.

152. 1, deviation of the canal 2, narrowing of the canal 3, periapical radiolucent area 4, narrowing of root; 5,darkening of roots 6, curving of root 7, loss of lamina dura of canal

153. Coronectomy: A, cutting crown below cement-enamel junction (arrow); B, trimming cutting surface to less than 3 to 4 mm below alveolar crest. Radiographic imaging showing pre and post coronectomy of the right mandibular third molar (48)

154. To avoid traumatizing the surrounding bone during elevation, implant drills were placed in the root canals to thin the root walls giving way to extraction with the application of much less force, thereby decreasing the chance of traumatizing the thin buccal bone.

155. RES O URCES Text books The extraction of teeth by – GEOFFREY L HOWE Oral & maxillofacial surgery volume 2 , by – DANIEL M. LASKIN Oral Surgery by - FRAGISKOS D. FRAGISKOS Contemporary Oral & maxillofacial surgery by- HUPP, ELLIS, TUCKER Text book of Oral & maxillofacial surgery by – S M BALAJI.

156. RES O URCES Technological Advances in Extraction Techniques and Outpatient Oral Surgery Adam Weiss, DDS *, Avichai Stern, DDS, Harry Dym, DDS Dent Clin N Am 55 (2011) 501– 513 doi:10.1016/j.cden.2011.02.008 dental.theclinics.com 0011-8532/11/$ – see front matter 2011 Elsevier Inc. Powertome® Assisted Atraumatic Tooth Extraction, The Journal of Implant & Advanced Clinical Dentistry, Jason White, Dan Holtzclaw, Nicholas Toscano, September 2009 Volume 1, No. 6 Staged Removal of Horizontally Impacted Third Molars to Reduce Risk of Inferior Alveolar Nerve Injury Luca Landi, DDS,* Paolo Francesco Manicone, DDS,† Stefano Piccinelli, DDS,‡ Alessandro Raia, DDS, PhD,§ and Roberto Raia, DDS, J Oral Maxillofac Surg 68:442-446, 2010 Enhancing Extraction Socket Therapy Robert A. Horowitz, Michael D. Rohrer, Hari S. Prasad, Ziv Mazor, The Journal of Implant & Advanced Clinical Dentistry, Jason White, Dan Holtzclaw, Nicholas Toscano, September 2009 Volume 1, No. 6 Coronectomy – oral surgery’s answer to modern day conservative dentistry V. Patel, S. Moore and C. Sproat, Refereed Paper Accepted 29 April 2010 DOI: 10.1038/sj.bdj.2010.673 ©British Dental Journal 2010; 209: 111–114, BRITISH DENTAL JOURNAL VOLUME 209 NO. 3 AUG 14 2010

157. RES O URCES 6. Atraumatic Teeth Extraction in Bisphosphonate-Treated Patients Eran Regev, DMD, MD,* Joshua Lustmann, DMD,†and Rizan Nashef, DMD‡ 2008 American Association of Oral and Maxillofacial Surgeons © J Oral Maxillofac Surg 66:1157-1161, 2008 0278-2391/08/6606-0011$34.00/0 doi:10.1016/j.joms.2008.01.059