SCOPE of OMS

Specialty recognized ADA Involves diagnosis & Rx of injuries,diseases & malformation of the mouth and jaws.
Minor oral surgery includes: Exodontia (extractions) Rx dental infection (incision & drainage) Biopsy of hard & soft tissue lesions Alveoloplasty (trimming of ridge, removal of tori)

SCOPE of OMS
Major OMS: Hospital procedures which include: Rx Fractures Pre-prosthetic: tuberosity reduction, implants, vestibuloplasty (extending vestibule) Re-constructive surgery: orthognatic, facial deformities. Administer general anesthesia

GENERAL PRINCIPLES OF SURGERY

A. Wound Healing: 1. Primary: clean incision + sutured to get good approximation. 2. Secondary: not tightly sutured early granulation tissue scar 3. Tertiary: wound excised extensively to remove devitalized tissues and debris granulation tissue healing (scar)
Depends on good nutrition (Vitamin C), medical condition, blood supply.

GENERAL PRINCIPLES OF SURGERY

B. Infection: control and isolation, culture & sensitivity test to choose specific antibiotics.
C. Nutrition: very important, knowledge of the physiology of nutrition, fluid balance , electrolyte content (Na, K, Cl, CO3 )

D. Body fluid & electrolytes: physiology of water balance, urinary out put, shifting between various fluid and electrolyte compartments like Cell &Tissues

GENERAL PRINCIPLES OF SURGERY

E. Diagnostic Workup: Cardiac function (Heart murmur, HBP) Respiratory function (asthma, COPD) Hematology: Bleeding & Coagulation times Medial History: diabetes, stomach ulcers, cirrhosis, kidney function Drug history: coumadin (blood thinner) Systemic disease: immunosupresson (steroid)

EVALUATION OF PATIENT
A. General 1. History: Reviewed verbally with patient Drug allergies (penicillin) Chief complaint + History of Present Illness (symptoms & duration, what exacerbates pain, history of similar episodes)
2. Extra & intra oral exam

EVALUATION OF PATIENT
3. Diagnostic Aids: X-rays Photos before/after Sialographs Biopsy Diagnostic nerve blocks Transillumination (sinuses, nose) Lab tests (CBC) Bacterial stains (Gram stain +/- ) KOH fungi Viral Ab studies

EVALUATION OF PATIENT
4. Hospitalization: Considerations: Medically compromised: un-controlled diabetes, hemophilia, HBP, MI, CVA)
Difficulty & Extent of Procedure Special patients: emotionally disturbed, physically handicapped. Cost: base room rate, OR fee, anesthesia, Lab tests, consultant fees

EVALUATION OF PATIENT
Hospitalization (cont) Dental Emergency Infection: Increase temperature (> 101 F) Increased sweating dehydration Decreased BP, cold, pale IV therapy Increased WBC count (.> 20,000) Compromised airway No response to oral antibiotics

EVALUATION OF PATIENT
Hospitalization (cont) Dental Emergency: Bleeding: Uncontrolled (hemangioma,
hemophilia) Monitor: Pulse Blood pressure Hematocrit (HCT) Hemoglobin (Hb) Patients orientation.

Hospital Arrangements & Orders

A. Procedures for Admission 1. Tell patient what will occur; blood drawn, I.V. started, probable length of hospital stay.
2. Give following info to hospital: Patients name, address, age, insurance etc Admitting diagnosis & procedure planned Preferred date of admission Need for special equipment (drills saws Physical exam 48 prior to admission)

ADMISSION ORDERS
1. General & Nursing Orders: Diagnosis Patients condition Allergies Diet Activity (bed rest) Specific problems

ADMISSIONS ORDERS
2. Laboratory Tests: Hematocrit, Hemaglobin, CBC Urine analysis Chest x-ray (general anesthesia) E. K. G. (Electro-cardio-gram) Blood glucose level Prothrombin Time (PT-liver function, clotting) Partial Thromboplastin Time (PTT), platelet count.

ADMISSIONS ORDERS
Lab tests (con): ESR (erythrocyte sedimentation rate-infection) Vital signs: pulse, respiration rate, BP, Temperature
Chem-12 or S.M.A.-12: includes liver function tests, albumin, total protein, calcium, phosphorous, alkaline phosphatase, serum cholesterol.

Other Admission Procedures

Medications: dose and frequency Informed Consent Form: Discuss surgery & risks. Separate form for general anesthesia.
Prior to surgery: Review record to ensure patient saw all appropriate consultants. Evaluate lab results. Write pre-operative notes in chart

Other Admission Procedures

Pre-operative Notes: Discuss patients condition State abnormal findings in medical history & physical exam; plans to deal with them.
Record & evaluate lab tests Stating plans for surgical procedures

RADIOLOGIC AIDS for OMS

Panoramic Radiograph (Panorex) Screening for pathologic lesions Diagnosis & Rx Plan impacted third molars Observe TMJ, Sinuses, Sialography
Waters view: View para-nasal sinuses, bones of mid face Best for mid facial fractures

RADIOLOGIC AIDS for OMS

Sub-mental vertex view: Dx facture of base of skull Dx fracture of zygomatic process, mandible
Townes view: Visualizing condyle Lateral oblique view: Body & ramus Mandibular occlusal view: symphysis area Cervical spine series: neck fractures TMJ views

PRINCIPLES of OMS
A.

TISSUE HANDLING: 1. Use of Flaps: Access to & visibility of deep structures Bone removal Prevent soft tissue damage
2. Types of Incisons: Linearenvelope(no vertical component) Releasing (vertical component) Semi-lunar

PRINCIPLES of OMS
3. Flap Design:

Blood supply not compromised: wide base, no acute angles Size & thickness: big & mobile enough Full thickness mucoperiosteal flap for dentoalveolar surgery Soft tissue surgery: mucosal incision then dissection in layers identifying vital structures

PRINCIPLES of OMS
4. Re-positioning of Flap: Incision clean, sharp, perpendicular to wound
Flap margins over solid bone

For dento-alveolar surgery releasing incison should end in inter-proximal areas.

PRINCIPLES of OMS
5. Principles in Working with Bone: Use burs, chisels, rongeurs, files Complicated by: sharp edges exposed bone (pain, delayed healing) Devitalzation of bone necrosis Infection necrosis

PRINCIPLES of OMS
B. Aseptic Technique: Prevent pathogenic extra oral bacteria from getting into wound
Sterilization of instruments Thorough hand washing Patients face washed and draped.

PRINCIPLES of OMS
C. Wound Care: Mechanically remove calculus & dead tissue Irrigation to wash away bone chips & debrs
Elimination of dead space prevented by: Closing wound inlayers Pressure bandages Draining hematomas

SUTURE MATERIALS & TECHNIQUES

Needle Type: mostly curved, and triangular (cutting) Suture diameter: Intraoral 3-0 or 4-0
Suture material: Black silk: inexpensive, easy to see intraoral, and removed in 7 days Gut:(sheep intestine) Resorbable, light tan color Nylon: not soft or pliable, mainly used on skin

BIOPSY TECHNIQUE
INDICATIONS: Confirm clinical diagnosis Distinguish benign from malignant An ulcer that persists for more than 2 weeks in spite of removal of local irritant factors MUST be examined histologically
Persistent white lesions biopsied and diagnosed as Hyperkeratosis MUST be followed closely and biopsied if changes occur.

BIOPSY TECHNIQUE
INDICATIONS (cont): To establish type of treatment (in the hospital all tissues remove teeth etc are sent for gross and histologic description)
Where or How to Biopsy: Small (< I cm) benign appearing = Excision Vesiculo-bulluous lesions = Incision (Michel solution)

BIOPSY TECHNIQUE
Where & How to Biopsy (cont): Large ulcers or White lesions Sample normal into abnormal areas Sample several areas if large lesion Sample must extend into connective tissue Pigmented lesions MUST ALL be excised with wide margins

BIOPSY TECHNIQUE
Where & How to Biopsy (cont) Intra bony Lesions: If compressible, pulsate, blue or bruit heard BEWARE of vascular lesion. Biopsy in hospital.
Aspirate all radiolucent lesions first. Cystic lesions: biopsy benign areas also Encapsulated lesions = shelled (enucluated) out as a whole

BIOPSY TECHNIQUE
Where & How to Biopsy (cont): Punch biopsy = skin (small & difficult to orient for sectioning)
Tissue Handling & Instrumentation: No tweezers or hemostats to grasp lesion Anesthesia = Do not inject into lesion Fixative = 10% formalin immediately

BIOPSY TECHNIQUE
Tissue Orientation: The pathologist need to cut the lesion perpendicular to the surface to see progression of the disease process. Thin biopsies should be placed connective tissue side down on a piece of thick paper before placing into fixative. The pathologist need know margins (up, down front, back etc); to see if lesion extends to the edge of what margin.

BIOPSY TECHNIQUE
Pathology Request Form: Patients name, age, sex, ethnic background Lesions size, shape, color, location, duration, texture, symptoms Differential Diagnosis (Three)

FRACTURES
Classification (4 types) 1. Simple: (Closed) Divided bone into two parts, no external communication thru skin or mucosa
2. Compound: (Closed) (Mostly children) Incomplete, may extent thru cortical plate.

FRACTURES
Classification (cont) Compound: Communicate with outside of skin/mucosa Exposed fragments
Comminuted: Multiple fractures of a single bone Simple or compound

MAXILLARY FRACTURES
La Fort 1: Simplest Horizontal Maxillary alveolus containing dentition separated from upper face
Segment pushed backwards & downwards X-ray show fracture thru maxillary sinus Rx: closed reduction, immobilze 5 7 wks

MAXILLARY FRACTURES

Le Fort type 1

MAXILLARY FRACTURES
La Fort 11 Fracture (pyramidal fracture): Alveolar fracture + across bridge of nose Fracture near Lacrimal sac, along Infraorbital ridge, exits around Infraorbital foramen to wall of sinus and underneath Zygomatic process, then to up Pterygoid plates.
Clinical: periorbital edema + ecchymosis, subconjuntival hemorrhage, epistaexis. Rx: intermaxillary fixation

MAXILLARY FRACTURES

Le Fort type 11

MAXILLARY FRACTURE
La Fort 111 Thru Zygomatic arch Down lateral orbital wall To Inferior orbital fissure Along Medial wall of orbit Over Bridge of nose Thru Pterygmaxillary fissure Craniofacial disarticulation Clinical: Epistaxis

MAXILLARY FRACTURE

Le Fort type 111

POST-OP COMPLICATIONS
HEMORRHAGE: Mostly due to poor clot formation (use tea bag + pressure) Remove large exophytic jelly-like clots Use local anesthesia with epinephrine to control bleeding to facilitate exam
Suture to control bleeding If bleeding continues take to Emergency Room for Blood Tests

POST-OP COMPLICATIONS
PAIN: DRY SOCKET (most common) Loss of clot + inflammation of bone 3rd mandibular molar area most common Pain radiated to ear on ipsilateral (same side) Goals of Rx: Clear out local irritants(food) Apply topical analgesic Prevent irritants from getting in socket

POST-OP COMPLICATIONS
PAIN (cont) Rx Dry Socket: Do not currette out socket Irrigate socket with saline Place sedative dressing in socket Bacteriostatic agent: iodine, bacitracin Analgesic: benzocaine, eugenol Change dressing every 24 48 hrs

POST-OP COMPLICATIONS
PAIN (cont)
SEQUESTRUM: Fragment of tooth or non-vital bone in wound. Rx: X-ray and surgical removal with LA

POST-OP COMPLICATIONS
SWELLING: (due to infection) Mild infection suppuration (no fever) Infection facial planes cellulitis or pus Infection buccal, lateral pharyngeal, pterygoid, peri-tonsllar, sublingual, submandibular spaces Rx: Drainage Antibiotics (culture & sensitivity test), systemic support fluids)

POST-OP COMPLICATIONS
FEVER: Infectious or non-infectious etiology Mild temperature elevation = fluid loss or altered metabolism
Post oral surgery mild elevation of temperature due to transient bacteremia (12 24 hrs) High fever (> 99.8 F) for more than 48 hrs need aggressive Rx.

OMS & DIABETIC PATIENT

OUT PATIENT MANAGEMENT: Early morning appointments Short appointment time Have patient take normal morning dose of insulin or oral agent + normal breakfast Mid morning hypoglycemic (weak, trembling) Have orange juice available

Management of Emergencies in the Dental Surgery

A = Airway B = Breathing C = Circulation SYNCOPE (fainting): Cause: anxiety, nervousness, hypoglycemia Made worse by lack of food, fever,infection, lack of sleep Patient become anxious, sweaty, pale, nauseous

Management of Emergencies in the Dental Surgery

Syncope (cont) Patient becomes unresponsive (drowsiness to unconscious) Pulse is weak and slow
Management: Supine position increased blood to head Airway open, tilt head backwards Breathing oxygen by face mask Circulation check vital signs Pupils dilated

Management of Emergencies in the Dental Surgery

Syncope (cont) Management: Apply cool wet towel to forehead Remove tight bulky clothing

Management of Emergencies in the Dental Surgery

RESPIRATORY OBSTRUCTION:: Patient trying to breathe but something blocking airway stridor (high pitch) or crowing noise Management: Heimlich maneuver: quick forceful pressure on abdomen, below rib cage, upwards Pull mandible forward, insert oropharyngeal tube Hemostat, kelly clamp or suction remove object

Management of Emergencies in the Dental Surgery

Respiratory Obstruction Management (cont) If object can not be dislodged, place in supine position Give oxygen under pressure
Laryngoscopy intubation or tracheostomy Chest x-ray ASAP

Management of Emergencies in the Dental Surgery

RESPIRATORY ARREST: Patient is making no effort to breathe, although airway is clear. Management: Check mouth for obstructive object Oxygen via breathing bag Dial 119, continue to breathe for patient every 3 to 4 seconds

Management of Emergencies in the Dental Surgery

CARDIAC ARREST (Circulatory collapse): Management: CPR Dial 119 Patient supine on flat hard surface Start CPR 2 person = 1 breathe : 5 compressions 1 persons = 2 breaths : 15 compressions Check pupils and pulse

PAIN CONTROL
DIAGNOSIS & HISTORY: Ask if pain is: Superficial or deep Constant or intermittent What relieves and exacerbates pain Is it sharp, dull, burning Unilateral or bilateral

PAIN CONTROL
If patient describes pain in a bizarre manner it feels like bugs are crawling up my face arm, think of psychogenic origin.
Psychotic pain mostly occurs in head & neck Iatrogenic pain = cause by HCW Be patient, interested Listen carefully Look for simple causes first Do meticulous Extra & intra oral exam

PAIN CONTROL
SOMATIC PAIN: Caused by noxious stimulus (exogenous, endogenous or spontaneous (no apparent cause) Warning sign of physical injury
Peripheral stimuli interpreted in subcortical & cortical areas of brain. Transmitted by pain conducting fibers when heat, cold, proprioceptive fibers are extremely stimulated.

PAIN CONTROL
Methods of Controlling Somatic Pain: Block conduction local anesthetic Eliminate noxious stimuli Analgesic drugs Sedative & consciousness altering drugs General anesthesia Hypnosis & Acupuncture Beliefs (cultural, religious etc)

PAIN CONTROL
PSYCHOGENIC (PSYCHOSOMATIC) PAIN: Cortical & subcortical areas in the absence of peripheral impulses produce the interpretation of pain Patient is calm, smiling, facial expression free of distress. Burning sensation & depression go together. Rx: Psychiatric consultation Establish good relationship and treat dental needs.

PHYSIOLOGY OF PAIN
Stimuli neural signals nervous system Nervous system influenced by past experiences, culture, anxiety etc These brain processes participate in the selection, abstraction & synthesis of information of total sensory input. Action potential begins in pain receptors
Free endings covered by Schwann cell sheath (no capsule) located in deep epithelium & lamina propria

PHYSIOLOGY OF PAIN
Distribution of Receptors: Skin (MOST) Mucous membrane Periodontium Periosteum Arteries Ligaments
Tendons Facia Veins CT of muscle (Least)

PHYSIOLOGY OF PAIN
Coded pattern of nerve impulses Anterior-lateral Spinal cord Thalamus (spinothalmic tracts) Reticular formation (lower Brain)
Different speeds & frequencies High threshold receptors = small diameter fibers (A-delta & C) Low threshold receptors = large diameter fibers (A-beta & C-fibers)

PHYSIOLOGY OF PAIN
Means for Transmitting Signals Spatial summation: stimulation of many fibers in a nerve trunk simultaneously rather than of a single fiber intensified effect.
Temporal summation: # of impulses along a single fiber (10, 30, 100). Stronger the impulse the greater number of fibers involved & greater rate of impulse transmission by each fiber.

Differential Diagnosis of Facial Pain

Most pain DHCW deal with = Odontogenic Maxillary sinusitis Maxillary molars Ear infection Mandibular molars
Most Common Causes of Facial Pain: Caries Acute or chronic pulpitis Exposed dentin or cementum Fractured tooth syndrome Impacted tooth Gingivitis or periodontitis

Differential Diagnosis of Facial Pain

Most Commmon causes of Facial Pain (cont): Bacterial & Viral infection Pericoronitis Alveolar osteitis (dry socket) Periapical infection Osteomyelitis Oro-antral complications Malignant tumors Post-op complications

PERICORONITIS
Mostly associated with mandibular 3rd molar. Acute infection around crown of tooth with suppuration around pericoronal flap (operculum) Rx: Irrrigate under flap Rx antibiotics (Penicillin or Clindamycin) Operculectomy If not treated infection can spread thru facial planes of face & neck trismus, pain, elevated temperature

Facial Spaces & Spread of Infection

MASSETERIC: extension from submandibular space, lateral pharyngeal space, from mandibular infections, suppurative middle ear infections.
SUBMANDIBULAR & SUBLINGUAL: Ludwigs Angina bilateral cellulitis. Apices of lower posterior below Mylohyoid muscle asphyxiation. Rx: IV antibiotics & Tracheotomy.

Facial Spaces & Spread of Infection

LATERAL PHARYGEAL: Rapid spread of infection Lies medial to ramus Infection can extent to base of skull & chest Trismus of Medial Pterygoid Muscle PERITONSILLAR: Most commonly involve tonsillar infections

Routes of Spread of Infections

Hematogenous Lymphogenous Facial spaces Direct extension All sinuses are in direct communication with each other Maxillary canine infection Cavenous Sinus Thrombosis Mandibular molar infections Ludwigs angina

ANESTHESIA
MAXILLARY: Ant, Mid, Post SAN All Teeth + Bu gingiva Post SAN D B roots 1st, 2nd, 3rd Molars Mid SAN M-B root 1st molar + PMs Ant SAN Incisors + Canine
Nasopalatine N soft tissue palatal to incisor + canine Greater Palatine N soft tissue palatal & distal to canine

ANESTHESIA
MANDIBULAR: Inf Alveolar N pulp of all teeth + Bu gingiva & periosteum anterior to 1st molar
Long Buccal N 1st, 2nd, 3rd Molar + Bu gingiva & periosteum Lingual N gingiva + muco-periosteum lingual of mandibular teeth

LOCAL ANESTHETICS
ESTERS OF BENZOIC ACID: Procaine (Novocaine) AMIDES: Xylocaine (Lidocaine) 2% + Epinephine 1:100,000 Carbocaine (Mepivicaine) 3% (NO epinephrine)
Topical Anesthesia: 2% xylocaine ointment Ethyl chloride (cold spray)

CHARACTERISTICS OF LA
Highest Concentration Needed for: Motor nerves fibers Pain fibers Autonomic fibers
LA Results in Order of Loss of Function: Pain (unmylinated) Proprioception Temperature Muscle tone (myelinated) Touch

MODE OF ACTION OF LA
LOCAL ANESTHETICS: Lipid soluble + weak organic bases Converted to water soluble acid salts Dissolved in water for injection Non-ionized free base penetrates nerve membrane Cationic form required for anesthetic activity within cell

Mode of Action of LA
Potency increases with increased lipid solubility
Cationic form available in injection capsule Cationic form changes to free base on injection into alkaline buffers in tissue Free base enters cell reconverted to cationic form blocks Na channel

MODE OF ACTION OF LA
Tissue pH should be slightly alkaline to hydrolyze free base from water soluble salt form Acidc pH (infection) ionic form poor anesthesia
LA stabilize nerve membrane elevated membrane threshold no depolarization Na channels do not open, Na will not enter

axon

EXCRETION & ABSORPTION OF LA

PROCAINE: Hydrolyzed by plasma esterase paraamino benzoic acid (PABA) diethylaminoethanol (80% excreted in urine) (3% in urine)
XYLOCAINE (LIDOCAINE): 80% metabolized in Liver by microsomal enzymes 2% Xylocaine: 1cc=20 mgs. Max adult (70 kg) dose = 300 mg or 15cc (8 carpules)

ACTION OF LA
Depress action of nerves, smooth, cardiac & skeletal muscles
Initial effect on Brain stimulation (then depression) Factors that Decrease effectiveness of LA: Too high/low tissue pH (infection) Excessive dilution by blood (hematoma) Too rapid absorption in tissue fluid

ACTION OF LA
Concentration of LA = 6x greater than that needed to affect CNS
Smallest amount necessary should be used Aspiration extremely important Toxicity of LA results in respiratory arrest before cardiac arrest

Action of vasopressors (epinephrine) in LA

Increase depth & length of anesthesia Retains LA solution in the area injected by diminishing blood(vasoconstriction) prolong anesthesia
Reduces bleeding better visibility of field Reduces the toxicity of LA by decreasing rapid absorption into blood Most common vasopressor used = epinephrine 1:50,000 1:100,000 1:200,000

Contents of 1.8 ml carpule of 2% Xylocaine with epinephrine

36 mg Lidocaine 0.018 mg Epinephrine NaCl Na-metabisulfate (preservative to stabilize epinephrine)

Methylparaben (preservative, cause of allergy) NaOH (stabilize pH)

Toxicity & Adverse Reactions to LA

Majority of toxic reactions due to overdose Urticaria (local edema) + bronchospasm (rare) Rx Benadryl 10 mg/1 cc + epinephrine 1:100,000
Intravascular injection cardiac arrhythmias Tissue irritation if injected into muscle CNS stimulation then depression & peripheral cardiovascular depression Increased salivation

Toxicity & Adverse Reactions to LA

Tremors Convulsions Coma Hypertension Tachycardia Hypotension Paralysis of orbital nerves Blindness (wrong injection technique)

Pre-op Medication
Tranquillizer(Valium) Psycho-sedative(Librium) Both produce no hang over (barbiturates do) Both are muscle relaxants + anti-convulant Both no analgesic property Both show little depression of respiration or heart Amnesia = IV Valium (not in 1st trimester) Barbiturates relieve anxiety Demerol (narcotic) drowsiness + euphoria + elevated pain threshold (Lorfan, Nalline antagonist)

PRINCIPLES OF MINOR EXODONTIA

A. Reasons for Exodontia: Pulpal pathology: endodontics not feasible Peridontal pathology: peridontics not feasble Trauma: fractured or displaced teeth beyond repair Impacted teeth Orthodontic indications: create space Prosthodontic indications: path of insertion Esthetic indcations: micro or macrodont

PRINCIPLES OF MINOR EXODONTIA

B. Contra-indications for Exodontia: Acute periapical infection Acute periodontal infection ANUG Osteo-radionecrosis Uncontrolled Systemic conditions

PRINCIPLES OF MINOR EXODONTIA

C. Factors re Difficulty Level of Exodontia: Number of roots Length of roots Hypercementosis Periodontal disease Density of bone (condensing ostitis) Vitality of tooth (tooth brittle) Degree of caries Relation to sinus, mandibular canal etc

PRINCIPLES OF MINOR EXODONTIA

D. Mechanics of Tooth Extraction 1. Forceps Luxation forces perpendicular to long axis of tooth (not pulling along long axis) Fulcrum close to apex of tooth High ratio of lever to action arm Beaks short & concave to adapt to root Place beaks opposite each other at same level Beaks parallel to long axis of tooth

MECHANICS OF TOOTH EXTRACTION

2. Elevators: Used as wedge or lever Point at which it contacts and exerts force is the purchase point
Used in root retrieval Loosening tooth prior to placement of forceps.

MECHANISM OF EXTRACTION
3. Types of Elevators Straight: most commonly used Crane pic: off set blade placed in purchase point & furcation and used as a lever.
Root elevators (right & left): blades off set to reach into back of socket. Cryer elevators (EastWest): (right & left): triangular pointed blades, used primarily on lower molar roots.

MECHANISM OF EXTRACTION
4. Procedures in Minor Exodontia A. Use opposite hand to: 1. Retract soft tissues for visibility & protection
2. Help guide beaks of forceps into position 3. Stabilize jaws & apply counter pressure to take stress of neck & jaw muscles

PROCEDURES IN MINOR EXODONTIA

B. Test for anesthesia & reflect periodontal attachment. Use elevator to facilitates placement of beaks & prevents tearing marginal gingival
C. Place beaks sub-gingivally on cementum. Handles held in hammer-type grip for applying forces

PROCEDURES IN MINOR EXODONTIA

D. Extraction forces Initial force directed apically (places fulcrum point near apex + minimize root fracture)
Next forces ether buccal-lingual luxation or

rotation (incisors + canines) No pulling until tooth is loose

PROCEDURES IN MINOR EXODONTIA

E. WOUND CARE: Compress buccal plate with finger Use curette to remove periapical pathology
Pressure applied by patient biting on gauze

Suture only if severe bleeding or marginal gingiva is torn or loose

PROCEDURES IN MINOR EXODONTIA

F. EXODONTIA FOR DECIDUOUS TEETH Molars have flared spindly roots which increase risk of root fracture
For maxillary molars the primary direction of luxation is palatal (buccal in adults). Deciduous molars more palatally positioned & palatal root is strong. Caution not to disturb permanent tooth bud

EXTRACTION FORCES
MAXILLA Anteriors
1st PM

LUXATION Labail + Palatal + Rotation Buccal + Palatal (no rotation)

2nd PM

Buccal + Palatal + Rotation Molars Buccal + Palatal (N.B. Palatal delivery for deciduous molars)

EXTRACTION FORCES
MANDIBLE Incisors LUXATION Labial + Lingual + Rotation
Labial +Lingual + Rotation Buccal + Lingual + Rotation Buccal + Lingual

Cuspid

Premolars Molars

POST EXTRACTION PATIENT INSTRUCTIONS

A. Mouth rinses: No rinses for 24 hrs (prevents loosing clot dry socket B. Pressure dressings: 2x2 gauze over site + patient bite down. Tea bag (Tannic acid). C. Avoid spitting vigorously D. Application of Ice: first 24 hrs on out side of face (reduces edema) Application of Heat: after 24 hrs if there is lots of swelling. Causes increased blood supply. Diet: avoid exceptionally hot or cold foods