2. 1. Teeth with deep caries or severe abrasion, which
can not be treated by conservative methods such
as fillings and crowning.
2. Teeth with severe peridontal disease.
3. Teeth with non-vital pulps, or with
acute or chronic pulpitis when root
canal treatment is not possible.
Dr. Firas Kassab 2
3. 4.Teeth with apical pathology such as abscess,
granuloma, or cyst; in cases where apicoectomy
is contraindicated.
5.Teeth interfering with the stability and fitness of
dentures and bridges.
6.Teeth traumatizing soft tissues. If no
other treatment will prevent this
trauma.
Dr. Firas Kassab 3
4. 7.Malposed and crowded teeth not responding to
orthodontic treatment as request of the
orthodontist.
8.Teeth may be extracted to facilitate correction of
jaw deformities.
9.Impacted teeth and unerupted teeth
or embedded teeth.
Dr. Firas Kassab 4
6. 13.Teeth involved in the fracture lines of the jaws.
(Questionable ??)
14.Remaining fractured roots and fragments.
15.Teeth should be extracted and a very
extensive alveolectomy performed
before radiation therapy for oral
malignancy.
Dr. Firas Kassab 6
7. ⢠1.the oral cavity is restricted by the lips&cheeks
2.Movement of the tongue particularly in patient with broad
&bulky tongue 3.Movement of the mandible which is a
hinged structure
Dr. Firas Kassab 7
8. ⢠4.The mouth communicate with posteriorly with the pharynx
which opens into esophagus &larynx 5.The oral cavity is
flooded with saliva
Dr. Firas Kassab 8
9. ⢠6.The floor of the mouth&the tongue&the hard and soft palate
may be endangered due to lack of care during extraction 7.the
mouth is close to vital centers as brain &base of the skull
Dr. Firas Kassab 9
11. Acute gingival infections, such as
fusospirochetal or
streptococcal infection
Extraction of maxillary teeth
during acute maxillary sinusitis
Acute pericoronal infection
Teeth involved in tumours or
neoplasm
Dr. Firas Kassab 11
16. 1. History (of general disease or difficult extraction
and anaesthesia).
2. Examination of all upper and lower teeth.
3. Examine the condition of the tooth to be extracted.
4. Examine the mobility of the tooth.
5. Examine the relation of tooth to
important anatomical structures
6. Examine the condition of the oral
hygiene. Dr. Firas Kassab 16
18. 1.A history of difficult extraction.
2.A tooth which is abnormally resistant to
forceps extraction.
3.Any teeth related to maxillary
antrum.
4.All mandibular and maxillary third
molars Dr. Firas Kassab 18
19. 5.Any tooth which has been subjected to trauma.
6.Any partially erupted or unerupted tooth.
7.Any tooth with abnormal crown form.
8.Any tooth that has been decided to
be removed surgically.
Dr. Firas Kassab 19
20. 9. Any condition which predisposes to dental or
alveolar abnormality, such as cleido-cranial
dysostosis, osteitis deformans, or cleft palate.
10.Heavily restorated and pulpless teeth.
11.Any isolated upper molar for long
time.
Dr. Firas Kassab 20
21. 1.Should show the whole root structure.
2.Should show the bone investing the tooth.
3.Should show the relation to any important
anatmoical structures.
Dr. Firas Kassab 21
22. 1.Indicate abnormal number, shape or pattern of
roots.
2.Indicate caries extending to the root.
3.Indicate root fracture, resorption or
hypercementosis.
4.Indicate ankylosis and bony sclerosis.
Dr. Firas Kassab 22
23. 5.Indicate gemination.
6.Indicate impacted teeth.
7.Indicate approximation to the maxillary sinus, and
the inferior dental canal.
8.Indicate the presence of intra-bony
pathology such as: abscesses,
granulomas, or cysts.
Dr. Firas Kassab 23
24. 9. Quick diagnosis of complications during extraction.
a)Fracture of the roots.
b)Displacement of a tooth or a root into the
maxillary sinus or into the soft tissues.
c) Fracture of the maxillary tuberosity.
d)Fracture of alveolar or mandible.
Dr. Firas Kassab 24
28. ⢠A. Absolute Indications
⢠B. Relative Indications
Dr. Firas Kassab 28
29. Absolute Indications
1. Allergy to local anaesthetic drugs: occurs in
sensitive individuals ands may take any of the
following:
A. Minor form: Skin rash, erythema or skin
papules
B. Moderate form: Angioneurotic oedema â
causing bronchospasm carrying potential danger
to respiration.
Dr. Firas Kassab 29
30. C. Severe form: called anaphylactic shock.
*notes:
Skin test before administration of local anaesthetic drugs should be done
to distinguished allergic individuals.
Dr. Firas Kassab 30
31. Absolute Indications:
2. Major faciomaxillary surgery: as in massive trauma,
removal of large tumor or major cosmetic surgery.
Dr. Firas Kassab 31
32. A. L.A. Block will be difficult and may require the use of a large
amount of L.A. drug, which may exceed the safety limit result in
toxicity.
Dr. Firas Kassab 32
33. B. Difficulty of protecting the airway of the patient during such
procedure without the use of endotracheal tubes which in itself
requires the use of G.A.
Dr. Firas Kassab 33
34. C. Difficulty of insuring patient cooperation during such
procedures under L.A., while under G.A., both patient and
operator will be comfortable
Dr. Firas Kassab 34
35. Relative Indications
1. Uncooperative patient: G.A. maybe the only way to insure
cooperation and proper surgery as in:
a. Children: here sedation is difficult as controlled by force
Dr. Firas Kassab 35
36. b. Nervous individuals: sedation here may be successful in some
cases.
c. Mentally retarded patients: sedation might render them more
uncooperative.
Dr. Firas Kassab 36
37. Relative Indications:
2. Extensive Surgical field: When surgery id to be performed in
more than 2 quadrants of the mouth, which may require the use
of more than the safe dose of the L.A. drug causing toxicity
Dr. Firas Kassab 37
38. Relative Indications
3. Prolonged Dental procedure; Doing a full mouth job
that will take several hours, L.A. will be uncomfortable
for both the patient and operator, while under G.A.,
the procedure may be completed in a much shorter
time
Dr. Firas Kassab 38
39. Relative Indications:
4. Presence of infection for the following reasons:
a. The acidic pH of the infected area will prevent penetration
of the L.A. drug to the nerve fiber, rendering the anaesthesia
ineffective.
Dr. Firas Kassab 39
40. Relative Indications:
b. Due to hyperaemia of the infected area, there will be
greater and faster absorption of the L.A. drug from the site of
injection, resulting in shorter duration in addition to increased
risk of toxicity.
Dr. Firas Kassab 40
41. Relative Indications:
C. Multiple injections of L.A. may result in opening of nerve tissue
spaces with spread of infection.
Dr. Firas Kassab 41
42. Relative Indications:
d. If trimus is present, it will prevent adequate opening of the
mouth during surgery and only G.A. drugs may render this
possible.
Dr. Firas Kassab 42
43. Patient Demand:
Many patient will feel more comfortable having their operation
done under G.A. In the presence of very safe G.A. drugs and
techniques
This can be granted.
Dr. Firas Kassab 43
45. Steam under pressure to destroy bacteria spore
forms and fungi.
a.For 30 minutes: instruments, cotton rolls, towels and
gauses.
b.For 15 minutes: rubber tubing and
gloves.
Dr. Firas Kassab 45
47. At 100° ď°C for 5â10 minutes to destroy bacteria in
boiling water.
o Spores and fungi resist these conditions for 60 and
20 minutes respectively.
o Addition of sodium carbonate raise
the boiling point to 110°°°°°ď°Â°C and
reduce boiling time.Dr. Firas Kassab 47
49. â Hot air ovenâ: at 160 ď°C for 60 minutes to destroy
all form of bacteria.
o Used for instruments, hand pieces, bone waxes, oil
of cloves, zinc oxide, etcâŚ
Dr. Firas Kassab 49
51. As 70% absolute alcohol with chlorhexidine,
digluconate, and cetrimide.
o Used for instruments having sharp cutting edges.
o The instruments immersed in the
solution for 30 minutes.
Dr. Firas Kassab 51
55. o For extraction of all upper teeth: front and to the right
side.
o For extraction of left lower teeth: frontal and to the
right side.
o For extraction of right lower teeth: back and to the
right side.
Dr. Firas Kassab 55
58. 1. Expansion of bony socket (By forceps).
2. The use of lever and fulcrum principles (by
elevators).
3. The wedging principle (by elevators).
Dr. Firas Kassab 58
68. ⢠1. OUTWARD AND INWARDMOVEMENT
⢠2. ROTARY MOVEMENTS
⢠3. FINAL MOVEMENT
Dr. Firas Kassab 68
69. ⢠Outward movements is initiated in extraction of all the
maxillary and the mandibular teeth (with exception of
mandibular third molarand to a less extend the mandibular
second molar)
Dr. Firas Kassab 69
70. ⢠Inward movement is initiated in extraction of the lower third and
second molar as the lingual alveolar bony plate related to
these teeth is thinner than the buccal one
Dr. Firas Kassab 70
71. ⢠1.Applied in extraction of teeth with conical roots
⢠2.In chronically infected roots
⢠3. Misplaced teeth or supernumerary teeth
⢠4. Secondary rotary movement could be used as a final
movement when the tooth become completely loosen
Dr. Firas Kassab 71
72. ⢠By which the tooth is completely removed from the bony socket
⢠It should be directed outward
Dr. Firas Kassab 72
73. ⢠1)Avoid traumatizing the teeth of the opposing jaw 2)Avoid
slipping of the tooth from the
forceps&falling inside the mouth
Dr. Firas Kassab 73
74. 1. Local anaesthesia.
2. Handling and application of the forceps.
3. Soft tissue retraction and alveolar support.
4. Tooth grip (Apical movement).
5. Displacement of the tooth from its socket.
6. Post extraction care and instruction.
Dr. Firas Kassab 74
82. 6.Immediate post extraction care:
1. Cleaning of the wounds.
2.Trimming of the alveolar bone.
3.Squeeze the socket.
4.Apply pressure to the margins of the
socket.
5.Clean the patientâs lips and face from any
blood
Dr. Firas Kassab 82
85. 7.Post extraction instructions:
1.Keep biting pressure on wounds.
2.No mouth wash for 24 hours.
3.Avoid any hot food or drink for the rest of
day.
4.Cold applications.
5.See back your dentist in case of
complications.
6.Use of mouth wash and analgesic.Dr. Firas Kassab 85
86. 1. Maxillary central incisors:
o Primary rotatory movement.
o Removed with labio-palatal movement, or
rotation.
2.Maxillary lateral incisors:
o Labio-palatal movement.
3.Maxillary canines:
o Labio-palatal movements.
o Secondary distal rotation.Dr. Firas Kassab 86
92. 7.Mandibular canines:
o Bucco-lingual movements.
8.Mandibular premolars:
o Bucco-lingual movement.
o Primary and secondary rotatory movement.
Dr. Firas Kassab 92
94. 10.Extraction of deciduous teeth:
o No root mass.
o Uneven resorption.
o Permanent successors.
ďUse of pediatric forceps.
ďBuccal movement.
Dr. Firas Kassab 94
99. A localized source of inflammation.
It may cause residual periapical lesion
It may act as mechanical irritations
It may give rise to neuralgic pain
Dr. Firas Kassab 99
102. A.According to use:
1. To remove the entire tooth.
2. To remove roots.
3. To reflect the mucoperiosteum.
B.According to form:
1. Straight elevators all types.
2. Curved elevators right and left.
3. Angulated elevators right and left.
4. Cross bar design elevators.
Dr. Firas Kassab 102
104. 1. Never use the adjacent tooth as a fulcrum.
2. Never use the buccal plate as a fulcrum except in
3. The index finger should rests against the alveolar
bone to avoid slipping of its tip.
88
Dr. Firas Kassab 104
105. 1. Loosing or extraction the adjacent teeth.
2. Fracturing the alveolar process or the mandible.
3. Penetrating the maxillary antrum.
4. Damage of the soft tissue by its slipping.
Dr. Firas Kassab 105
106. At the gingival line.
Broken off halfway to the
apex
Removal of root tips
A
Removal of broken
single rooted teeth
Dr. Firas Kassab 106
107. At the gingival line
Broken one root
C
Removal of roots of
maxillary molars
Dr. Firas Kassab 107
112. 1. Any tooth that resists forceps extraction.
2. Retained roots which can not be removed by the
closed technique.
3. Brittle teeth.
4. Hyper cementosed and ankylosed teeth.
5. Teeth with abnormal tooth form.
Dr. Firas Kassab 112
113. 6. Geminated and dilacerated teeth.
7. Malposed and impacted teeth.
8. Supermumerary teeth.
9. Isolated maxillary molars.
10.Thin mandible.
11.Multiple extraction.
Dr. Firas Kassab 113
114. 1. Outline the extent of mucoperiosteal flap.
2. Bone removal.
3. Sectioning of the teeth.
4. Elevating of tooth from its socket.
5. Debridment of wound before closure.
6. Closure of the incisions.
7. Post operative care.
Dr. Firas Kassab 114
115. 1.No. 10: for extraoral incision.
2.No. 11: for stab incision.
3.No. 12: for retromolar and gingival incision.
4.No. 15: for oblique incision.
Dr. Firas Kassab 115
116. 1. The incision line should be away from nerves and
vessels.
2. The incision must include mucosa and periosteum.
3. The base should be broader than its free margin.
4. The flap should be large enough.
5. Flap should be well repositioned.
Dr. Firas Kassab 116
120. 1.Surgical chisel and mallet.
2.Surgical burs on conventional micromotor,
airmotor or air turbine hand pieces.
3.Rongeur forceps.
Dr. Firas Kassab 120
125. 1. To reduce resistance.
2. Minimize amount of bone removal.
3. To protect vital anatomical structure.
o Avoid heavy forces.
o Avoid injuries to the adjacent structures.
Dr. Firas Kassab 125
128. 1.The root must be small (4-5 mm)
2.Deeply embedded in bone.
3.The involved root must not be
infected.
Dr. Firas Kassab 128
129. 1. Granulation tissues.
2. Irregular edges of bone.
3. Fragments of bone and teeth.
4. Bleeding points.
5. Irrigation with saline.
o Black 00 or 000 silk.
o Adequate repositioning of the flap.
o Space for drainage.
Dr. Firas Kassab 129
137. 1. Fractures of teeth.
2. Fractures of alveolar process.
3. Fracture of maxillary tuberosity.
4. Dislocation of the mandible.
5. Fracture of the mandible.
6. Lossening or extraction of an adjacent
tooth.
7. Extraction of or injury to an unerupted
tooth.
Dr. Firas Kassab 137
138. 8. Disturbing artificial restorations.
9. Gingival laceration.
10.Bruising the lip or cheek.
11.Wounding the tongue.
12.Emphysema.
13.Breaking an instrument.
14.Injury to the inferior dental nerve.
15.Forcing a tooth or root into the surrounding
tissue.
16.Forcing a tooth or root into the maxillary
sinus or opening of maxillary sinus.
Dr. Firas Kassab 138
141. Causes:
⢠Devitalized teeth (with R.C.T) or badly decayed
teeth.
⢠Teeth with sever curvature or hypercementosis.
⢠Abnormality of the supporting structures.
1- Fracture of the teeth
⢠Misapplication of forceps or
levers.
⢠Improper extraction
movements. Dr. Firas Kassab 141
143. ⢠If this complication occurs we must inform the
patient.
⢠If the tooth is fractured near the neck, it may be
removed with forceps.
⢠In multi-rooted teeth it may be removed with
forceps-elevator-or by open method.
Dr. Firas Kassab 143
146. 2- Fracture of alveolar process
⢠This occurs when the extraction is difficult. The
fractured bone may be removed with the tooth or
remain attached to the periosteum.
⢠If the bone attached to the
periosteum, it should be
replaced in its position by one
or two sutures through the
gingival margins. Dr. Firas Kassab 146
147. This usually occurs when extraction of
3- Fracture of the tuberosity of the maxilla
87 78
Causes:
⢠Ankylosed tooth.
⢠Malposed tooth.
⢠Prominent tuberosity.
⢠Isolated tooth.
⢠Divergent or hypercementosed
sea root formation.
Dr. Firas Kassab 147
148. 3- Fracture of the tuberosity of the maxilla
⢠If this occurs, the operator finds himself grasping
a large segment of detached bone. Extraction
should not be continued.
⢠It may cause fracture
tuberosity, lacerated soft
tissues, opening of the
antrum and profuse
bleeding.
Dr. Firas Kassab 148
150. Management
⢠If it is small fragment excision should be done and we
remove the tooth and the fragment of bone.
⢠If the maxillary sinus is exposed, the bone is debrided,
and the flaps are trimmed, reopposed and sutured and
nasal drops is very important to facilitate drainage.
⢠If the fragment is a large one and
carrying more than one sound
tooth, it should be repositioned and
fixed with suitable splint and the
tooth removed later on by its
dissection. Dr. Firas Kassab 150
151. 4- Dislocation of the mandible
⢠It is dislodgement of condyloid process from the
glenoid fossa. One or both joints may be
dislocated as a result of using too mush
pressure.
Dr. Firas Kassab 151
153. The symptoms
⢠The mouth is open and rigidly set in position.
⢠The patient can not close his mouth.
⢠A depression is visible anterior to the ear.
⢠If the dislocation is unilateral
the jaw is directed towards
the normal side.
Dr. Firas Kassab 153
154. Treatment
1. Lower the dental chair.
2. The operator wraps his thumbs with gauze to
protect them from quick and immediate closure
of the jaw.
3. The thumbs are placed on
the occlusal surface of the
mandibular molar and
applied dawnward and
backward pressure.Dr. Firas Kassab 154
155. 4. A four tail bandage is applied to hold the jaw in
place for 48 hour and patients instructed to
restrict opening to the thickness of spoon for the
next two weeks.
Dr. Firas Kassab 155
157. 5- Fracture of the mandible
⢠A fracture is a break in the continuity of the bone. It is
uncommon complication but it has occurred. The
common sites are in the premolar region and the angle
of the jaw..
Causes:
⢠Excessive force.
⢠Senile osteoporosis.
⢠Atrophic mandible.
⢠Irradiated mandible.
⢠Osteomyelitis.
⢠Fibrous dysplasia.
⢠Unerupted teeth, cyst or tumors.
Dr. Firas Kassab 157
163. 6- Loosening or extraction of
an adjacent tooth
Causes
⢠Hasty or ill directed extraction movements.
⢠Using the tooth as a fulcrum during application
of elevator.
⢠Lack of vision if an excess of
blood is allowed to
accumulate.
⢠In cases of fusion of two teeth.
Dr. Firas Kassab 163
164. Management
⢠When the complication occurs:
ď The luxated tooth should be forced back into normal
position by heavy thumb pressure.
ď Ligated the tooth in its place.
If completely extracted:
ď Immediate replantation of the extracted tooth and
splinting to the adjacent teeth.
ď Relief the replant tooth from the
bite by selective grinding of the
opposing teeth.
ď Proper postoperative instructions
and follow up.
Dr. Firas Kassab 164
165. 7- Extraction of or injury to
an unerupted tooth
⢠This complication may occur as a result of
pushing the beaks of the forceps beyond the
essential area when extracting a deciduous tooth
thus holding it with its permanent successor.
Causes
⢠The permanent tooth bud
should be repositioned in its
place and the mucosa should
be sutured over it. Dr. Firas Kassab 165
166. 8- Disturbing artificial restoration
9- Gingival laceration
⢠As a result of slipping of a forceps or an elevator
during extraction.
⢠As a result of slipping or
misapplication of the
instruments. Also in some
cases the gum may adhere to a
tooth. Dr. Firas Kassab 166
167. Causes
⢠The tooth should be carefully dissected from
the gum by scalpel or scissors.
⢠The lacerated gum should be sutured back in
its place.
Dr. Firas Kassab 167
168. 10- Bruising the lip or cheek
Causes
⢠Small mouth orifice.
⢠Presence of trismus.
⢠Following an inferior dental n.block as in children.
⢠Careless handling of the forceps.
⢠We found immediate swelling
ecchymosis, a braded skin or
mucous membrane, trauma to
cheek.
Dr. Firas Kassab 168
169. Causes
⢠Proper attention to the position of the thumb
and finger of the left hand and proper
instruction after inferior dental block.
Dr. Firas Kassab 169
170. 11- Wounding of the tongue
Causes
⢠Hasty extraction or slipping of an elevator.
Profuse bleeding is a common finding. Such
wounds should be sutured to control the
bleeding.
Dr. Firas Kassab 170
171. ⢠Most soft tissue injuries are precipitated by unexpected patient
movement resulting in lacerations or abrasions from rotating
dental instrument.
⢠The tongue and buccal mucosa should be carefully retracted and
immobilized while using elevators or other sharp instruments.
⢠Strict attention to the lips is needed when using rotating
instruments to avoid burn injuries and abrasions.
⢠When local anesthetic has been used, postoperative instructions
should always include avoidance of self-inflicted soft tissue
injuries such as lip and tongue biting.
Dr. Firas Kassab 171
172. Step 1 Identify the area of injury and inform the patient of the
extent of the problem.
Step 2 Gently debride and irrigate the area
Step 3 Prescribe antibiotics for a period of 7 to 10 days.
Step4 Evaluate the patientâs immunization status for tetanus, and
refer the patient for an initial immunization series or for a tetanus
booster if immunizations are not current.
Dr. Firas Kassab 172
173. 12- Emphysema
Causes
⢠It is due to accumulation of air into the connective
tissue of intermuscular or facial planes.
⢠It also follows an oro-antral
fistula. The swelling is very
rapid in onset. It takes from 1-2
weeks to be absorbed.Dr. Firas Kassab 173
174. ⢠Subcutaneous emphysema can be caused by gases and air that
are blown into the tissues by the air syringe or handpiece during
routine dental procedure or surgery.
⢠Air can enter the cervicofacial spaces and can extend as far as
the mediastinum or be localized in the soft tissues of the area
being treated.
⢠Mild to severe emphysema is seen secondary to the combination
of an elevated mucoperiosteal flap and the use of high-pressure
nonsterilecoolant spray over burs operating on bone or sectioning
teeth.
⢠Emphysema is usually transient, with subcutaneous manfestions
resolving in a days.
Dr. Firas Kassab 174
175. ⢠Submandibular, cervical, or facial swelling that occurs during or
immediately following a dental procedure is usually associated
with air or high pressure coolant spray over burs.
⢠There may be a crackling sound heard by the dentist or the
patient when the tissues are palpated.
Dr. Firas Kassab 175
176. ⢠If swelling occurs suddenly and the cause is not apparent, the
dentist needs to differentiate between a hematoma and air
emphysema.
⢠Aspiration is quick way to determine the difference.
⢠Aspirate with an 18- to 20-gauge needle-the absence of blood
confirms air emphysema.
Dr. Firas Kassab 176
177. Step 1 If sudden swelling occurs during a dental procedure, stop
the procedure, the irrigation, and the air spray.
Step 2 Examine the patient and establish a diagnosis.
Step 3 Place the patient on antibiotics.
Step 4 Complete the procedure if the patient is stable and the
remainder of the procedure will be short.
Step 5 Reassure the patient.
Step 6 Reevaluate the patient daily to ensure resolution without
infection.
Step 7 Discontinue the antibiotics 24 hours after resolution of the
air emphysema.
Dr. Firas Kassab 177
178. 13- Breaking an instrument
⢠The beak of the forceps, the blade of an elevator
or the tip of a surgical drill may be broken.
⢠Any broken part should be immediately located
and removed.
Dr. Firas Kassab 178
179. 14- Injury to the Inferior Dental Canal
Causes
⢠Root related to the inferior dental nerve.
⢠Careless curetting and blind use of elevators to
remove root apices.
⢠Traumatic extraction of lower
third molar in which the lingual
soft tissues are trapped in the
forceps. Dr. Firas Kassab 179
180. Signs and symptoms
⢠Usually the injury to the inferior dental N. accompanied
by injury to the neurovascular bundle & cause.
⢠Severe haemorrhage.
⢠Sometime small bone fragment press the nerve and this
will result in numbness and parasthesia of half of lower
lip and chin.
Management
⢠Control bleeding.
⢠The nerve usually regenerates
within six weeks to six months.
Dr. Firas Kassab 180
181. 15- Forcing a tooth or root into the
surrounding soft tissues
⢠Sometimes during removal of broken roots of
mandibular molar teeth, they are pushed in the region
of submandibular fossa. Sometimes the fracture roots
are pushed below the mylohyoid muscle and can not
be reached easily by intra oral approach and
removed through extra-oral approach.
Dr. Firas Kassab 181
182. 16- Maxillary sinus Involved
⢠The maxillary sinus may be opened and the roots
of teeth or whole teeth may be pressed into it.
⢠The first molars, second
premolars, first premolars and
canines are more common when
the teeth project into the sinus.
Dr. Firas Kassab 182
183. 7653 3567
Causes
1. During removal of fractured roots
2. Apical infection and other pathological processes
favour perforation because the bone completely
destroyed âosteomylitis, tumor, cystâ.
3. Sinus approximation.
Dr. Firas Kassab 183
185. Signs and Symptoms
1. If this perforation occur the patient is asked to blow air
into the nose while holding the nostrils together, we
found the air comes through the extraction wound.
2. Bleeding comes from the site of perforation and from
the nose epistaxis.
3. Alteration of voice.
4. Inability to blow-out the cheek.
5. Regurgitation of liquids from the
mouth into the nose.
Dr. Firas Kassab 185
186. ⢠If the root or tooth has been forced into the
antrum, there are several tricks to remove the
roots from the sinus.
1. Ask the patient to blow with the nostrils
closed while the perforation is carefully
washed for the appearance of the root.
2. The use of suction tip in
the socket may aid in the
removal.
Dr. Firas Kassab 186
187. 3. A long piece of 1/2 inch wide iodoform gauze tape
may be packed through the socket into the
antrum. This is pulled out in one stroke
sometimes removes the root by friction or
because it strikes to the gauze.
Dr. Firas Kassab 187
190. 4. Mucoperiosteal flap is prepared on the buccal
surfaces after enlarged the perforation to give
sufficient access and the root can be seen &
removed by instrument.
5. In other cases a cold well-luc operation is
necessary.
Dr. Firas Kassab 190
191. ⢠After removal of the root or tooth from the sinus,
the perforation of the sinus (oroantral fistula)
should be closed by:
ď Buccal flap.
ď Palatal flap.
ď Combination of buccal & palatal flap.
ď Tongue flap.
Dr. Firas Kassab 191
192. Post operative instructions
1. Maintenance of a pressure pack on the wound for at
least six hours.
2. Any suction, such as occurs when drinking from a
straw, blowing the nose must be through the mouth.
3. Ephedrin nasal drops should be prescribed to insure
proper drainage.
4. Antibiotic therapy as a prophylactic measure against
infection.
5. The patient should be instructed
to return in 48 hours for follow up.
Dr. Firas Kassab 192
194. 1- Hemorrhage
Is the escape of blood outside the vascular
system.
Types
A. External if the blood escape outside
B. Internal if the blood escape inside the body
cavities.
e.g. Periotoneal or pleural cavities.
e.g. Submandibular or sublingual space.Dr. Firas Kassab 194
195. ⢠The common type of Hemorrhage in oral cavity is
the external one. Also the Hemorrhage may be:
A. Arterial ďŽ spuring or pumping bright red
blood.
B. Venous continuous flow of dark bluish
blood.
C. Capillary continuous oozing.
Dr. Firas Kassab 195
196. Also the Hemorrhage may be
A-Primary ďŽ occurs at the time of operation.
B-Intermediate ďŽ occurs within 24 h after operation.
C-Secondary ďŽ occurs at any time after 24 h e.x. 2
weeks.
⢠Intermediate Hemorrhage may be due to
loose tie. The secondary Hemorrhage
may be due to disintegration of the blood
clot by infection.
Dr. Firas Kassab 196
197. Causes of Hemorrhage
1- Local causes
1. Interference of the patient to the formed clot.
2. Improper instructions for the use of packs.
3. Laceration of soft tissue.
4. Failure of the blood clot to form on the top of
severed vessels. E.g. Root in the socket.
5. Presence of nutrient canal in the wall of bony
socket.
ď e.g. nutrient canals: is a bony canals running
in the alvealor bone contain nutrient vessels
their common location is in the interseptal
bone of lower mandibular teeth.
Dr. Firas Kassab 197
198. 2- Systemic causes
1. Vascular Defects: Due to defect in the vessels
E.g. hemorrhagic telangiectasia or scurvy.
2. Coagulation Disorder: Due to absence of one
or more factors necessary for normal
coagulation. It may be acquired as a result of
illness, drugs or genetically.
Dr. Firas Kassab 198
199. Mechanism of coagulation:
in case of injured B.V.
A- Primary hemostasis: It has 3 phases:
⢠Vasoconstriction of the injured vessel to reduce the
blood flow.
⢠Extra vascular phase: Increase the extra vascular
pressure which lead to obliteration of the vessel.
⢠Platelets adhere to the wall of injured vessel and
aggregate one another to form platelets plug
âthrombusâ.
⢠In case of injured large vessels the platelets plug may
be prevented by the active pumping action of the vessel
so the bleeding vessel must be clamped.Dr. Firas Kassab 199
200. B- Permanent hemostasis:
⢠Which involve the process by which the fluid blood is
transformed into coagulated blood and formation of fibrin
There are 13 coagulation factors which are responsible for
coagulation:
⢠I- Fibrinogen II- Prothrombin
⢠III- Thromboplastin IV- Calcium
⢠V- Proaccelerin VI- Activated factor
⢠VII- Proconvertin
⢠VIII- Antihemophilic globulin (AHG)
⢠IX- Plasma thromboplastic component (PTC)
⢠X- Stuart-Bower factor
⢠XI- Plasma thromboplastin antecedent (PTA)
⢠XII- Hageman factor (HF)
⢠XIII-Fibrin stabilizing factor (FSF).Dr. Firas Kassab 200
202. Management of Patient with Hemorrhage
following Extraction of Teeth
1-Prevention and treatment of psychogenic shock
⢠Causes usually due to fear, colour of the blood:
⢠Calm the patient and relatives this prevent fainting.
⢠Put the patient in a position to help the increase of
cerebral circulation.
⢠Clear the air way.
⢠Use of aromatic spirits âammoniaâ for several breaths.
Dr. Firas Kassab 202
203. 2-Diagnosis and Looking for the cause of hemorrhage
⢠Regarding the actual cause of hemorrhage we
decide the line of treatment.
⢠Find out the tendency of blood clot by visual
examination. If the blood has tendency to clot this
means that the blood clotting mechanism is normal
and the bleeding due to local factor.
⢠It the blood is watery does not show clotting
tendency, this means that the blood clotting
mechanism is disturbed.
Dr. Firas Kassab 203
204. ⢠Template bleeding time- 1 to 9 minutes
⢠Prothrombin time (PT)- 11 to 16 seconds
⢠Partial thromboplstin time (PTT)- 32 to 46 seconds
⢠Platelets- 140000 to 440000/ml
Dr. Firas Kassab 204
205. Treatment of Hemorrhage due to Local
Factor
1. Clear the mouth from the accumulated blood by
suction apparatus or gauze sponges.
2. If the bleeding due to soft tissue laceration can be
simply corrected by local suturing.
3. Clamping and ligation of all accessible bleeding
vessels.
4. If bleeding due to interference by the patient to the
formed clot: application of local pressure sponges,
or dental compound.
Dr. Firas Kassab 205
206. 5. Application of ice compresses: this will help
hemostasis by causing vasoconstriction.
6. The use of local hemostatic agents e.g. thrombin,
epinephrine, oxidized cellulose fibrin foam and
gelatin sponge âdelayed healingâ.
7. If the bleeding is due to the presence of a nutrient
canal bleeding: could be controlled either by the
use of bone wax to occlude the canal or by crushing
of some spongy bone into the bleeding point by the
tip of a blunt instrument.
Dr. Firas Kassab 206
207. Management of patient with coagulation
disorder or systemic hemorrhage
1. The patient must be hospitalized after minimize
the amount of blood loss.
2. Careful family history.
3. Evaluation of the patientâs liver, spleen, kidneys.
4. Inspection for ecchymosis, petechiae.
Dr. Firas Kassab 207
208. 5. Laboratory procedure.
⢠B.T
⢠C.T
⢠Platelet abnormality Fresh blood
treated by
or packed plasma transfusion.
⢠Fibrinogen deficiency Fresh whole
treated by
blood transfusion or concentrated
fibrinogen.
Dr. Firas Kassab 208
209. ⢠Patient will experience tenderness to palpation near the
surgical site.
⢠Trismus and limited opening may also be a problem.
⢠The diagnosis of persistent bleeding may be made after any
exuberant clot formation has been removed and after
reapplying pressure dressings for a period of 15 to 20 minutes.
Dr. Firas Kassab 209
210. Step 1 Reanesthetize the patient to allow careful examination and
manipulation of the tissues in the surgical site.
⢠Anesthesia should be obtained with local anesthetic without a
vasoconstrictor.
Step 2 Following application of local anesthetic, thoroughly irrigate,
suction, and inspect the surgical site.
⢠If a single bleeding source can be identified, obtain control using
electrocautery or hemostatic agents such as Surgicel or Gelfoam.
Dr. Firas Kassab 210
211. Step 3 After the placement of hemostatic dressings and suturing,
observe the area 15 to 20 minutes to confirm hemostasis.
⢠If bleeding persists, the site should be packed and patient
referred to an oral and maxillofacial surgeon or emergency
facility for blood testing.
⢠Transamin â250mg/5ml/amp
Step 4 If the patient shows any signs of hypovolemia or hemorrhagic
shock, vital signs should be obtained and the patient should be
referred to an emergency treatment facility.
Dr. Firas Kassab 211
212. ⢠Dry socket is a common occurrence following the surgical
removal of mandibular molar ( 20% to 25%).
⢠Rarely observed in the maxilla.
⢠The suspected mechanism involves lysis or loss of the blood clot
following extraction of a tooth.
⢠The incidence appears to increase in smokers and in those taking
oral contraceptives
Dr. Firas Kassab 212
214. ⢠It is faulty healing of the socket, the blood clot
disintegrates and falls leaving the bony socket
bare of granulation tissue and results in sever
neuralgic pain.
⢠The condition starts the day after extraction but
sometimes occurs seven days after extraction
and occurs in the mandible then in the maxilla
due to better blood supply in the maxilla.
Dr. Firas Kassab 214
215. Etiology and predisposing factors
1. Pre-existing infection in the apex before extraction.
2. Trauma to socket and surrounding bone by burs or
elevators.
3. The use of a high concentration of vasoconstrictor
in the L.A.
4. Excessive use of mouth washes.
5. Patients under cortisone therapy.
6. Extraction of teeth in systemic disease e.g.
Diabetes, leukemia.
Dr. Firas Kassab 215
216. Treatment
1. L.A.
2. Irrigate the socket with warm normal saline
solution.
3. All the degenerating blood clot removed.
4. Sharp bony edges excised with rongeur.
5. Loose dressing composed zinc oxide and oil of
cloves packed in the socket.
6. Sedation and antibiotic could be prescribed.
Dr. Firas Kassab 216
217. 3- Swelling
⢠It is common after extensive surgical interference
âopen-methodâ. Cold applications to the face will
prevent or reduce swelling. Sedatives are used for
relief of pain.
Dr. Firas Kassab 217
218. 4- Trismus
⢠It is defined as inability to open the mouth due to
muscle spasm.
Types
1. Oedema.
2. Haematoma formation.
3. Inflammation of soft tissue.
4. Infection of the needle âmandibular blockâ.
Treatment
1. Hot fomentation âhot salineâ.
2. Ab and analgesic. Dr. Firas Kassab 218
219. 5- Acute osteomylitis
⢠It is an extensive infection involving the bone, bone
marrow and periosteum and affects a large area of
the bone.
Clinical picture
1. Severe pain.
2. Pus may be seen.
3. Swelling.
4. Tenderness.
5. In chronic cases there is sinus tracks or fistulas
draining pus.
6. Sequestration: separation of necrotic dead bone by
osteoclastic activity. Dr. Firas Kassab 219
220. ⢠The sequestration occurs with Staph infection which
cause bone resorption, also there is a subperiosteal
new bone formation which is the body defense
mechanism âinvolucrumâ.
⢠x-ray: irregular radio-opaque lesion
surrounded by radiolucent line.
Treatment
1. Intra bony drainage.
2. Removal of sequestra (sequestrectomy).
3. Ab and analgesic.
Dr. Firas Kassab 220
