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Cysts of The Jaws Symptoms INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com

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Cysts of The Jaws Symptoms Pathological fracture Mistaken for abscess Displacement of denture Displacement of teeth Discoloration of tooth www.indiandentalacademy.com


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Cysts of the Jaws Marsupialisation – Rationale

By making a small cystic Contents are evacuated thereby Causing decompression of the Cyst. www.indiandentalacademy.com


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How often are teeth Impacted Only 17% of people over 20 years Have an impacted tooth Maxillary third molars Mandibular third molars Maxillary canine Ref:- Dachi S.F,Hovell over surg 14:1165.1961 www.indiandentalacademy.com

22% 18% 0.9%


• What is so special about third molars ?!

• last tooth to erupt • More likely to be impacted • More likely to cause complication

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ETIOLOGICAL THEORIES PHYLOGENIC MENDELIAN ENDOCRINE DISORDERS SKELETAL GROWTH DISTURBANCES SYSTEMIC CONDITIONS LOCAL FACTORS www.indiandentalacademy.com


INDICATION FOR REMOVAL Recurrent Pericoronitis Periodontal Orthodontic Reasons Dental Caries Resorbtion Of Second Molar www.indiandentalacademy.com


INDICATIONS FOR REMOVAL 1.Reffered pain 2. Cyst Formation 3. Prophylactic Reasons 4. Edentulous Mandible 5. In the line of fractures www.indiandentalacademy.com


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IMPACTED LOWER THIRD MOLAR Classification : George Winter’s Pell and Gregory’s Kay’s

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GERGE WINTER’S CLASSIFICATION Based on the relationship of the long Axis of impacted 3rd molar with the Long axis of 2nd molar:Vertical Mesioangular Distoangular Horizontal Buccoangular Aberrant Positons www.indiandentalacademy.com


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Pell & Gregory(1942) Classification Based on Three Aspects Position & Angulation Space between second molar and ramus Depth of the third molar in the bone

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Pell & Gregory Position & Angulation George Winter’s Classification is adopted www.indiandentalacademy.com


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Kay’s Classification ( Based on three aspects) 1.Position & Angulation - Winter’s Classification States of Eruption -a) Erupted b) Partly erupted c) Unerupted 3. Number & Pattern - Fused of Roots Two Multiple Favourable Unfavourable www.indiandentalacademy.com


Difficulty index Pederson) Minimal

3-4

Moderate

5-7

Very difficult

7-10

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Difficulty index values(Pederson) Mesioangular 1 horizontal 2 vertical 3 distoangular 4 level A level B level C

1 2 3

Class I 1 Class II 2 Class III 3 www.indiandentalacademy.com


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WINTER’S IMAGINARY LINES White Line - Indicates position of 3rd molar Amber Line - Indicates margin of alveolar bone Red Line - Indicates dept of 3rd molar www.indiandentalacademy.com


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Clinical Assissment General Factors - Age - Medical Condition - Temperament

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Assessment of Impacted Third Molar Purpose of Assessment Possible Difficulties & Complications Facilities Available Necessary Surgical Skill Decision to remove or to refer to A specialist www.indiandentalacademy.com


Radiological Assessment - Radiograptus Required - Periapical Film - Lateral oblique view of mandible - Orthopantomogram www.indiandentalacademy.com


Clinical Assessment Local factors Small Factors Small mouth Mandibula retrusion Relationship of external Oblique eidue to the 3rd molar www.indiandentalacademy.com


Radiological Assessment Points to be noticed in radiograph:Augulation and depth Number and shape of rooths Relationship with mandibular canal Condition of crown & rooth of 2nd molar Density of the bone Bone loss around the tooth Presence of first molar www.indiandentalacademy.com


Relationship with mandibular canal Normal relationship Variations - Groove - Deep Groove - Perforation www.indiandentalacademy.com


Considerations in perdicting difficulty Age Anatomy Facial from www.indiandentalacademy.com


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Age:- Does it affect surgery ? Young age

Easy surgery less morbidity

old age

Difficult surgery Greater morbidity www.indiandentalacademy.com


Accessibility based on facial from Tapering

Easy surgery

Square & Compact

Difficult www.indiandentalacademy.com


Asymptomatic third molar - let sleeping dogs lie - don’t bother it, if it does not bother you - don’t touch if asymptomatic www.indiandentalacademy.com


Should a general practitioner remove an impached third molar ? Answer is yes and no

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Operative Plan - Incision - Removal of bone] - Removal of tooth - To let of the wound - Closure of the wound www.indiandentalacademy.com


Removel of Third Molar Careful Assessment Instruments selection Choice of anaesthesia Operative plan Post operative care www.indiandentalacademy.com


Choice of Anaesthesia Local Intravenous sedation And local - General

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Scientific foundations of Minor oral surgery Muco Periosteal Flaps Visibility Vascularity Healing www.indiandentalacademy.com


Scientific Foundtions of minor oral surgery Access Mucoperiosteal flaps Bone Removel www.indiandentalacademy.com


Complication During Surgical Removal Incision

- Haemorrhage Lingul Nerve damage Bone removal - Injury to soft tissues Damage to 2nd molar Splitting of ramus Damage to bone Elevation of - Fracture of tooth Damage to 2nd molar Damage to I.D Bundle Fracture of mandible Toilet of the - Damage to I.D Nerve www.indiandentalacademy.com Wond And Vessels


Complications (Postoperative) - Haemorrhage - Haematoma - Oedema - Pain - Trismus www.indiandentalacademy.com


Exodontia Complications :- Dry socket Synonyms:Alveolitis, Alveolar osteitis, Etc Defn:“ A post extraction socket which lacks a physiological blood clot.” www.indiandentalacademy.com


Exodontia Dry Socket Etiology Exact etiology unknown Trauma Infection Vasoconstrictor effect Mechanical dislodgement Fibrinolytic theory www.indiandentalacademy.com


Exodontia Dry Socket :- Clinical Features Symptoms:Pain, Swelling, Trismus, Halitosis Signs:Lack of clot in the socket Exposed bone tender to touch Inflammed gingival margin Enlarged lymph nodes www.indiandentalacademy.com


Exodontia Dry Socket:- Treatment Aimed at Control of pain Sedative dressing Analgesics Control of infection Antibiotics www.indiandentalacademy.com


Exodontia Post Extraction Bleeding Investigation Bleeding time Plastelet count Prothrombia time Partial thrombopiastin time www.indiandentalacademy.com


Exodontia Post Extraction Bleeding Causes Local Trauma Infection Systemic Defect in vessel wall Defect in plastelets Defect in coagulation www.indiandentalacademy.com


Exodontia Post Extraction Bleeding Management - local measures Soft Tissue Pressure packs, vasoconstrictors Suturing, chemicals,cautery Bone Burnishing,bone wax Haemostatic agents Socket plugs www.indiandentalacademy.com


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Exodontia Indications Impacted, Malposed, Supernumerary Attrition, abrasion, erosion Involved in cysts & tumours Fractured teeth In line of fracture www.indiandentalacademy.com


Exodontia Objectives To remove the tooth completely With minimum trauma Elimination of pathology in the socket Prepare the socket for proper Healing & repair www.indiandentalacademy.com


Exodontia Techniques Intra alveolar - forceps method Transalveolar - open method Elevators metod

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Exodontia Intra Aloveolar- Principles Parallelism Beaks placed on cementum Maximum contact between Beaks & the root surface Amount & types of force Expansion of the bony socket www.indiandentalacademy.com


Exodontia Intra Alveolar Movements Primary rotation Buccolingual or palatal Buccolingual & secondary rotation

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Exodontia Trans Alveolar - Indications Gross destruction of crown Fallure to extract with forceps Abnormallties of root Non vital teeth Ankylosis of root Brittle teeth Increased dentsity of bone www.indiandentalacademy.com


Exodontia Trans Alveolar Advantages Good visibility Prevent laceration of gingival Minimal trauma to bone Root fracture prevented Less post operative discomfort

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Exodontia Trans Alveolar Surgical Step

Anaesthesia Incision & raising flap Remove of bone Removal of tooth or root Debridement of the socket Closure of the wound Post operative care www.indiandentalacademy.com


Exodontia Complication During Extraction Fracture of root Fracture of alveolues Damage to soft tissues Damage to adjacent teeth Haemorrhage

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Exodontia Complication Root Fracture Fallure to follow principles Structural weakness of tooth Bone investing the tooth

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Exodontia Complacations Maxillary posterior teeth Oro antral communication Rooth displacesment in to sinus Fracture of maxillary tuberoslty Mandibular posterior teeth Dislocation of TM joint Fracture of mandible www.indiandentalacademy.com


Exodontia Complications- TMJ Dislocation DEF : Condyle comes out of glenold fossa Unllateral or bllateral CAUSES Fallure to support mandlble Excessive mount opening Use of mount gag under G.A Use of certain drugs www.indiandentalacademy.com


Exodontia Complication-post Extraction Plain Swelling Trismus Dry Socket Haemorrhage

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Scientific Foundations of Minor Oral Surgery Dental Bacteremla In Children A study conducted involving patiients who Underwent variety of dental procedures Including rubberdam application matrix band With wedge and tooth brushing revealed Significant bacteremia.

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Post Operative Pain Influenced By Pathophysiologic Impact Site of Surgery Preoperative Preparation Physical & Emotional Status Intra operative management Post operative team www.indiandentalacademy.com


Scientific Foundation of Minor Oral Surgery Suture Material And Bacterial Adherence A study conducted in vitro to see the Bacterial adherence to silk and cotton Sutures revealed significantly higher Adherence to silk than cotton.cotton should Be the preferred suture material for skin and Mucosal closure. www.indiandentalacademy.com


Most feared modality Pain Anaesthetic Injection Swelling Numbness Other

43% 18% 17% 10% 06% 06%

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Pain Mechanisms Peripheral Tissue Injury Transmission Through The Nerves Perception Withhin The Brain

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Dental Elevators In Common Use Coupland Chisel Cryers Warwick james Hospital Pattern Apexo Winter’s crossbar

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Dental Elevators Classification Use: Removal of teeth Root broken at C.E junction Root broken below C.E junction Form: Straight Curved Crossbar www.indiandentalacademy.com


Dental Elevators Principles Lever Wedge Wheel & axle

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Scientific Foundations of Oral Surgery Surgical Gloves How often They Puncture The incidence may be as high as 50 to 70% when the operations last more Than 2 hours. The left index finger is The most common site of perforation

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Scientific Foundation of Minor Oral Surgery Face Mask is it Essential ? A prospective randomised study, From sweden found no difference in Wound infection rates when masks Were climinated

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Diagnosis In Oral Surgery Components

History taking Clinical examination Investigations

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Diagnosis In Oral Surgery Diagnosis:- Definition “ Careful investigation of the facts To determine the nature of a think�

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Diagnosis In Oral Surgery History Taking General information Chief complaint History of present illness Personal, medical & Dental histories Family & Social histories

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Diagnosis In Oral Surgery Singn:- Definition

“ Any change I the body or its Function which is perceptible to a Trained observer and may indicate Disease.�

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Diagnosis In Oral Surgery Singn:- Definition

“ Any change I the body or its Function which is perceptible to a Trained observer and may indicate Disease.�

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Diagnosis In Oral Surgery Singn:- Definition

•General examination •Local examination • Extra oral • Intra oral www.indiandentalacademy.com


Diagnosis In Oral Surgery Examination:- Extra Oral •T.M. Joints •Maxillary sinuses •Lymph nodes •Lips •Lesion www.indiandentalacademy.com


Diagnosis In Oral Surgery Examination:- Extra Oral

Soft tissues Hard tissues Occlusion Special pathology (lession of interest) www.indiandentalacademy.com


Diagnosis In Oral Surgery Investigation:- General Temperature Pulse & B.P Urine analysis Haemogram Tests for haemorrhage Blood chemistry www.indiandentalacademy.com


Diagnosis In Oral Surgery Investigation:-Dental X-Rays Percussion Vitality tests Aspiration Bacteriology Biopsy www.indiandentalacademy.com


Antibiotics Principles of Treatment Diagnosis Choice of drug Dosage and route Accompanying treatment Combination of drugs Hypersensitivity www.indiandentalacademy.com


Antibiotics Site of Action Cell Wall Cell Membrane Protein Synthesis Nucleic acid synthesis

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Antibiotics Site of Action:-Cell Wall Prevention of cross linkage of peptide strands e.g. Penicillins Cephalosporins www.indiandentalacademy.com


Antibiotics Site of Action Selective permeability of the Membrance is affected e.g. Polymyxins Nystatin Amphotericin-B

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Antibiotics Site of Action:-Protein Synthesis Block of amino acid transfer Tetracyclins Block of transpeptidation Chloremphenicol Interference with MRNA function Aminoglycosides Block of traslocation Macrolids www.indiandentalacademy.com


Antibiotics Site of Action:- Nucleic Acid Metabolism Interference in the production of DNA Or RNA e.g. Sulphonamides Trimethoprim

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Antibotics Uses Therapeutic Prophylactic General Specific www.indiandentalacademy.com


Impacted Maxillary Canine classification Labial Position Palatal Position Intermediate Position Unusual Position

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Impacted Maxillary Canine Localization-Clinical Evidence of eruption Bulge on labial aspect Bulge on palatal aspect

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Impacted Maxillary Canine Localization-Radiological

Vertex occlusal view Lateral skull radiograph Parallox method of clark

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Impacted Maxillary Canine Management

No surgical intervention Surgical exposure & othodontic alignment Surgical removal & auto transplantation Surgical removal www.indiandentalacademy.com


Strategies for Pain Control

Use of A Long Acting L.A, Agent e.g. Bupivicaine Etidocaine

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Supression At Higher Sites In CNS Use of Oploids Morphine Pethidine Codeine www.indiandentalacademy.com


Strategies For Pain Control Pre operative Administration Of Nsaids

There is sufficient scientific evidence Suggesting delay and low pain levels after Preoperative administration of nsaids www.indiandentalacademy.com


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Scientific Foundations of Minor Oral Surgery Influence of socket closure on post operative pain and swelling Complete closure of third molar socket lead to increased post Operative pain and swelling experience compared with maintaining The socket partially open with a dressing www.indiandentalacademy.com


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Strategies For Pain Control Use of Oplods Codeine 60 mgs. Oxycodone 5 to 10 mgs.

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Seientific Foundations of Minor oral Surgery Anxiety Measures To Overcome Information Procedural Sensation Modeling Distraction Relaxation Hypnosis www.indiandentalacademy.com


Scientific Foundations of Minor oral Surgery Preoperative Visits To Reduce Patient Anxiety A Study to evaluate the effect of Preoperative visits by health Professionals showed a significant Decrease in anxiety during the post Operative period A Positive relationship Between preoperative anxiety levels and The level of pain was found. www.indiandentalacademy.com


Scientific Foundations of Minor oral Surgery Post Operative Pain Management In Childern A study conducted to assess the efficacy Of pre-operative administration of Acetaminophen indicated a high prevalence Of post operative pain irrespective of the Procedure used and there was a trend Toward reduced pain in acetaminophen pre Treatment group. www.indiandentalacademy.com


Reduction of Post Operative Pain

“ irrigation of third molar socket With Bupivacaine 0.75% produced Significant reduction in pain on the First post operative day�

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Reduction of alveolar osteitis incidence

“ a prospective double blind placebo Controlled study to determine the effect Preoperative 0.1% chlorhexidine gluconate Rinse showed 60% reduction in the Incidence of alveolar osteitis� www.indiandentalacademy.com


Scientific Foundations of Minor oral Surgery Post Operative Pain In Oral Surgery Aspirin, Mefenamic Acid and Their Combination A double-bind randomized single Dose study of the effects of 650 mgs Aspirin, 250 mgs mefenamic acid, the Combination of the both in same dosage Indicated relief from pain in each group Compared to the placebo and the combination Appeared more effective than both drugs alone. www.indiandentalacademy.com


Do All Intraoral Incission require Suturing

With proper understanding of surgical Principal and appropriate modification The indication for suturing and post Operative inconvenience to the patient Can be reduced www.indiandentalacademy.com


Scientific Foundations of Minor oral Surgery

The value of bupivavaine and Presurgical treatment with Nsaids and steroids in the Management of postoperative Complication Dr. Neelima

Prof.C.B.Roa

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Scientific Foundations of Minor oral Surgery Post Operative Pain The study indicated that the group which had Third molars removed with bupivacaine as the L.A. agent and pretreatment administration Of lbuprofen 400 mg and 8 mgs of dexamethasone Have experienced less and delayed pain. www.indiandentalacademy.com


Post Operative Management - Pain - Swlling Infection

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Post Operative Management Pain Swlling Infection

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Is antibiotic Prophylaxis Necessary

“ A clinical double blind placebo study to Test the value of prophylactic use of Phenoxy methyl penicillin and tinidazole Indicated that neither of them have more Effect on post op complications than placebo� www.indiandentalacademy.com


Antibiotic Prophylaxis Who needs it ? -In minor oral surgery – unnecessary -In evidence that it is necessary in Surgical removal of third molars Rood (1970) reported that the use of prophylaxis confers no advantages even when surgically removing Third molar in the presence of acute pericoronitis or Acute ulcerative gingivitis www.indiandentalacademy.com


Scientific Foundations of Minor oral Surgery Antibiotics-Prophylactic Use “ A Clinical trail with prophylactic use of Phenoxymethy1 Penicillin and tinidazole In mandibular third molar surgery had no Effect on the reduction of post operative Complications� www.indiandentalacademy.com


Scientific Foundations of Minor oral Surgery Who Needs It ? 1. Patients with impaired host defense 2. Patients undergoing surgical procedure where The risk of infection is small but Consequences are very serious e.g.. Infective Endocarditis. 3. Patients undergoing surgical procedures which Have a high rate of infections (normal host defense mechanisms), But the nature of surgery vulnerable to infection. www.indiandentalacademy.com


Scientific Foundations of Minor oral Surgery Antibiotic Prophylaxis Has Timing Any Influence Administration of antibiotic immediately Prior to surgical incision incision should be Effective prophylaxis for surgical wound Infections. www.indiandentalacademy.com


Scientific Foundations of Minor oral Surgery Antibiotic Prophylaxis What should Be The Duration of Administration ? A study conducted using three different Antibiotic regimens suggested that a Single done of preoperative antibiotic is Sufficent for prophylaxis when surgery Is completed with in 3 hours. Antibiotic Converage should extend for operation Of longer duration no value of antibiotic www.indiandentalacademy.com After the operation.


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T.M.Joint MPDS Treatment •Reassurance •Occlusal Correction •Anterior bite splint •Full occlusal splints •Soft splints

•Drug therapy •Intermaxillary fixation •Inter articular injection •Phychiatric consultation •Surgery

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T.M.Joint MPDS Locking Joint •Increased muscle load •Alteration in the articular surface •Interference with free sliding of Upper joint comoartment •Disc fails to slide forwaed, remains stuck •Locking of the jaw www.indiandentalacademy.com


T.M. Joint MPDS Clicking Joint •Muscular overloading of joint •Frictional hesitation of movements of disc •Disc sticks in early opening •On further opening suddenly Recommences its forward movement Resulting in click www.indiandentalacademy.com


T.M.Joint MPDS Signs

•Joint tenderness •Muscle tenderness •Abnormalities of mandibular movement www.indiandentalacademy.com


T.M.Joint MPDS Symptoms Pain Limitation of mandibular movement Clicking

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T.M.Joint MPDS Evidence In Support Of Theory Higher level of steroids & Catecholamines Reaction to stress by somatization & repression Electromyography www.indiandentalacademy.com


T.M.Joint MPDS Psychophysiologic Theory Stress Clenching & grinding Muscle – fatigue spasm Pain

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T.M.Joint MPDS Etiological Concepts

Over closure hypothesis Defects in dental occlusion Abnormalities in muscle & muscle activities

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T.M.Joint MPDS Synonyms Costen syndrome (1934) T.M.J pain dysfunction syndrome Schwartz (1956) Myo facial oain dysfunction Syndrome Laskin (1969) www.indiandentalacademy.com


T.M.Joint MPDS Surgical Procedures Condylotomy – Ward (1960) Myotomy – Laskin & Cooper (1972) High condylectomy – Henny & Bald ridge (1967) Reduction of articular eminence – lrby (1980) Menisectomy – Lanz (1909) Capsular rearrangement. www.indiandentalacademy.com


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Haemorrhage Classification :- Depending on vessel

Arterial Bright red, spurting as a jet Venous Dark red, steady flow Capillary Bright red ooze www.indiandentalacademy.com


Haemorrhage Classification

External Visible or revealed Internal Invisible or concealed www.indiandentalacademy.com


Haemorrhage Classification :- Time of occurence

Primary At the time of injury Reactionary Within 24 hours Secondary After 7 to 14 days www.indiandentalacademy.com


Haemorrhage Acute Blood Loss :- Clinical Features

•Increasing Pallor •Increasing Pulse rate •Restlessness •Deep inspiration •Cold clammy skin •Empty veins, thirst www.indiandentalacademy.com


Shock Definition

“ Inadequate blood flow to vital Organs or failure of the cells of vital Organs to utilise oxygen� Shift from aerobic to anaerobic Metabolism by the cells www.indiandentalacademy.com


Shock Recognition :- compensatory Changes

Desreased cardiac output Cool clammy extremities Tachycardia & Tachypnea Arterial blood pressure Postural hypotension is early Sensitivewww.indiandentalacademy.com sign


Shock Recognition :- Compensatory Changes Central venous pressure Decreased because of poor venous Return & reduced volume Arterial blood gases Renal function Haematocrit www.indiandentalacademy.com


Shock Treatment:- Monitoring Vital singns Renal flow Arterial blood gases Central venous pressure Haematocrit Drugs www.indiandentalacademy.com


Shock Treatment :- Principles

Oxygen exchange Ensure and maintain homeostasis Position Relief of symptoms Monitoring www.indiandentalacademy.com


Cardiovascular Disease Antibiotic Prophylaxis Amoxycillin 3gm, oral, 1 hour before Erythromycin 1gm, 0.5gm 6 hours later Vancomycin 1gm I.V Penicillin v 2gm, oral, 1gm 6 hours later Amplcillin 1gm I.V or I.M Gentamycin 80gm www.indiandentalacademy.com


Cardiovascular Disease Conditions requiring Prophylaxis

Congenital heart disease Rheumatic fever Valvular heart disease Prosthetic replacements www.indiandentalacademy.com


Medical Emergencies Epileptic Seizure:- Recognition

Generalized convulsions Loss of consciousness Urinary & fecal incontinence Injuries Jerky www.indiandentalacademy.com respiration


Scientific Foundations of Minor oral Surgery General Practitioner – Guide lines Steroids could be used in the management Of post operative pain and swelling Antibiotics to be employed only with Specific indications Strict adherence to basic surgical principles is mandatery for successful outcome. www.indiandentalacademy.com


Conclusions General practitioners should undertake minor Surgical procedures based on certain determinants -Minimal & moderately difficult third molars -May be removed after accurate assesment.

-Effective post operative pain control with availabl - stratagies. -Exercise caution with the used of sterolds in -Post operative managament of pain and -Swelling. www.indiandentalacademy.com


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Post Operative Pain Control

Objectives Minimise discomfort Facilitate recovery Avoid Treatment Related Side effects www.indiandentalacademy.com


Who Needs Prophylaxis ? Three groups of patients :i. Patients with impaired host defence mechanisms ii. Patients under going surgical procedures where the risk Of infection is small but cosequences are very serious.Eg. Infective endocarditis Patients with orthopaedic joint prosthesis iii. Patients under going surgical procedures which have a High rate of infectious complications. ( Normal host defence mechanisms. www.indiandentalacademy.com But the nature of surgery vulnerable to infections)


Minor Oral Surgery Basic Surgical Principles

- Asepsis - Pain less surgery - Access - Control of Haemorrhage - Wound Closure - Post operative care www.indiandentalacademy.com


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Successful Management sepends on Proper pre surgical planning Careful diagnosis Good surgical execution Well managed post operative care www.indiandentalacademy.com


Scientific foundation of minor oral surgery Incidence of Infection After Periodontal Surgery A stady conducted to evaluate the incidence of Clinical Infection after periodontal surgery with and without antibiotic cover did not show any difference between the two groups. www.indiandentalacademy.com


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Impacted tooth and I. Dent canal Radiological signs On the root

Appearance Of canal

- darkening - Deflected roots - narrowing - Dark & bifid root - interruption of white lines - Diversion of I.D canal - Narrowing of I.D canal

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Tooth Extraction & Bacteremia

Bacterial Isolates Aerobes – 1.6% Anaerobes – 71.1% Facultative Anaerobes – 27,3% www.indiandentalacademy.com


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Prevention: Antibiotic Prophylaxis Defn: Prevention of infection by the administration of Antibiotics.

Efficacy: several studies have shown that prophylactic Antibiotics reduce the incidence of postoperative woundinfection after Compound mandibular or maxillary fractures. Timing: animal and clinical surveys have clearly established That anyibiotics should be administered so that peak serum and tissue Concentrations coincide with the operation or Induced bactermia. Therefore: It is anachronistic to startantibiotics postoperatively A delay of three hours after contamination result in infection Rate essentially Prolonged antibiotic administration beyond a day or more is not Beneficial and may actually increase the resistant bacteria. www.indiandentalacademy.com


Scientific foundation of minor oral surgery Should a General Fractitioner Do Surgery ? If So To What Extent ?

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Scientific foundation of minor oral surgery

- Cystic Lessions - Dento – Alveolar Fractures - Odontogenic Infections - Biopsy www.indiandentalacademy.com


Radiological Signs Of Significance

Diversion of the canal Darkening of the root Interruption of white lines www.indiandentalacademy.com


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Scientific foundation of minor oral surgery Commonly Performed Procedures

Removal of Buried Roots Impacted Teeth Preprosthetic surgery Surgical Exposure of teeth www.indiandentalacademy.com


Acute Dento-Alveolar Abscess-Microbiology

Recent Studies Poly Microbial Co2 dependent streptococcl Anarobic gram + coccl Anaerobic gram – bacilli www.indiandentalacademy.com


Tooth Extraction & Bacteremia Favouring Factors - Inflammed dental disease - More number of teeth - Age of the patient - More than 50 ml blood loss - Operating time > 100 Mins www.indiandentalacademy.com


Acute Dento Alveolar Abcess Antibiotic Strategy

Amoxycillin And / Or Metronidazole www.indiandentalacademy.com


Pain is a perfect misery, The worse all evils, And excessive, overturns all Patience,

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Pain is a perfect misery, The worse all evils, And excessive, overturns all Patience,

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Trigeminal Neuralgia

Acute paroxysmal facial pain Experienced in the areas supplied by One or more branches of trigeminal Nerve.

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Maxillary Sinus Caldwell- Luc:- surgical procedure

Anaesthesia Incision Bony window Removal of lining,root,cyst etc Haemostasis Closure Post operative care www.indiandentalacademy.com


Maxillary Sinus Caldwell – Luc Advantages

# Easy access # Thin bone # No vital structures

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Maxillary Sinus Caldwell – Luc:- Indications

Chronic sinusitis Root in the sinus Cysts & tumours Biopsy Orbital floor fractures Foreign bodies www.indiandentalacademy.com


Maxillary Sinus Disease

- Sinusitis - Oro antral fistula - Root displacement - Cysts involving sinus - Tumours www.indiandentalacademy.com


Maxillary Sinus Surgical Approaches

Through the tooth socket Caldwell – Luc approach Denker’s www.indiandentalacademy.com


Maxillary Sinus Oro Antral Fistula:- Management

Buccal advancement Palatal rotation Palatal island flap Buccal pad of fat Palatal flap anterior based Tongue flap www.indiandentalacademy.com


Maxillary Sinus Oro Antral Fistula :- Clinical Features Chronic: Sinusitis Change in voice Nasty smell & taste Mucosal polyps protrude out of Opening. www.indiandentalacademy.com


Maxillary Sinus Oro Antral Fistula :- Cauese

-Extraction of maxillary posterior Teeth - Root displaced in to sinus - Chronic osteomyelitis - Malignancy - Trauma www.indiandentalacademy.com


Maxillary Sinus Oro Antral Fistula :- Clinical Features

Acute : Unilateral epistaxis Escape of fluids through nose Air escapes through opening While blowing. www.indiandentalacademy.com


Trigeminal Neuralgia Clinical Features More in females Over the age of 45 Unilateral, rarely bilateral More on right side Second & third division involved more www.indiandentalacademy.com


Trigeminal Neuralgia Etiology Exact etiology unknown Pathilogic change in the nerve Angiospasm of gasserian ganglion Allergic concept Loss of myelin sheath Vascular compression www.indiandentalacademy.com


Trigeminal Neuralgia Intra Cranial Surgery

Retrogasserian Neurectomy Trigeminal tractotomy Microvascular decompression www.indiandentalacademy.com


Trigeminal Neuralgia Clinical Features Pain Characteristics Intensity – severe, lancinating Duration – Few seconds only Area- Trigeminal didtribution Initiated by – Touching trigger Zones Between attacks – free from pain Does not cross midline www.indiandentalacademy.com


Trigeminal Neuralgia Peripheral Neurectomy

Mental nerve Inferior dental nerve Infra orbital nerve www.indiandentalacademy.com


Trigeminal Neuralgia Chemical Neurectomy

Hot Water Phenol Alcohol Glycerol www.indiandentalacademy.com


Trigeminal Neuralgia Pharmacotherapy

Phenytoin – 300 to 400 mg daily Carbamazepine – 200 to 1200 mg Baclofen – 8mg daily www.indiandentalacademy.com


Trigeminal Neuralgia Management

Pharmacotherapy Chemical neurectomy Peripheral neurectomies Intracranial surgery Radiofrequency lesion www.indiandentalacademy.com


Post Operative Management - Pain - Swelling - Infection

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Pain Definition

“ An unpleasant sensory and emotional Experience associated with actual or Potential tissue damage or described in terms Of such damage� www.indiandentalacademy.com


Relationship Between Postoperative Pain & Operative Trauma No significant relationship was qbserved Between operative trauma & pain from day One to day seven period

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Does Pericoronitis Contribute to more Post operative pain ?

‘ Patients with a history of Paricoronitis experienced Significantly higher pain scores Through out seven day period’ www.indiandentalacademy.com


Scientific foundation of minor oral surgery Influence of suturing on post Operative pain and swelling ‘ A study comparing the influence of Complete closure partial closure and Dressing of lower third molar sockets Showed more pain and swelling when the Socket is closed completely in a significant Number of patients.� www.indiandentalacademy.com


Influence of socket Closure on post operative Pain & Swelling “ Complete closure of third Molar sockets leads to Increased post operative pain And swelling experience pain And swelling experience Compared with maintaining the Sockets partlassy open with a Dressing�www.indiandentalacademy.com


Sex And Pain Score Levels

Over a seven days investigation period of Overall pain scores females reported Significantly higher levels of pain than Males

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Scientific foundation of minor oral surgery Haslaser Any Effection Post Operative Events ?

A study to evaluate local effects of soft laser Therapy using a helium – neon laser application For 2 min. following removal of third molars Did not reveal any advantage over the control Group. www.indiandentalacademy.com


Scientific foundation of minor oral surgery Has Homeopathy Any Effect On Post Operative Pain ? A double blind randomized placebo trial to Estimate whether homeopathy has any effect On post operative events following oral Surgery did not show any significant difference. www.indiandentalacademy.com


Efficiency of methods of removal

A comparison of morbidity following Removal of impacted third molars Using lingual split technique and Surgical bur technique showed no Difference in either efficieny or Outcome between the two methods. www.indiandentalacademy.com


Influence of Psychological Factors On post operative pain

“ Psychiatric morbidity, neuroticism and Anxiety were related to increased pain Which tended to persist longer than Normal� www.indiandentalacademy.com


Acute post surgical Pain Long Term Memory There is a positive correlation Between experienced and Remembered intensities of Postsurgical pain upto 3 years After surgery www.indiandentalacademy.com


Scientific foundation of minor oral surgery Pain Mechanisms

Peripheral tissue injury Transmission through the nerves Perception within the brain

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Tissue Injury Inflammatory Mediators Synthesis of prostaglandins Release of bradykinin Release of histamine Excite and sensitise Peripheral Nerve Endings www.indiandentalacademy.com


Pain Transmission Chemical Basis Prostaglandins (PGE2) Leukotrienes (LTB4) Neuropeptides (Substance P) www.indiandentalacademy.com


Stimulus Damage of cell membrane Phospholipids Arachidonic Acid

Cyclo - Oxygenase

Lipoxygenase

Prostaglandins PGE2 , PGI2

Leukotrienes LTB4

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Tissue Injury Neuropeptides Release of substance p from Nerve endings (Highly concentrated In Dental Pulp Nerves)

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Tissue Injury Neuropeptides Release of Substance p from Nerve endings ( Health concentrated in dental pulp nerves)

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Pain Transmission Three Major Nociceptive Afferents Type

Diameter Myelination

Conduction

Polymodal 0.3-3µm

Un Myelinated

0,5-2m/s

A-delta

2-5µm

Thinly Myelinated

5-30m/s

A-beta

6-22µm

Heavity Myelinated

33-75m/s

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Scientific foundation of minor oral surgery Target Areas For pain Control Blockade of Prostaglandin Synthesis Intervening Peripheral Nerve conduction Suppression of higher sites in CNS www.indiandentalacademy.com


Pain Transmission Modulation Gate Control Theory Endogenous Peptides

Leucine Enkephalin Beta Endorphin www.indiandentalacademy.com


Classification of Nsaids Weak Paracetamol Mild To Moderate Ibuprofen Mefenamic Acid Strong Aspirin Phenyl Butazone Diclofenac www.indiandentalacademy.com Piroxicam


Blockade of Prostaglandin Synthesis Use of Nsaid

Ibuprofen Ketorolac

Fluriprofen Diclofenac

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Intervention At Peripheral Nerve Level Use of longer acting L.A agents Duration Short Intermediate

Agents Procaine Lignocaine, Prilocaine

Prolonged- Amethocaine, Bupivacaine, Etidocaine www.indiandentalacademy.com


Steroids In Minor Oral Surgery

Use of peri operative corticosteroids Appeared to be safe and rational method Of reductiing postoperative complications Following minor surgery www.indiandentalacademy.com


Intervention At Peripheral Nerve Level Use of longer acting L.A agents Duration Short Intermediate

Agents Procaine Lignocaine, Prilocaine

Prolonged- Amethocaine, Bupivacaine, Etidocaine www.indiandentalacademy.com


Thank you For more details please visit www.indiandentalacademy.com

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