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Cysts of The Jaws Symptoms INDIAN DENTAL ACADEMY Leader in continuing dental education

Cysts of The Jaws Symptoms Pathological fracture Mistaken for abscess Displacement of denture Displacement of teeth Discoloration of tooth

Cysts of the Jaws Marsupialisation – Rationale

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

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

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


INDICATION FOR REMOVAL Recurrent Pericoronitis Periodontal Orthodontic Reasons Dental Caries Resorbtion Of Second Molar

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

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

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

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

Pell & Gregory Position & Angulation George Winter’s Classification is adopted

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

Difficulty index Pederson) Minimal




Very difficult


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

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

Clinical Assissment General Factors - Age - Medical Condition - Temperament

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

Radiological Assessment - Radiograptus Required - Periapical Film - Lateral oblique view of mandible - Orthopantomogram

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

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

Relationship with mandibular canal Normal relationship Variations - Groove - Deep Groove - Perforation

Considerations in perdicting difficulty Age Anatomy Facial from

Age:- Does it affect surgery ? Young age

Easy surgery less morbidity

old age

Difficult surgery Greater morbidity

Accessibility based on facial from Tapering

Easy surgery

Square & Compact


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

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

Operative Plan - Incision - Removal of bone] - Removal of tooth - To let of the wound - Closure of the wound

Removel of Third Molar Careful Assessment Instruments selection Choice of anaesthesia Operative plan Post operative care

Choice of Anaesthesia Local Intravenous sedation And local - General

Scientific foundations of Minor oral surgery Muco Periosteal Flaps Visibility Vascularity Healing

Scientific Foundtions of minor oral surgery Access Mucoperiosteal flaps Bone Removel

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 Wond And Vessels

Complications (Postoperative) - Haemorrhage - Haematoma - Oedema - Pain - Trismus

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

Exodontia Dry Socket Etiology Exact etiology unknown Trauma Infection Vasoconstrictor effect Mechanical dislodgement Fibrinolytic theory

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

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

Exodontia Post Extraction Bleeding Investigation Bleeding time Plastelet count Prothrombia time Partial thrombopiastin time

Exodontia Post Extraction Bleeding Causes Local Trauma Infection Systemic Defect in vessel wall Defect in plastelets Defect in coagulation

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

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

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

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

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

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

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

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

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

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

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

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

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

Exodontia Complication-post Extraction Plain Swelling Trismus Dry Socket Haemorrhage

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.

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

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.

Most feared modality Pain Anaesthetic Injection Swelling Numbness Other

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

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

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

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

Dental Elevators Principles Lever Wedge Wheel & axle

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

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

Diagnosis In Oral Surgery Components

History taking Clinical examination Investigations

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

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

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.�

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.�

Diagnosis In Oral Surgery Singn:- Definition

•General examination •Local examination • Extra oral • Intra oral

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

Diagnosis In Oral Surgery Examination:- Extra Oral

Soft tissues Hard tissues Occlusion Special pathology (lession of interest)

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

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

Antibiotics Principles of Treatment Diagnosis Choice of drug Dosage and route Accompanying treatment Combination of drugs Hypersensitivity

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

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

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

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

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

Antibotics Uses Therapeutic Prophylactic General Specific

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

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

Impacted Maxillary Canine Localization-Radiological

Vertex occlusal view Lateral skull radiograph Parallox method of clark

Impacted Maxillary Canine Management

No surgical intervention Surgical exposure & othodontic alignment Surgical removal & auto transplantation Surgical removal

Strategies for Pain Control

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

Supression At Higher Sites In CNS Use of Oploids Morphine Pethidine Codeine

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

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

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

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

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.

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.

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�

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�

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.

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

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


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.

Post Operative Management - Pain - Swlling Infection

Post Operative Management Pain Swlling Infection

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�

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

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�

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.

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.

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 After the operation.

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

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

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

T.M.Joint MPDS Signs

•Joint tenderness •Muscle tenderness •Abnormalities of mandibular movement

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

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

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

T.M.Joint MPDS Etiological Concepts

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

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

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.

Haemorrhage Classification :- Depending on vessel

Arterial Bright red, spurting as a jet Venous Dark red, steady flow Capillary Bright red ooze

Haemorrhage Classification

External Visible or revealed Internal Invisible or concealed

Haemorrhage Classification :- Time of occurence

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

Haemorrhage Acute Blood Loss :- Clinical Features

•Increasing Pallor •Increasing Pulse rate •Restlessness •Deep inspiration •Cold clammy skin •Empty veins, thirst

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

Shock Recognition :- compensatory Changes

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

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

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

Shock Treatment :- Principles

Oxygen exchange Ensure and maintain homeostasis Position Relief of symptoms Monitoring

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

Cardiovascular Disease Conditions requiring Prophylaxis

Congenital heart disease Rheumatic fever Valvular heart disease Prosthetic replacements

Medical Emergencies Epileptic Seizure:- Recognition

Generalized convulsions Loss of consciousness Urinary & fecal incontinence Injuries Jerky 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.

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.

Post Operative Pain Control

Objectives Minimise discomfort Facilitate recovery Avoid Treatment Related Side effects

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. 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

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

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.

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

Tooth Extraction & Bacteremia

Bacterial Isolates Aerobes – 1.6% Anaerobes – 71.1% Facultative Anaerobes – 27,3%

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.

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

Scientific foundation of minor oral surgery

- Cystic Lessions - Dento – Alveolar Fractures - Odontogenic Infections - Biopsy

Radiological Signs Of Significance

Diversion of the canal Darkening of the root Interruption of white lines

Scientific foundation of minor oral surgery Commonly Performed Procedures

Removal of Buried Roots Impacted Teeth Preprosthetic surgery Surgical Exposure of teeth

Acute Dento-Alveolar Abscess-Microbiology

Recent Studies Poly Microbial Co2 dependent streptococcl Anarobic gram + coccl Anaerobic gram – bacilli

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

Acute Dento Alveolar Abcess Antibiotic Strategy

Amoxycillin And / Or Metronidazole

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

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

Trigeminal Neuralgia

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

Maxillary Sinus Caldwell- Luc:- surgical procedure

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

Maxillary Sinus Caldwell – Luc Advantages

# Easy access # Thin bone # No vital structures

Maxillary Sinus Caldwell – Luc:- Indications

Chronic sinusitis Root in the sinus Cysts & tumours Biopsy Orbital floor fractures Foreign bodies

Maxillary Sinus Disease

- Sinusitis - Oro antral fistula - Root displacement - Cysts involving sinus - Tumours

Maxillary Sinus Surgical Approaches

Through the tooth socket Caldwell – Luc approach Denker’s

Maxillary Sinus Oro Antral Fistula:- Management

Buccal advancement Palatal rotation Palatal island flap Buccal pad of fat Palatal flap anterior based Tongue flap

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

Maxillary Sinus Oro Antral Fistula :- Cauese

-Extraction of maxillary posterior Teeth - Root displaced in to sinus - Chronic osteomyelitis - Malignancy - Trauma

Maxillary Sinus Oro Antral Fistula :- Clinical Features

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

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

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

Trigeminal Neuralgia Intra Cranial Surgery

Retrogasserian Neurectomy Trigeminal tractotomy Microvascular decompression

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

Trigeminal Neuralgia Peripheral Neurectomy

Mental nerve Inferior dental nerve Infra orbital nerve

Trigeminal Neuralgia Chemical Neurectomy

Hot Water Phenol Alcohol Glycerol

Trigeminal Neuralgia Pharmacotherapy

Phenytoin – 300 to 400 mg daily Carbamazepine – 200 to 1200 mg Baclofen – 8mg daily

Trigeminal Neuralgia Management

Pharmacotherapy Chemical neurectomy Peripheral neurectomies Intracranial surgery Radiofrequency lesion

Post Operative Management - Pain - Swelling - Infection

Pain Definition

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

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

Does Pericoronitis Contribute to more Post operative pain ?

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

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.�

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�

Sex And Pain Score Levels

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

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.

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.

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.

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�

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

Scientific foundation of minor oral surgery Pain Mechanisms

Peripheral tissue injury Transmission through the nerves Perception within the brain

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

Pain Transmission Chemical Basis Prostaglandins (PGE2) Leukotrienes (LTB4) Neuropeptides (Substance P)

Stimulus Damage of cell membrane Phospholipids Arachidonic Acid

Cyclo - Oxygenase


Prostaglandins PGE2 , PGI2

Leukotrienes LTB4

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

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

Pain Transmission Three Major Nociceptive Afferents Type

Diameter Myelination


Polymodal 0.3-3µm

Un Myelinated




Thinly Myelinated




Heavity Myelinated


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

Pain Transmission Modulation Gate Control Theory Endogenous Peptides

Leucine Enkephalin Beta Endorphin

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

Blockade of Prostaglandin Synthesis Use of Nsaid

Ibuprofen Ketorolac

Fluriprofen Diclofenac

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

Agents Procaine Lignocaine, Prilocaine

Prolonged- Amethocaine, Bupivacaine, Etidocaine

Steroids In Minor Oral Surgery

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

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

Agents Procaine Lignocaine, Prilocaine

Prolonged- Amethocaine, Bupivacaine, Etidocaine

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