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SEMINAR
ONCOMPLICATION OF
OOTH EXTRACTION AND
THEIR MANAGEMENT
CHIEF GUEST
PROFESSOR Dr. ISMAT ARA HAIDER
HEAD OF DEPARTME...
Classification
of
COMPLICATION
Pre - Extraction
During
Extraction
Post Extraction
Pre -
Extraction
Associated
with LA
Difficulty in
Achieving
Pain During
Needle
Breaking
Others
Difficulty in
Co-operation
...
 During Extraction
1.ABNORMAL RESISTANCE
2.EXTRACTION OF WRONG TEETH
3.DISLOCATION OF
-ADJACENT TOOTH
-TEMPOROMANDIBULAR ...
 Post Extraction
• DRY SOCKET
• TRISMUS
• POST EXTRACTION HAEMORRHAGE
• HEMATOMA
• EDEMA
• INFECTION
• ACUTE OSTEOMYELITI...
PRE – EXTRACTION
COMPLICATIONS
1. Associated with Local Anaesthesia
A. Failure to secure
anaesthesia:
Cause-
 Faulty Technique
 Insufficient Dosage
Prevention
Careful Diagnosis of Nerve Distribution
Appropriate Technique
FIG: VARIOUS TECHNIQUES OF LA
B. PAIN AND BURNING SENSATION DURING ANAESTHESIA
PREVENTION –
1. USE SHARP NEEDLE
2. USE TOPICAL ANAESTHETIC
3. USE STERIL...
C. NEEDLE BREAKAGE –
1. DO NOT USE SHORT NEEDLES FOR INFERIOR ALVEOLAR
NERVE BLOCK IN ADULTS OR LARGER IN CHILDREN
2. DO N...
• ENSURE ANAESTHESIA BY
PUSHING A BLUNT PROBE FIRMLY
INTO THE GINGIVAL CREVICE ON THE
BUCCAL AND LINGUAL SURFACES OF
THE T...
2.DIFFICULTY IN CO-
OPERATION:
• DO NOT FORCE THE
PATIENT
• SOUGHT ALTERNATIVE
METHOD
• IF NECESSARY USE
SEDATIVE OR GA.
3.DIFFICULTY OF ACCESS
A . TRISMUS -
EXTRINSIC – FACIAL SCARS AND INFLAMMATORY SWELLINGS
INTRINSIC – ABNORMALITIES IN THE ...
B. REDUCED APERTURE
OF MOUTH
CAUSE -
• MALFORMATION – (MICROSTOMIA)
• SCARRING
• PREVENTION – SURGICAL APPROACH
THROUGH AN...
DURING
EXTRACTION
ABNORMAL RESISTANCE:
CAUSES:
1.ROOT ABNORMALITIES- TWISTED, DIVERGENT,
BULBOUS, HYPERCEMENTOSIS.
2. SCLEROSIS OF ALVEOLAR ...
EXTRACTION OF WRONG TEETH
-COMMON SOURCE OF LITIGATION AND INDEFENSIBLE
PRECAUTIONS -
1.CHECK IMMEDIATELY BEFORE EXTRACTIO...
DISLOCATION OF ADJACENT TOOTH/RESTORATION
CAUSES-
1. MISUSE OF FORCEP
- ACCIDENTALLY ENGAGE PART OF NEXT TOOTH
- WITHOUT S...
DISLOCATION OF
TEMPOROMANDIBULAR JOINT
ETIOLOGY-
1. EXCESSIVE APPLICATION OF FORCE
2. INADEQUATE JAW SUPPORT
3. IT COMMONL...
MANAGEMENT-
TAKE A RADIOGRAPH FIRST-
IT SHOULD BE REDUCED IMMEDIATELY THE OPERATOR
STANDS IN FRONT OF THE PATIENT AND PLAC...
FRACTURE
FRACTURE OF THE CROWN OF THE TOOTH TO BE EXTRACTED
CAUSE –
1. IF THE TOOTH IS WEAKENED BY CARIES OR A LARGE RESTORATION
2....
FRACTURE OF THE CROWN
PREVENTION -
1. WHEN CORONAL FRACTURE OCCURS THE METHOD USED TO REMOVE THE
RETAINED PORTION OF TOOTH WILL BE GOVERNED BY T...
ROOT-FRACTURE OF THE TOOTH TO BE EXTRACTED
• A ROOT APEX MAY BE DEFINED AS A ROOT FRAGMENT WHEN
ITS LESS THEN 5mm IN ITS G...
CAUSTIONS:
• ALL FRAGMENT SHOULD BE REMOVED
• WHEN THEY ARE LIABLE TO BECOME
EXPOSED WHEN DENTURES ARE WORN.
• BUT IN CERT...
TREATMENT :
1. THE USE OF LUXETORS MAY FURTHER EXPAND THE
ALVEOLUS TO ALLOW ELEVATION OR SAFE APPLICATION OF
ROOT FORCEPS....
ALVEOLAR PROCESS
• IT’S A COMMON COMPLICATION
• FRACTURE OF LINGUAL CORTICAL
PLATE IS SPCIALLY SIGNIFICANT
BECAUSE THE LIN...
PREVENSION
IF 2, 3, 4 ARE TO BE EXTRACTED AT ONE VISIT, THE CANINE
SHOULD BE REMOVED FIRST
TREATMENT
1. REMOVE ANY FRAGMEN...
MAXILLARY TUBEROSITY
CAUSES -
• INVATION OF TUBEROSITY BY MAXILLARY ANTRUM IN CASE OF POSTERIOR
MAXILLARY TOOTH.
• PATHOLO...
EFFECT
• MAY LEAD TO ORO-ANTRAL COMMUNICATIONS
• CREATE PROBLEM FOR RETENSION OF FULL DENTURE
IN FUTURE.
TREATMENT
1. WHEN FRACTURE OCCURS THE FORCEPS SHOULD BE DISCARDED AND
A LARGE BUCCAL MUCO-PERIOSTEAL FLAP RAISED.
2. THE F...
ADJACENT OR OPPOSING TEETH
CAUSE:
• CARIOUS TOOTH
• HEAVILY RESTORED
• OPPOSITE TOOTH LIES ALONG THE LINE OF WITHDRAWAL
• ...
FRACTURE OF MANDIBLE
RARE COMPLICATION MAINLY ASSOCIATED WITH IMPACTED THIRD MOLAR.
CAUSE
• EXCESSIVE FORCE WITH ELEVATOR
...
TREATMENT
• PERFORM RADIOGRAPHIC AND CLINICAL ASSESMENT FIRST
• IF THERE IS ANY OFFENDING TOOTH THAT MUST BE REMOVED
• AFT...
 DISPLACEMENT OF ROOT/IMPACTED TOOTH
-INTO THE SOFT TISSUE
-MAXILLARY ANTRUM
-UNDER GENERAL ANESTHESIA DURING DENTAL CHAIR
 INTO THE SOFT TISSUE
ETIOLOGY- IT IS USUALLY THE RESULT OF INEFFECTUAL
ATTEMPTS TO GRIP THE ROOT WHEN VISUAL ACCESS IS
I...
 INTO THE MAXILLARY
ANTRUM
A ROOT DISPLACED INTO THE
ANTRUM IS USUALLY THAT OF A
MAXILLARY PREMOLAR OR MOLAR
AND IS MOST ...
 PREVENTION-
1. NEVER APPLY FORCEPS TO A MAXILLARY CHEEK TOOTH OR ROOT UNLESS
SUFFICIENT OF IT'S LENGTH IS EXPOSED, BOTH ...
3. NEVER ATTEMPT TO REMOVE A
FRACTURED MAXILLARY ROOT BY PASSING
THE INSTRUMENT UP THE SOCKET. IF
REMOVAL IS INDICATED, RA...
 DISPLACED OF ROOT INTO EITHER THE ANTRUM OR SOFT
TISSUE UNDER GENERAL ANESTHESIA IN DENTAL CHAIR
MANAGEMENT-
1. THE ANES...
5. IF THE ROOT IS NOT LOCATED THE PATIENT SHOULD BE GIVEN AN APPOINTMENT
FOR EXAMINATION IN 3 DAYS
6. HE SHOULD BE INSTRUC...
 EXCESSIVE HEMORRHAGE
• DURING TOOTH REMOVAL
• ON COMPLETION OF THE EXTRACTION
• POSTOPERATIVELY
 ETIOLOGY-
1. ACCIDENTA...
MANAGEMENT -
1. MANUAL PRESSURE OR GAUZE PACK PLACED OVER THE
AREA CAN BE USED BY THE DENTIST TO ARREST THE
BLEEDING.
2. I...
 SOFT TISSUE INJURY
 GUM INJURY
 LIP INJURY
 NERVE INJURY
 TONGUE AND FLOOR OF MOUTH INJURY
 GUM INJURY
• PREVENTED BY-
1. CAREFUL SELECTION OF FORCEP AND
GOOD TECHNIQUE.
2. GUM ADHERE TO A TOOTH SHOULD BE
CAREFUL...
 LIP INJURY
 LOWER LIP MAY BE CRUSHED BETWEEN THE HANDLES OF THE
FORCEPS.
 LIPS MAY BE BURNED IF INSTRUMENT ARE NOT ALL...
PREVENTION-
1. USE OPERATOR'S LEFT HAND TO RETRACT THE LIP
PROPERLY.
2. ALLOW THE INSTRUMENTS TO COOL BEFORE USING.
3. EXT...
*TREATMENT
1.WHEN THE INJURIES ARE SMALL AND LOCALIZED
THERE IS NO PARTICULAR TREATMENT.
2.IN CERTAIN CASES HEALING IS FAC...
 INJURY TO THE TONGUE AND FLOOR OF THE
MOUTH
 IT MAY HAPPEN DURING THE APPLICATION OF FORCEPS AND THE
USE OF ELEVATORS.W...
*NERVE INJURY
-THE MOST COMMON NERVE INJURIES
ARE-
INFERIOR ALVEOLAR
MENTAL AND
LINGUAL NERVE INJURY
ACCORDING TO SEDDONS
...
*EITIOLOGY
1. NERVE BLOCK OF THE INFERIOR ALVEOLAR
NERVE AND MENTAL NERVE.
2. INCISION THAT EXTEND TO THE REGION OF
THE ME...
* FEATURES-
THE PATIENT WITH A NERVE INJURY MAY EXPERIENCE A VARIETY OF
SENSATION SUCH AS-
1. NUMBNESS OF TONGUE (LINGUAL ...
* TREATMENT
1. NO PARTICULAR TREATMENT IS INDICATED FOR
NEURAPRAXIA OR AXONOTMESIS, UNLESS THERE IS A ROOT
TIP/OTHER FOREI...
 BROKEN INSTRUMENT IN
TISSUE
• ETIOLOGY-
1. EXCESSIVE FORCE DURING LUXATION OF THE
TOOTH.
2. REPEATED USE OF THE INSTRUME...
• OROANTRAL COMMUNICATION
DEFINITION:
-IT IS AN ABNORMAL COMMUNICATION BETWEEN
THE MAXILLARY SINUS AND THE ORAL CAVITY.
-I...
 CONFIRMATORY TEST
-CONFIRMED BY OBSERVING THE PASSAGE OF AIR OR
BUBBLING OF BLOOD FROM THE POST EXTRACTION
ALVEOLUS WHEN...
MANAGEMENT
1. SMALL SIZED OROANTRAL COMMUNICATION WHICH IS PERCEIVED
IMMEDIATELY AFTER EXTRACTION,TREATMENT CONSISTS OF SU...
EMERGENCIES
EMERGENCY:
1.SYNCOPE
2.ANAESTHETIC EMERGENCY
3.ACUTE HYPOGLYCAECAEMIA
4.ANAPHYLACTIC REACTION
5.RESPIRATORY ARREST
6.CARDI...
SYNCOPE
FACTORS PREDISPOSING TO SYNCOPE:
1. ANXIETY
2. PAIN
3. INJECTIONS
4. FATIGUE
5. HUNGER
SIGNS & SYMPTOMS :
1.PREMON...
 MANAGEMENT OF A SYNCOPAL ATTACK:
1. LOOSEN ANY TIGHT CLOTHING ROUND THE NECK
2. LOWER THE HEAD
3. MUST BE GIVEN A SWEETE...
ANAESTHETIC EMERGENCY :
MANAGEMENT:
1.THE ANAESTHETIC MUST BE STOPPED IMMEDIATELY.
2.THE AIRWAY SHOULD BE CLEARED.
3. ALL ...
ACUTE HYPOGLYCAECAEMIA :
SIGNS & SYMPTOMS :
1. SIGNS ARE SIMILAR TO THOSE OF A SYNCOPAL ATTACK
2. UNCONSCIOUSNESS STEADILY...
ANAPHYLACTIC REACTION :
SIGNS & SYMPTOMS :
1.INITIAL FACIAL FLUSHING, ITCHING, PARAESTHESIA OR COLD EXTREMITIES.
2.FACIAL ...
MANAGEMENT :
1.LAY THE PATIENT FLAT.RAISE THE LEGS TO IMPROVE CEREBRAL BLOOD FLOW
2.SHOULD BE GIVEN 0.5-1 ML OF 1-1000 EPI...
RESPIRATORY ARREST:
SIGNS & SYMPTOMS :
1. SKELETAL MUSCLES BECOME FLACCID
2. THE PUPILS ARE WIDELY DILATED
MANAGEMENT :
1.THE PATIENT SHOULD BE LAID FLAT ON THE FLOOR
2.HIS AIRWAY SHOULD BE CLEARED
3.MANDIBLE SHOULD BE PULLED UPW...
CARIAC ARREST:
SIGNS & SYMPTOMS:
1.SUDDEN LOSS OF CONSCIOUSNESS
2.ABSENCE OF ARTERIAL PULSE
3.ABSENCE OF BREATHING
4.PATIE...
MANAGEMENT :
IN CASE OF ADULT:
• DENTAL SURGEON KNEELS AT ONE SIDE OF HIS TRUNK AND
PLACES THE HEEL OF HIS LEFT HAND ON TH...
STATUS ASTHMATICUS :
SIGNS & SYMPTOMS :
1.BREATHLESSNESS
2.INABILITY TO TALK
3.EXPIRATORY WHEEZING
4.RAPID PULSE
5.CYANOSIS
MANAGEMENT :
1. CALL AN AMBULANCE FOR TRANSFER TO
HOSPITAL
2. REASSURE THE PATIENT
3. PATIENT SHOULDN'T BE LAID FLAT
4. GI...
Post
Extraction
 Post Extraction
• DRY SOCKET
• TRISMUS
• HEMATOMA
• SPACE INFECTION
• EDEMA
• NERVE PARALYSIS
• POSTEXTRACTION GRANULOMA...
Dry socket
IT IS THE MOST COMMON AND PAINFUL IN
THE HEALING OF EXTRACTION WOUNDS.
Causes-
-EXCESSIVE FORCE
-LIMITED LOCAL ...
**PATHOLOGY
* DESTRUCTION OF THE BLOOD CLOT EITHER BY
1.PROTEOLYTIC ENZYMES PRODUCED BY BACTERIA.
2.EXCESSIVE LOCAL FIBRIN...
Clinical features-
 MANDIBLE IS MOSTLY AFFECTED
 DEEP SEATED ,SEVERE, ACHING,THROBBING PAIN
 USUALLY PAIN STARTS AFTER ...
TREATMENT-
 IRRIGATION WITH WARM SALINE OR ANTISEPTIC
SOLUTION
 SUITABLE DRESSING PACK IS PLACED IN THE SOCKET -
USUALLY...
PREVENTION
1.MINIMAL TRAUMA
2. SQUEEZED THE SOCKET EDGE FIRMLY AFTER EXTRACTION
3.IN CASE OF DIS-IMPACTION OF 3RD MOLAR DR...
Trismus
AFTER EXTRACTION IT USUALLY OCCURS DUE TO
EDEMA AND SWELLING.
Causes-
 DAMAGE TO TEMPOROMANDIBULAR
JOINT DUE TO E...
TREATMENT -
 RECOVERS WITH TIME , USUALLY
6 WEEKS.
 WARM SALINE MOTH BATHS.
 PHYSIOTHERAPY
POST EXTRACTION HAEMORRHAGE
IT IS A COMMON COMPLICATION OF TOOTH EXTRACTION.
REACTIONARY HAEMORRHAGE-
OCCURS WITHIN 48 HRS...
LOCAL CAUSE -
EXCESSIVE TRAUMA
DISLODGEMENT OF CLOT
SLIPPING OF LIGATURE
IMPROPER STITCH
REPEATED CHANGE OF COTTON PACK
SY...
Management -
-RAPID HISTORY TAKING
- ASSESMENT OF GENERAL HEALTH CONDITION
- EXAMINE THE BLEEDING SITE UNDER SUFFICIENT LI...
INFECTION
POST EXTRACTION INFECTION MAY TAKE ANOTHER FORM IN WHICH EXUBERANT
GRANULATION AND DISCHARGE OF PUS LOCALISED TO...
ACUTE OSTEOMYELITIS
Predisposing factor - EXTRACTION OF LOWER MOLARS UNDER LOCAL
ANAESTHETIC IN PRESENCE OF ACUTE GINGIVAL...
HAEMATOMA
o OCCUR WHEN THE CORRECT MEASURE FOR CONTROL OF BLEEDING
ARE NOT TAKEN(LIGATION OF VESSELS, ETC.) OR VESSEL INJU...
TREATMENT
 IF A HEMATOMA IS FORMED DURING THE FIRST FEW HOURS AFTER
THE SURGICAL PROCEDURE, THERAPEUTIC MANAGEMENT CONSIS...
SUBCUTANEOUS /SUBMUCOSAL EMPHYSEMA
-IT IS A WELL ESTABLISHED COMPLICATION OF TRAUMA.
-RESULTS FROM AIR ENTERING TROUGH LOO...
EDEMA
• OCCUR SECONDARY TO SOFT TISSUE TRAUMA.
• IT IS THE RESULT OF EXTRAVASATION OF FLUID BY
THE TRAUMATISED TISSUES BEC...
TREATMENT
• A SMALL SIZED EDEMA DOES NOT REQUIRED ANY
THERAPEUTIC MANAGEMENT. FOR PREVENTIVE
REASONS, COLD PACKS SHOULD BE...
OROANTRAL FISTULA IS AN
EPITHELIALIZED,PATHOLOGICAL, UNNATURAL
COMMUNICATION BETWEEN ORAL CAVITY AND
MAXILLARY SINUS.
Clin...
*In established
communication -
- MILD PAIN
- PERSISTENT,PURULENT FOUL
UNILATERAL DISCHARGE
- POST NASAL DRIP
- POPPING OU...
Management -
Preoperative:
-WELL FITTED ACRYLIC BASE PLATE
- INFECTED ANTRUM WASHED WITH WARM NORMAL SALINE
- DECONGESTANT...
Post operative:
- INSTRUCTIONS TO PATIENT
• AVOID SNEEZING
• AVOID NOSE BLOWING
• AVOID EXPLORE THE WOUND
WITH TONGUE
• AV...
GENERAL PREVENTIVE MEASURES TO AVOID
COMPLICATION OF TOOTH EXTRACTION :
1. CAREFUL MEDICAL HISTORY SHOULD BE TAKEN
2. PROP...
Complication of Tooth extraction and management
Complication of Tooth extraction and management
Complication of Tooth extraction and management
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Complication of Tooth extraction and management

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This is a brief presentation on the complications during and after tooth extraction that we face in Exodontia , prepared for a semiinar project. The contents were collected from reference books and ofcourse, internet.

Published in: Health & Medicine
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Complication of Tooth extraction and management

  1. 1. SEMINAR ONCOMPLICATION OF OOTH EXTRACTION AND THEIR MANAGEMENT CHIEF GUEST PROFESSOR Dr. ISMAT ARA HAIDER HEAD OF DEPARTMENT, OMS DHAKA DENTAL COLLEGE AND HOSPITAL PRESENTED BY- DR. NUSRAT FAHMIDA TRISHA
  2. 2. Classification of COMPLICATION Pre - Extraction During Extraction Post Extraction
  3. 3. Pre - Extraction Associated with LA Difficulty in Achieving Pain During Needle Breaking Others Difficulty in Co-operation Difficulty of Access Trismus Restricted mouth opening Crowded or Misplaced Teeth
  4. 4.  During Extraction 1.ABNORMAL RESISTANCE 2.EXTRACTION OF WRONG TEETH 3.DISLOCATION OF -ADJACENT TOOTH -TEMPOROMANDIBULAR JOINT 4.FRACTURE OF -CROWN OF TOOTH BEING EXTRACTED -ROOTS OF TOOTH BEING EXTRACTED -ALVEOLAR BONE -MAXILLARY TUBEROSITY -ADJACENT OR OPPOSITE TOOTH -MANDIBLE 5.DISPLACEMENT OF A ROOT -INTO THE SOFT TISSUE -INTO THE MAXILLARY ANTRUM -UNDER GENERAL ANESTHESIA IN THE DENTAL CHAIR 6.EXCESSIVE HAEMORRHAGE -DURING TOOTH REMOVAL -ON COMPLETION OF TOOTH REMOVAL -POSTOPERATIVELY 7.SOFT TISSUE INJURIES 8.BROKEN INSTRUMENT 9.ORO-ANTRAL COMMUNICATION 10.NERVE INJURY 11.EMERGENCIES
  5. 5.  Post Extraction • DRY SOCKET • TRISMUS • POST EXTRACTION HAEMORRHAGE • HEMATOMA • EDEMA • INFECTION • ACUTE OSTEOMYELITIS • ORO-ANTRAL FISTULA
  6. 6. PRE – EXTRACTION COMPLICATIONS
  7. 7. 1. Associated with Local Anaesthesia A. Failure to secure anaesthesia: Cause-  Faulty Technique  Insufficient Dosage
  8. 8. Prevention Careful Diagnosis of Nerve Distribution
  9. 9. Appropriate Technique FIG: VARIOUS TECHNIQUES OF LA
  10. 10. B. PAIN AND BURNING SENSATION DURING ANAESTHESIA PREVENTION – 1. USE SHARP NEEDLE 2. USE TOPICAL ANAESTHETIC 3. USE STERILE LA SOLUTION 4. INJECT LA SLOWLY 5. MAINTAIN TEMPERATURE 6. BUFFERED LA, AT A pH APPROXIMATELY 7.4 , HAVE BEEN DEMONSTRATED TO BE MORE COMFORTABLE ON ADMNISTRATION.
  11. 11. C. NEEDLE BREAKAGE – 1. DO NOT USE SHORT NEEDLES FOR INFERIOR ALVEOLAR NERVE BLOCK IN ADULTS OR LARGER IN CHILDREN 2. DO NOT USE 30 GAUZE NEEDLES FOR IA NERVE BLOCK 3. DO NOT BEND NEEDLES WHEN INSERTING THEM INTO SOFT TISSUES 4. DO NOT INSERT A NEEDLE INTO SOFT TISSUE TO ITS HUB UNLESS IT IS ABSOLUTELY ESSENTIAL FOR THE SUCCESS OF THE INJECTION. 4. OBSERVE EXTRA CAUTION WHEN INSERTING NEEDLES IN YOUNGR CHILDREN OR EXTREMELY PHOBIC ADULT OR CHILD PATIENT.
  12. 12. • ENSURE ANAESTHESIA BY PUSHING A BLUNT PROBE FIRMLY INTO THE GINGIVAL CREVICE ON THE BUCCAL AND LINGUAL SURFACES OF THE TOOTH. • EXPLAIN THE PATIENT THAT ALTHOUGH HE MAY FEEL PRESSURE BUT HE SHOULD NOT FEEL ANY SENSATION OF SHARPNESS. • BUT IF PAIN FELT THAT INDIACATES A FURTHER INJECTION IS REQUIRED
  13. 13. 2.DIFFICULTY IN CO- OPERATION: • DO NOT FORCE THE PATIENT • SOUGHT ALTERNATIVE METHOD • IF NECESSARY USE SEDATIVE OR GA.
  14. 14. 3.DIFFICULTY OF ACCESS A . TRISMUS - EXTRINSIC – FACIAL SCARS AND INFLAMMATORY SWELLINGS INTRINSIC – ABNORMALITIES IN THE TMJ PREVENTION- 1. WAIT UNTIL THE CONDITION RESOLVES 2. IF THERE IS A RISK TO THE AIR WAY – DO NOT DELAY IN REMOVING CAUSE AND INSTITUTING DRAINAGE. 3. THE ACUTE PHASE MAY BE TREATED WITH ANTIBIOTIC AND DRAINAGE 4. DO NOT FORCE THE JAW TO OPEN WHEN TRISMUS THAT IS CAUSED DUE TO INFECTION AS IT MAY BREAK DOWN THE PYOGENIC MEMBRANE AND CAUSE SPREAD.
  15. 15. B. REDUCED APERTURE OF MOUTH CAUSE - • MALFORMATION – (MICROSTOMIA) • SCARRING • PREVENTION – SURGICAL APPROACH THROUGH ANGLE OF MOUTH C. CROWDED OR MISPLACED TEETH CAUSES LOOSENING OF ADJECENT TOOTH PREVENTION – SURGICAL TECHNIQUE TO DIVIDE AND ELEVATE THE TOOTH TO BE EXTRACTED.
  16. 16. DURING EXTRACTION
  17. 17. ABNORMAL RESISTANCE: CAUSES: 1.ROOT ABNORMALITIES- TWISTED, DIVERGENT, BULBOUS, HYPERCEMENTOSIS. 2. SCLEROSIS OF ALVEOLAR BONE- - PERIODONTAL DISEASE - GERIATRIC PATIENT 3. ISOLATED TOOTH IN OCCLUSION OWING TO NARROWING OF THE PDL 4. UNERUPTED TOOTH IMPACTED AGAINST THE ROOTS OF TOOTH TO BE EXTRACTED eg; LOWER THIRD MOLARS AGAINST SECOND MOLAR ROOTS PREVENTION: 1. CAUSE SHOULD BE SOUGHT 2. TRANSALVEOLAR APPROACH
  18. 18. EXTRACTION OF WRONG TEETH -COMMON SOURCE OF LITIGATION AND INDEFENSIBLE PRECAUTIONS - 1.CHECK IMMEDIATELY BEFORE EXTRACTION. 2. RE-CHECK RADIOGRAPH 3. LET THE PATIENT CONFIRM IF OCCURS- 1.INFORM THE PATIENT 2.EXTRACT RIGHT TOOTH 3.MAKE DECISION IMMEDIATELY -RE- IMPLANT -ACCEPT THE SITUATION
  19. 19. DISLOCATION OF ADJACENT TOOTH/RESTORATION CAUSES- 1. MISUSE OF FORCEP - ACCIDENTALLY ENGAGE PART OF NEXT TOOTH - WITHOUT SUFFICIENT CONTROL,IT MAY BANG AGAINST THE UPPER TEETH. 2. MISUSE OF ELEVATOR - MISUSED AS CLASS -1 LEVER. -EMPLOYING THE NEIGHBOURING TOOTH,NOT BONE,AS FULCRUM. 3.SOME UNAVOIDABLE CAUSE- eg-LUXATION OF PERMANENT PREMOLARS WHILE EXTRACTING DECIDUOUS MOLAR DUE TO ROOT FORMATION OR INFECTION. PREVENTION 1.WATCHING FINGERS- TO SUPPORT THE ADJACENT TOOTH AND TO DETECT ANY FORCE TRANSMITTED TO IT. 2. IN CASE OF MISPLACED/MILDLY IMPACTED TOOTH, SURGICAL METHOD SHOULD BE FOLLOWED. 3.DON'T PLACE ELEVATOR TO MESIAL SURFACE OF 1 ST PERMANENT MOLAR,BECAUSE SMALLER 2ND PREMOLAR MAY BECOME DISLODGED.
  20. 20. DISLOCATION OF TEMPOROMANDIBULAR JOINT ETIOLOGY- 1. EXCESSIVE APPLICATION OF FORCE 2. INADEQUATE JAW SUPPORT 3. IT COMMONLY OCCUR IN SOME PATIENTS WHO HAVE POSITIVE HISTORY OF RECURRENT DISLOCATION. 4.IT MAY BE CAUSED BY INJUDICIOUS USE OF GAGS. 5. IN LENGTHY PROCEDURES PREVENTION - 1.LOWER JAW SHOULD BE SUPPORTED DURING EXTRACTION. 2. DO NOT FORCE OPEN THE MOUTH
  21. 21. MANAGEMENT- TAKE A RADIOGRAPH FIRST- IT SHOULD BE REDUCED IMMEDIATELY THE OPERATOR STANDS IN FRONT OF THE PATIENT AND PLACES HIS THUMBS INTRAORALLY ON THE EXTERNAL OBLIQUE RIDGES LATERAL TO ANY MANDIBULAR MOLARS WHICH ARE PRESENT AND HIS FINGERS EXTRAORALLY UNDER THE LOWER BORDER OF MANDIBLE. DOWNWARD PRESSURE WITH THE THUMBS AND UPWARD PRESSURE WITH THE FINGERS REDUCE THE DISLOCATION. 2.IF TREATMENT IS DELAYED, MUSCLE SPASM MAY MAKE REDUCTION IMPOSSIBLE, EXCEPT UNDER GENERAL ANESTHESIA. 3.THE PATIENT SHOULD BE WARNED NOT TO OPEN HIS MOUTH TOO WIDELY OR TO YAWN FOR A FEW DAYS POSTOPERATIVELY. 4.AN EXTRAORAL SUPPORT TO THE JOINT SHOULD BE APPLIED AND WORE UNTIL TENDERNESS IN THE AFFECTED JOINT SUBSIDES. **IF THE CONDYLE IS INTO MIDDLE CRANIAL FOSSA, REFER TO AN ORAL SURGEON.
  22. 22. FRACTURE
  23. 23. FRACTURE OF THE CROWN OF THE TOOTH TO BE EXTRACTED CAUSE – 1. IF THE TOOTH IS WEAKENED BY CARIES OR A LARGE RESTORATION 2. IMPROPER APPLICATION OF THE FORCEPS TO THE TOOTH, THE BLADES BEING EITHER APPLIED TO THE CROWN INSTEAD OF THE ROOT OR ROOT MASS, OR WITH THEIR WRONG AXIS ACROSS THAT OF THE TOOTH 3. IF THE BLADES ARE TO BROAD AND GIVE ONLY “ONE-POINT CONTACT” , THE TOOTH MAY COLLAPSE. 4. IF FORCEP HANDLES ARE NOT FIRMLY HELD TOGETHER 5. EXCESSIVE FORCE OR SHORT JERKY MOVEMENT
  24. 24. FRACTURE OF THE CROWN
  25. 25. PREVENTION - 1. WHEN CORONAL FRACTURE OCCURS THE METHOD USED TO REMOVE THE RETAINED PORTION OF TOOTH WILL BE GOVERNED BY THE AMOUNT OF TOOTH REMAINING AND THE CAUSE OF MISHAP. 2. SOMETIMES A FURTHER APPLICATION OF THE FORCEP OR ELEVATOR WILL DELIVER THE TOOTH. 3. OTHERWISE TRANS-ALVEOLAR METHOD SHOULD BE USED.
  26. 26. ROOT-FRACTURE OF THE TOOTH TO BE EXTRACTED • A ROOT APEX MAY BE DEFINED AS A ROOT FRAGMENT WHEN ITS LESS THEN 5mm IN ITS GREATEST DIMENTION. CAUSE - • SAME FACTORS CAUSING CROWN FRACTURE • IN DEVITALIZED TEETH AND PERIODONTAL DISEASE AND IN AGED PATIENTS • BRITTLE ROOT • SCLEROSIS • LOSS OF ELASTICITY OF ALVEOLAR BONE
  27. 27. CAUSTIONS: • ALL FRAGMENT SHOULD BE REMOVED • WHEN THEY ARE LIABLE TO BECOME EXPOSED WHEN DENTURES ARE WORN. • BUT IN CERTAIN CIRCUMSTANCES IT IS WISE TO LEAVE THEM SUCH AS • WHEN IT REQUIRES REMOVAL OF LARGE AMOUNT OF BONE SUCH AS EXTRACTION OF APICAL ONE-THIRD OF PALATAL ROOT OF A MAXILLARY MOLAR INVOLVES REMOVAL OF A LARGE AMOUNT OF ALVEOLAR BONE AND MAY BE COMPLICATED BY DISPLACEMENT OF FRAGMENT INTO MAXILLARY ANTRUM OR CREATION OF ORO-ANTRAL COMMUNICATION.
  28. 28. TREATMENT : 1. THE USE OF LUXETORS MAY FURTHER EXPAND THE ALVEOLUS TO ALLOW ELEVATION OR SAFE APPLICATION OF ROOT FORCEPS. 2. EXTRACTED PORTION CAN BE USED AS GUIDE FOR RETAINED PORTION. 3. TRANS-ALVEOLAR APPROACH 4. IF TRANS-ALVEOLAR METHOD IS NOT POSSIBLE, REMOVE ANY PULPAL TISSUE AND ZINC-OXIDE AND CLOVE OIL DRESSING SHOULD BE INCORPORATED OVER THE FRAGMENT , THEN SEND FOR MANAGEMENT
  29. 29. ALVEOLAR PROCESS • IT’S A COMMON COMPLICATION • FRACTURE OF LINGUAL CORTICAL PLATE IS SPCIALLY SIGNIFICANT BECAUSE THE LINGUAL NERVE MAY ALSO BE TRAUMATIZED CAUSE • ACCIDENTAL INCLUSION OF ALVEOLAR BONE WITHIN THE FORCEPS BLADES OR TO THE CONFIGURATION OF ROOTS • PATHOLOGICAL CHANGES TO BONE • THE EXTRACTION OF CANINES IS FREQUENTLY COMPLICATED BY FRACTURE OF LABIAL PLATE, SPECIALLY IF THE ALVIOLAR BONE HAS BEEN WEAKENED BY EXTRACTION OF LATERAL INCISOR OR FIRST PRE-MOLAR BEFORE CANINE.
  30. 30. PREVENSION IF 2, 3, 4 ARE TO BE EXTRACTED AT ONE VISIT, THE CANINE SHOULD BE REMOVED FIRST TREATMENT 1. REMOVE ANY FRAGMENT WHICH HAS LOST HALF OF ITS PERIOSTIAL ATTACHMENTS BY GRIPPING IT WTH HAEMOSTATIC FORCEP AND DISSECTING OFF THE SOFT TISSUES WITH PERIOSTIAL ELEVATOR, A MITCHELL TRIMMER OR A CUMINE SCALER. 2. SMOOTHEN ALL SHARP EDGES 3. IRRIGATE WITH NORMAL SALINE 4. SUTURE
  31. 31. MAXILLARY TUBEROSITY CAUSES - • INVATION OF TUBEROSITY BY MAXILLARY ANTRUM IN CASE OF POSTERIOR MAXILLARY TOOTH. • PATHOLOGICAL GEMINATION BETWEEN AN ERUPTED MAXILLARY SECOND MOLAR AND AN UNERUPTED MAXILLARY THIRD MOLAR. • ANKYLOSIS OF MAXILLARY MOLAR • DECREASE RESISTANCE OF THE BONE OF THE REGION, DUE TO SEMI-IMPACTED OR IMPACTED THIRD MOLAR. • INADEQUATE LUXATION • FORCEFUL CARELESS MOVEMENT
  32. 32. EFFECT • MAY LEAD TO ORO-ANTRAL COMMUNICATIONS • CREATE PROBLEM FOR RETENSION OF FULL DENTURE IN FUTURE.
  33. 33. TREATMENT 1. WHEN FRACTURE OCCURS THE FORCEPS SHOULD BE DISCARDED AND A LARGE BUCCAL MUCO-PERIOSTEAL FLAP RAISED. 2. THE FRACTURED TUBEROSITY AND THE TOOTH SHOULD THEN BE FREED FROM THE PALATAL SOFT TISSUES BY BLUNT DISSECTION AND LIFTED FROM THE WOUND. 3. THE SOFT TISSUE FLAPS ARE THEN APPOSED WITH MATTRES SUTURE, WHICH EVERT THE EDGES AND ARE LEFT IN SITU FOR ATLEAST 10 DAYS. 4. BROAD SPECTRUM ANTIBIOTIC AND NASAL DECONGESTENT ARE PRESCRIBED  IF THIS COMPLICATION OCCUR IN ONE MAXILLA, IT IS LIABLE TO OCCUR ON ANOTHER SIDE DURING EXTRACTION, SO CAREFUL DISSECTION SHOULD BE MADE WHILE TOOTH EXTRACTION.
  34. 34. ADJACENT OR OPPOSING TEETH CAUSE: • CARIOUS TOOTH • HEAVILY RESTORED • OPPOSITE TOOTH LIES ALONG THE LINE OF WITHDRAWAL • UNCONTROLLED FORCE PREVENTION: • IN CASE OF ABUTMENT, BRIDGE SHOULD BE DIVIDED WITH A VULCARBO OR DIAMOND DISK BEFORE THE EXTRACTION • LOOSE OR OVERHANGING FILLINGS SHOULD BE REMOVED & TEMPORARY DRESSING SHOULD BE INSERTED BEFORE EXTRACTION • DON’T USE AS A FULCRUM • GAGS OR PROPS SHOULD BE AVOIDED IN SUCH TOOTH • CAREFUL CONTROLLED TECHNIQUE SHOULD BE MAINTAINED • IF IT IS DONE UNDER GENERAL ANAESTHESIA, PRECAUTIONS MUST BE TAKEN.
  35. 35. FRACTURE OF MANDIBLE RARE COMPLICATION MAINLY ASSOCIATED WITH IMPACTED THIRD MOLAR. CAUSE • EXCESSIVE FORCE WITH ELEVATOR • INADEQUATE PATHWAY • ANKYLOSED TOOTH • WEAK MANDIBLE DUE TO • IMPACTED TEETH • SENILE OSTEOPOROSIS AND ATROPHY • OSTEOMYELITIS • FIBROUS DISPLASIA • CYST, TUMOR • HYPERPARATHYROIDISM
  36. 36. TREATMENT • PERFORM RADIOGRAPHIC AND CLINICAL ASSESMENT FIRST • IF THERE IS ANY OFFENDING TOOTH THAT MUST BE REMOVED • AFTERWARDS, DEPENDING ON THE CASE STABILIZATION BY WAY OF INTERMAXILLARY FIXATION OR REGID INTERNAL FIXATION OF THE JAW SEGMENTS IS APPLIED FOR 4 TO 6 WEEKS. • BROAD SPECTRUM ANTIBIOTIC • IN DENTAL OFFICE – PROVIDE EXTRA ORAL SUPPORT AND REFER TO ORAL SURGEON.
  37. 37.  DISPLACEMENT OF ROOT/IMPACTED TOOTH -INTO THE SOFT TISSUE -MAXILLARY ANTRUM -UNDER GENERAL ANESTHESIA DURING DENTAL CHAIR
  38. 38.  INTO THE SOFT TISSUE ETIOLOGY- IT IS USUALLY THE RESULT OF INEFFECTUAL ATTEMPTS TO GRIP THE ROOT WHEN VISUAL ACCESS IS INADEQUATE. PREVENTION- IT CAN BE AVOIDED IF THE OPERATOR ATTEMPTS TO GRASP ROOTS ONLY UNDER DIRECT VISION.
  39. 39.  INTO THE MAXILLARY ANTRUM A ROOT DISPLACED INTO THE ANTRUM IS USUALLY THAT OF A MAXILLARY PREMOLAR OR MOLAR AND IS MOST OFTEN THE PALATAL ROOT.  ETIOLOGY - THE PRESENCE OF LARGE ANTRUM IS A PREDISPOSING FACTOR.
  40. 40.  PREVENTION- 1. NEVER APPLY FORCEPS TO A MAXILLARY CHEEK TOOTH OR ROOT UNLESS SUFFICIENT OF IT'S LENGTH IS EXPOSED, BOTH PALATALLY AND BUCCALLY,TO ALLOW THE BLADES TO BE APPLIED UNDER DIRECT VISION. 2. LEAVE THE APICAL ONE THIRD OF THE PALATAL ROOT OF A MAXILLARY MOLAR IF IT IS RETAINED DURING FORCEPS EXTRACTION UNLESS THERE IS POSITIVE INDICATION FOR REMOVING IT.
  41. 41. 3. NEVER ATTEMPT TO REMOVE A FRACTURED MAXILLARY ROOT BY PASSING THE INSTRUMENT UP THE SOCKET. IF REMOVAL IS INDICATED, RAISE THE MUCOPERIOSTEAL FLAP AND REMOVE ENOUGH BONE TO PERMIT AN ELEVATOR TO BE INSERTED ABOVE THE BROKEN SURFACE OF THE ROOT,SO THAT ALL THE FORCE APPLIED TO THE ROOT TENDS TO MOVE IT DOWNWARDS AND AWAY FROM THE ANTRUM.
  42. 42.  DISPLACED OF ROOT INTO EITHER THE ANTRUM OR SOFT TISSUE UNDER GENERAL ANESTHESIA IN DENTAL CHAIR MANAGEMENT- 1. THE ANESTHESIA SHOULD BE STOPPED IMMEDIATELY AND THE PATIENT'S HEAD BROUGHT FORWARD. 2. AFTER THE COUGH REFLEX HAS RETURNED THE MOUTH IS EXAMINED AND PACK CAREFULLY REMOVED AMD INSPECTED. IF PROPER SAFEGUARDS HAVE BEEN TAKEN THE ROOT IS FOUND IN THE PACK IN MOST INSTANCES. 3. BUT IF THE ROOT CAN NOT BE LOCATED AFTER REMOVAL OF PACK, RADIOGRAPHS SHOULD BE TAKEN OF BOTH SOCKET AND THE CHEST. THE LATTER FILM IS TAKEN TO ENSURE THAT THE ROOT HAS NOT PASSED IN TO THE BRONCHI. 4. IF THE ROOT IS REVEALED LYING IN THE BRONCHUS, THE PATIENT MUST IMMEDIATELY REFERRED TO HOSPITAL, WHERE IT CAN REMOVED BY BRONCHOSCOPY.
  43. 43. 5. IF THE ROOT IS NOT LOCATED THE PATIENT SHOULD BE GIVEN AN APPOINTMENT FOR EXAMINATION IN 3 DAYS 6. HE SHOULD BE INSTRUCTED TO ATTEND HOSPITAL IMMEDIATELY IF HE DEVELOPS EITHER A TEMPERATURE, COUGH OR CHEST PAIN.
  44. 44.  EXCESSIVE HEMORRHAGE • DURING TOOTH REMOVAL • ON COMPLETION OF THE EXTRACTION • POSTOPERATIVELY  ETIOLOGY- 1. ACCIDENTAL TEARING OR CUTTING OF LARGE ARTERY OR VEIN. 2. LACERATION OF LARGE ARTERY OR VEIN DURING ROOT REMOVAL. 3. IF INFLAMMATION IS PRESENT. 4. PATIENT WITH HIGH BLOOD PRESSURE AND BLEEDING DISORDER.
  45. 45. MANAGEMENT - 1. MANUAL PRESSURE OR GAUZE PACK PLACED OVER THE AREA CAN BE USED BY THE DENTIST TO ARREST THE BLEEDING. 2. IF A LARGE VESSELS IS INVOLVED, THEN IT CAN BE CLAMPED WITH HEMOSTAT AND IS TIED WITH ABSORBABLE STICHES. 3. IF THE BLEEDING IS FROM BONE,THEN ABSORBABLE HEMOSTAT GAUZE OR BONE WAX OVER THE SITE OF BLEEDING CAN BE PLACED. PRECAUTION- 1. PROPER HISTORY SHOULD BE TAKEN. 2. AVOID VIGOROUS RINSING OF THE MOUTH 3. WARM SALINE RINSES 3-4 TIMES/DAY, 24 HOURS AFTER EXTRACTION SHOULD BE DONE WHICH WILL FASTEN THE HEALING PROCESS OF EXTRACTION SOCKET.
  46. 46.  SOFT TISSUE INJURY  GUM INJURY  LIP INJURY  NERVE INJURY  TONGUE AND FLOOR OF MOUTH INJURY
  47. 47.  GUM INJURY • PREVENTED BY- 1. CAREFUL SELECTION OF FORCEP AND GOOD TECHNIQUE. 2. GUM ADHERE TO A TOOTH SHOULD BE CAREFULLY DISSECTED FROM THE TOOTH EITHER A SCALPEL OR SCISSORS BEFORE ANY ATTEMPT.
  48. 48.  LIP INJURY  LOWER LIP MAY BE CRUSHED BETWEEN THE HANDLES OF THE FORCEPS.  LIPS MAY BE BURNED IF INSTRUMENT ARE NOT ALLOWED TO COOL BEFORE USE AFTER BEING STERILIZED.
  49. 49. PREVENTION- 1. USE OPERATOR'S LEFT HAND TO RETRACT THE LIP PROPERLY. 2. ALLOW THE INSTRUMENTS TO COOL BEFORE USING. 3. EXTRA CARE IS REQUIRED WHEN MAXILLARY TEETH ARE BEING EXTRACTED UNDER GENERAL ANESTHESIA.
  50. 50. *TREATMENT 1.WHEN THE INJURIES ARE SMALL AND LOCALIZED THERE IS NO PARTICULAR TREATMENT. 2.IN CERTAIN CASES HEALING IS FACILITATED IF THE LESION IS COVERED WITH PETROLATUM (VASELINE) OR WITH ANY OTHER APPROPRIATE OINTMENT. 3. WHEN THE INJURIES ARE EXTENSIVE, AND THERE IS ALSO HEMORRHAGIC, THE SURGICAL PROCEDURE MUST BE POSTPONED.
  51. 51.  INJURY TO THE TONGUE AND FLOOR OF THE MOUTH  IT MAY HAPPEN DURING THE APPLICATION OF FORCEPS AND THE USE OF ELEVATORS.WITHOUT PROPER CONTROL INSTRUMENT MAY SLIP AND DRIVE INTO TONGUE/FLOOR OF THE MOUTH.  MOST COMMONLY THESE MISHAPS OCCUR UNDER GENERAL ANESTHESIA.  MANAGEMENT-  TONGUE BLEEDING CAN BE CONTROLLED BY PULLING IT FORWARD AND BY INSERTION OF SUTURES. A SURGICAL SECOND OPINION SHOULD BE SOUGHT IN ALL SUCH CASES.
  52. 52. *NERVE INJURY -THE MOST COMMON NERVE INJURIES ARE- INFERIOR ALVEOLAR MENTAL AND LINGUAL NERVE INJURY ACCORDING TO SEDDONS CLASSIFICATION THERE ARE THREE TYPE OF NERVE DAMAGE- 1. NEURAPRAXIA 2. AXONOTMESIS 3.NEUROTMESIS
  53. 53. *EITIOLOGY 1. NERVE BLOCK OF THE INFERIOR ALVEOLAR NERVE AND MENTAL NERVE. 2. INCISION THAT EXTEND TO THE REGION OF THE MENTAL FORAMEN AND LINGUAL VESTIBULAR FOLD. 3. EXCESSIVE FLAP RETRACTION AND COMPRESSION WITH RETRACTORS DURING RETRACTION IN THE REGION OF THIRD MOLAR. 4. WHEN BONE NEAR A NERVE IS EXCESSIVELY HEATED. 5. IN THE CASE OF REMOVAL OF IMPACTED TEETH, ROOTS AND ROOT TIPS THAT ARE DEEP IN THE BONE AND CLOSE TO MENTAL/ INFERIOR ALVEOLAR NERVE.
  54. 54. * FEATURES- THE PATIENT WITH A NERVE INJURY MAY EXPERIENCE A VARIETY OF SENSATION SUCH AS- 1. NUMBNESS OF TONGUE (LINGUAL NERVE INJURY) NUMBNESS OF LIP/CHIN AND GUM.( INFERIOR ALVEOLAR NERVE INJURY) 2.TINGLING 3.BURNING 4. CRAWLING SENSATION 5.ELECTRIC SHOCK/ HYPERSENSITIVITY OF THE AFFECTED AREA.
  55. 55. * TREATMENT 1. NO PARTICULAR TREATMENT IS INDICATED FOR NEURAPRAXIA OR AXONOTMESIS, UNLESS THERE IS A ROOT TIP/OTHER FOREIGN BODY COMPRESSING THE NERVE, IN WHICH CASE IT MUST BE REMOVED. 2. ANALGESIC CAN BE ADMINISTRATED IN PAINFUL CONDITION. 3. MULTIVITAMIN SUPPLEMENT OF THE VITAMIN B COMPLEX TO RESTORE SENSATION. 4. IN CASE OF NEUROTMESIS, IT MUST BE TREATED AS SOON AS POSSIBLE, OFTEN A GRAFT MUST REPLACE THE INJURED NERVE SEGMENT OR THE SEVERED SEGMENTS MUST BE SUTURED.
  56. 56.  BROKEN INSTRUMENT IN TISSUE • ETIOLOGY- 1. EXCESSIVE FORCE DURING LUXATION OF THE TOOTH. 2. REPEATED USE OF THE INSTRUMENT ALTERING ITS METALLIC COMPOSITION. • MANAGEMENT AFTER PRECISE RADIOGRAPHIC LOCALIZATION, THE BROKEN PIECES ARE REMOVED SURGICALLY AT THE SAME TIME EXTRACT THE TOOTH/ROOT
  57. 57. • OROANTRAL COMMUNICATION DEFINITION: -IT IS AN ABNORMAL COMMUNICATION BETWEEN THE MAXILLARY SINUS AND THE ORAL CAVITY. -IT IS A COMMON COMPLICATION WITH EXTRACTION OF MAXILLARY POSTERIOR TEETH. • ETIOLOGY 1.DISPLACEMENT OF IMPACTED TOOTH/ROOT TIP INTO THE MAXILLARY SINUS DURING REMOVAL ATTEMPT. 2. CLOSENESS OF THE ROOT TIPS TO THE FLOOR OF THE MAXILLARY SINUS. 3. PRESENT OF PERIAPICAL LESION THAT HAS ERODED THE BONE WALL OF THE MAXILLARY SINUS FLOOR. 3. EXTENSIVE FRACTURE OF MAXILLARY TUBEROSITY. 4.EXTENSIVE BONE REMOVAL FOR EXTRACTION OF AN IMPACTED TOOTH OR ROOT.
  58. 58.  CONFIRMATORY TEST -CONFIRMED BY OBSERVING THE PASSAGE OF AIR OR BUBBLING OF BLOOD FROM THE POST EXTRACTION ALVEOLUS WHEN THE PATIENT TRIES TO EXHALE (GENTLY) TROUGH THEIR NOSE WHILE THEIR NOSTRILS ARE PINCED. (VALSALVA TEST).
  59. 59. MANAGEMENT 1. SMALL SIZED OROANTRAL COMMUNICATION WHICH IS PERCEIVED IMMEDIATELY AFTER EXTRACTION,TREATMENT CONSISTS OF SUTURING THE GINGIVA WITH A FIGURE OF EIGHT SUTURE. 2. WHEN THE SOFT TISSUES DO NOT SUFFICIENT, A SMALL PORTION OF THE ALVEOLAR BONE IS REMOVED WITH A BONE RONGEUR SO THAT THE BUCCAL AND PALATAL MUCOSA CAN BE RE-APPROXIMATE MORE EASILY, FACILITATING CLOSURE OF THE ORO-ANTRAL COMMUNICATION. 3. NASAL DECONGESTANTS SHOULD BE PRESCRIBED. 4. THE PATIENT IS GIVEN APPROPRIATE INSTRUCTIONS ( AVOID SNEEZING, BLOWING) AND IS SHOULD GO BACK FOR EXAMINATION IN 15 DAYS.
  60. 60. EMERGENCIES
  61. 61. EMERGENCY: 1.SYNCOPE 2.ANAESTHETIC EMERGENCY 3.ACUTE HYPOGLYCAECAEMIA 4.ANAPHYLACTIC REACTION 5.RESPIRATORY ARREST 6.CARDIAC ARREST 7. STATUS ASTHMATICUS 8.HAEMORRHAGE 9.DRUG INTERACTION
  62. 62. SYNCOPE FACTORS PREDISPOSING TO SYNCOPE: 1. ANXIETY 2. PAIN 3. INJECTIONS 4. FATIGUE 5. HUNGER SIGNS & SYMPTOMS : 1.PREMONITORY DIZZINESS, WEAKNESS OR NAUSEA 2.PALE,COLD MOIST SKIN 3.INITIALLY SLOW & WEAK PULSE BECOMING FULL & BOUNDING 4.LOSS OF CONSCIOUSNESS
  63. 63.  MANAGEMENT OF A SYNCOPAL ATTACK: 1. LOOSEN ANY TIGHT CLOTHING ROUND THE NECK 2. LOWER THE HEAD 3. MUST BE GIVEN A SWEETENED DRINK WHEN CONSCIOUSNESS HAS BEEN RECOVERED 4. IF NO RECOVERY WITHIN A FEW MINUTES, CONSIDER OTHER CAUSES OF LOSS OF CONSCIOUSNESS.  PREVENTION: REGULAR FAINTERS ARE FREQUENTLY HELPED BY AN ANXIOLYTIC, SUCH AS TEMAZEPUM 5 MG ORALLY,ON THE NIGHT BEFORE & AGAIN AN HOUR BEFORE TREATMENT.
  64. 64. ANAESTHETIC EMERGENCY : MANAGEMENT: 1.THE ANAESTHETIC MUST BE STOPPED IMMEDIATELY. 2.THE AIRWAY SHOULD BE CLEARED. 3. ALL PACKS,APPARATUS & DEBRIS BEING REMOVED FROM THE MOUTH. 4.THE MANDIBLE & TONGUE SHOULD BE PULLED FORWARDS,THE NECK EXTENDED,THE HEAD EITHER HELD DOWNWARDS & FORWARDS IF THE PATIENT CAN NOT BE LIFTED FROM THE CHAIR OR UPWARDS IF HE CAN BE LAID ON THE FLOOR. 5.OXYGEN SHOULD BE GIVEN IF THERE IS EXCESSIVE CONTRACTION OF THE ACCESSORY MUSCLES OF RESPIRATION. 6.IF THE OBSTRUCTION TO RESPIRATION IS NOT RELIVED, EITHER LARYNGOTOMY OR TRACHEOSTOMY MUST BE PERFORMED.
  65. 65. ACUTE HYPOGLYCAECAEMIA : SIGNS & SYMPTOMS : 1. SIGNS ARE SIMILAR TO THOSE OF A SYNCOPAL ATTACK 2. UNCONSCIOUSNESS STEADILY DEEPENS MANAGEMENT : 1. PATIENTS OFTEN AWARE OF WHAT IS HAPPENING AND ABLE TO WARN THE DENTIST. 2. BEFORE CONSCIOUSNESS IS LOST, GIVE GLUCOSE TABLETS OR PWDER/SUGAR AS A SWEETENED DRINK REPEATED IF SYMPTOMS NOT COMPLETELY RELIEVED. 3. IF CONSCIOUSNESS IS LOST,GIVE STERILE INTRAVENOUS GLUCOSE 4. IF STERILE GLUCOSE NOT AVAILABLE SHOULD BE GIVEN SUBCUTANEOUS GLUCAGON 1 MG THEN MUST BE GIVEN SUGAR BY MOUTH DURING THE RECOVERY PERIOD. 5. HYPOSTOP,A GEL CONTAINING GLUCOSE,MAY PROVIDE SUFFICIENT ABSORBED THROUGH THE ORAL MUCOSA.
  66. 66. ANAPHYLACTIC REACTION : SIGNS & SYMPTOMS : 1.INITIAL FACIAL FLUSHING, ITCHING, PARAESTHESIA OR COLD EXTREMITIES. 2.FACIAL OEDEMA OR URTICARIA 3.WHEEZING 4.LOSS OF CONSCIOUSNESS 5.PALLOR 6.COLD CLAMMY SKIN 7.RAPID WEAK OR IMPALPABLEB PULSE 8.DEEP FALL IN BLOOD PRESSURE.
  67. 67. MANAGEMENT : 1.LAY THE PATIENT FLAT.RAISE THE LEGS TO IMPROVE CEREBRAL BLOOD FLOW 2.SHOULD BE GIVEN 0.5-1 ML OF 1-1000 EPINEPHRIN(ADRENALIN) BY INTRAMUSCULAR INJECTION. REPEAT EVERY 15 MINUTES IF NECESSARY. UNTILL THE PATIENT RESPONDS 3.SHOULD BE GIVEN 10-20 MG CHLORPHENIRAMINE INTRAVENOUSLY SLOWLY 4.MUST BE GIVEN 200 MG OF HYDROCIRTISONE SODIUM SUCCINATE INTRAVENOUSLY 5.SHOULD BE GIVEN OXYGEN & IF NECESSARY, ASSISTED VENTILATION)
  68. 68. RESPIRATORY ARREST: SIGNS & SYMPTOMS : 1. SKELETAL MUSCLES BECOME FLACCID 2. THE PUPILS ARE WIDELY DILATED
  69. 69. MANAGEMENT : 1.THE PATIENT SHOULD BE LAID FLAT ON THE FLOOR 2.HIS AIRWAY SHOULD BE CLEARED 3.MANDIBLE SHOULD BE PULLED UPWARDS AND FORWARDS TO EXTEND THE HEAD FULLY 4.THE PATIENT'S NOSTRILS SHOULD BE COMPRESSED BETWEEN THE OPERATOR'S POINT FINGER & THUMB & MOUTH TO MOUTH RESUSCITATION SHOULD BE PERFORMED SO THAT THE CHEST IS SEEN TO RISE EVERY 3 0R 4 SECONDS 5.MUST CHECK THE CAROTID PULSE & APEX BEAT AT REGULAR INTERVALS.
  70. 70. CARIAC ARREST: SIGNS & SYMPTOMS: 1.SUDDEN LOSS OF CONSCIOUSNESS 2.ABSENCE OF ARTERIAL PULSE 3.ABSENCE OF BREATHING 4.PATIENT EXHIBIT A DEATHLY PALLOR & GREYNESS & HIS SKIN IS COVERD WITH A COLD SWEAT
  71. 71. MANAGEMENT : IN CASE OF ADULT: • DENTAL SURGEON KNEELS AT ONE SIDE OF HIS TRUNK AND PLACES THE HEEL OF HIS LEFT HAND ON THE LOWER THIRD OF THE PATIENT’S STERNUM. • THE OPERATOR THEN PLACES HIS RIGHT HAND ON THE BACK OF THE HEEL OF HIS LEFT HAND & PRESSES DOWNWARDS RHYTHMICALLY AT 1 SECONDS WITH SUFFICIENT FORCE TO COMPRESS THE HEART BETWEEN THE STERNUM & THE VERTEBRAL COLUMN. ** CONTINUE COMPRESSIONS & VENTILATIONS UNTIL THR VICTIM SHOWS SIGNS OF LIFE IN CASE OF CHILDREN: IF THE PATIENT IS CHILD, THE HEART WILL OFTEN START BEING AGAIN IF THE STERNUM IS TAPPED SHARPLY.
  72. 72. STATUS ASTHMATICUS : SIGNS & SYMPTOMS : 1.BREATHLESSNESS 2.INABILITY TO TALK 3.EXPIRATORY WHEEZING 4.RAPID PULSE 5.CYANOSIS
  73. 73. MANAGEMENT : 1. CALL AN AMBULANCE FOR TRANSFER TO HOSPITAL 2. REASSURE THE PATIENT 3. PATIENT SHOULDN'T BE LAID FLAT 4. GIVE NORMALLY USE ANTI-ASTHMATIC DRUG 5. GIVE HYDROCIRTISONE SODIUM SUCCINATE 200 mg INTRAVENOUSLY 6. GIVE OXYGEN 7. IF NO RESPONSE WITHIN 2-3 MINUTES, IDEALLY GIVE SALBUTAMOL 250 MG BY SLOW INTRAVENOUS INJECTION 8. IF I/V SALBUTAMOL NOT AVAILABLE AND PATIENT CONTINUES TO DETERIORATE, GIVE EPINEPHRIN AS FOR PROPHYLAXIS.
  74. 74. Post Extraction
  75. 75.  Post Extraction • DRY SOCKET • TRISMUS • HEMATOMA • SPACE INFECTION • EDEMA • NERVE PARALYSIS • POSTEXTRACTION GRANULOMA • DISTURBAMCES IN POST-OPERATIVE • WOUND HEALING • ORO-ANTRAL FISTULA
  76. 76. Dry socket IT IS THE MOST COMMON AND PAINFUL IN THE HEALING OF EXTRACTION WOUNDS. Causes- -EXCESSIVE FORCE -LIMITED LOCAL BLOOD SUPPLY - LOCAL ANAESTHETICS WITH ADRENALIN - ORAL CONTRACEPTIVE - OSTEOSCLEROTIC DISEASE - RADIOTHERAPY
  77. 77. **PATHOLOGY * DESTRUCTION OF THE BLOOD CLOT EITHER BY 1.PROTEOLYTIC ENZYMES PRODUCED BY BACTERIA. 2.EXCESSIVE LOCAL FIBRINOLYTIC ACTIVITY. -ANAEROBES ARE LIKELY TO PLAY A MAJOR ROLE. -DESTRUCTION OF THE CLOT LEAVES AN OPEN SOCKET, INFECTED FOOD AND OTHER DEBRIS ACCUMULATE. -THE NECROTIC BONE LODGES BACTERIA WHICH PROLIFERATE FREELY, LEUCOCYTES UNABLE TO REACH THEM TROUGH THE AVASCULAR MATERIAL. -DEAD BONE IS GRADUALLY SEPARATED BY OSTEOCLASTS. -HEALING IS BY GRANULATION TISSUE FROM THE BASE OF THE WALLS OF THE SOCKET.
  78. 78. Clinical features-  MANDIBLE IS MOSTLY AFFECTED  DEEP SEATED ,SEVERE, ACHING,THROBBING PAIN  USUALLY PAIN STARTS AFTER FEW DAYS  MUCOSA IS RED AND TENDER  NO CLOT IN THE SOCKET  SALIVA AND DECOMPOSING FOOD DEBRIS PRESENT IN THE SOCKET  WHITE DEAD BONE MAY BE SEEN  PAIN CONTINUES FOR 1-2 WEEKS
  79. 79. TREATMENT-  IRRIGATION WITH WARM SALINE OR ANTISEPTIC SOLUTION  SUITABLE DRESSING PACK IS PLACED IN THE SOCKET - USUALLY ZNO AND EUGENOL  ALVOGEL IS FREQUENTLY USED  REPEAT IRRIGATION AND DRESSING FOR FEW DAYS  ANALGESIC  SEDATIVE  METRONIDAZOLE  ORAL HYGIENE INSTRUCTIONS  NEWER TECHNIQUE: TOPICAL HONEY APPLICATION
  80. 80. PREVENTION 1.MINIMAL TRAUMA 2. SQUEEZED THE SOCKET EDGE FIRMLY AFTER EXTRACTION 3.IN CASE OF DIS-IMPACTION OF 3RD MOLAR DRY SOCKET IS MORE COMMON. -MINIMAL STRIPPING OF THE PERIOSTEUM. -MINIMAL DAMAGE TO THE BONE. -USE PROPHYLACTIC ANTIBIOTIC. 4.IN PATIENT WHO HAVE HAD RADIOTHERAPY, EVERY POSSIBLE PRECAUTION SHOULD BE TAKEN. 5.IN OSTEOSCLEROTIC DISEASE -LITTLE DAMAGE TO BONE(SURGICAL EXTRACTION) -PROPHYLACTIC ANTIBIOTIC. 6. STOP SMOKING FOR TWO DAYS POST EXTRACTION.
  81. 81. Trismus AFTER EXTRACTION IT USUALLY OCCURS DUE TO EDEMA AND SWELLING. Causes-  DAMAGE TO TEMPOROMANDIBULAR JOINT DUE TO EXCESSIVE DOWNWARD PRESSURE.  KEEPING PATIENT'S MOUTH WIDE OPEN FOR A LONG TIME.  DURING INFERIOR ALVEOLAR NERVE BLOCK  INJECTION TO MEDIAL PTERYGOID MUSCLE  INJURY TO SMALL VESSEL CAUSING HAEMATOMA
  82. 82. TREATMENT -  RECOVERS WITH TIME , USUALLY 6 WEEKS.  WARM SALINE MOTH BATHS.  PHYSIOTHERAPY
  83. 83. POST EXTRACTION HAEMORRHAGE IT IS A COMMON COMPLICATION OF TOOTH EXTRACTION. REACTIONARY HAEMORRHAGE- OCCURS WITHIN 48 HRS AFTER EXTRACTION. IT OCCURS DUE TO LOCAL RISE OF BLOOD PRESSURE. COMMON IN PATIENTS TREATED UNDER LOCAL ANAESTHETIA AS EFFECT OF VASOCONSTRICTOR WEARS OFF. SECONDARY HAEMORRHAGE - STARTS ABOUT 7 DAYS AFTER EXTRACTION. IT OCCURS DUE TO INFECTION WHICH DESTROYS BLOOD CLOT OR MAY ULCERATE VESSEL WALL.
  84. 84. LOCAL CAUSE - EXCESSIVE TRAUMA DISLODGEMENT OF CLOT SLIPPING OF LIGATURE IMPROPER STITCH REPEATED CHANGE OF COTTON PACK SYSTEMIC CAUSE- BLEEDING OR CLOTTING DISORDER ANAEMIA LEUKAEMIA RENAL FAILURE LIVER DISEASE HYPERTENSION DRUGS- ASPIRIN, WARFARIN, HEPARIN. OTHER- IF PATIENT DOES NOT FOLLOW INSTRUCTIONS
  85. 85. Management - -RAPID HISTORY TAKING - ASSESMENT OF GENERAL HEALTH CONDITION - EXAMINE THE BLEEDING SITE UNDER SUFFICIENT LIGHT - CLEAN THE AREA WITH GAUZE - DIGITAL PRESSURE - ANOTHER DAMP GAUZE IS PLACED UPON SOCKET - TANNIC ACID POWDER IS APPLIED OVER GAUZE - INTERRUPTED HORIZONTAL MATTRESS SUTURE - BITE UPON A GAUZE PACK FOR 5 MINUTES - IF FAILS , GELATIN OR FIBRIN FOAM MAY BE TUCKED INTO THE SOCKET AND REFERRED TO NEAREST HOSPITAL.
  86. 86. INFECTION POST EXTRACTION INFECTION MAY TAKE ANOTHER FORM IN WHICH EXUBERANT GRANULATION AND DISCHARGE OF PUS LOCALISED TO THE SOCKET APPEAR A WEEK OR SO AFTER EXTRACTION. Cause - FREQUENTLY BONE SEQUESTRA. Clinical feature- - RELATIVELY PAINLESS - GRANULATION MAY CAUSE PACKING DIFFICULT Treatment- - HOT MOUTH BATHS - IF NOT SUBSIDE RADIOGRAPH MAY BE NECESSARY TO CONFIRM THE LOCAL NATURE OF INFECTION - THE SOCKET IS OPENED ,SEQUESTRA AND GRANULATIONS ARE REMOVED #BUT FORCEFUL CURETTAGE IS CONTRAINDICATED
  87. 87. ACUTE OSTEOMYELITIS Predisposing factor - EXTRACTION OF LOWER MOLARS UNDER LOCAL ANAESTHETIC IN PRESENCE OF ACUTE GINGIVAL INFLAMMATION Clinical features- -GENERAL WEAKNESS - TOXICITY - PYREXIA - SEVERE PAIN - EXTRAORAL SWELLING - IMPAIRMENT OF LABIAL SENSATION SOME HOURS OR EVEN DAYS AFTER EXTRACTION IS CHARACTERISTIC. Treatment - - DEBRIDEMENT OF THE AREA - ANTIBIOTIC ACCORDING TO C/S - ANALGESICS
  88. 88. HAEMATOMA o OCCUR WHEN THE CORRECT MEASURE FOR CONTROL OF BLEEDING ARE NOT TAKEN(LIGATION OF VESSELS, ETC.) OR VESSEL INJURY OCCUR DURING ADMINISTRATION OF LA o BLOOD ACCUMULATE INSIDE THE TISSUES, WITHOUT ANY ESCAPE FROM THE CLOSED WOUNDS OR TIGHTLY SUTURED FLAPS UNDER PRESSURE.
  89. 89. TREATMENT  IF A HEMATOMA IS FORMED DURING THE FIRST FEW HOURS AFTER THE SURGICAL PROCEDURE, THERAPEUTIC MANAGEMENT CONSISTS OF PLACING COLD PACKS EXTRAORALLY DURING THE FIRST 24 HOURS, AND THEN HEAT THERAPY TO HELP IT TO SUBSIDE MORE RAPIDLY. SOME PEOPLE RECOMMEND THE ADMINISTRATION OF ANTIBIOTICS TO AVOID SUPPURATION OF HEMATOMA, AND ANALGESICS FOR PAIN RELIEF.
  90. 90. SUBCUTANEOUS /SUBMUCOSAL EMPHYSEMA -IT IS A WELL ESTABLISHED COMPLICATION OF TRAUMA. -RESULTS FROM AIR ENTERING TROUGH LOOSE CONNECTIVE TISSUE, WHEN AN AIR ROTOR IS USED IN SURGICAL PROCEDURE FOR THE REMOVAL OF BONE /SECTIONING THE IMPACTED TOOTH. CLINICAL FEATURES 1.SWELLING PRESENT ON THAT REGION, SOMETIMES EXTENDING INTO NECK AND FACIAL AREA. 2.ON CLINICAL EXAMINATION, CRACKING SOUND PRESENT DURING PALPATION. TREATMENT 1.NO SPECIFIC TREATMENT.IT USUALLY SUBSIDES SPONTANEOUSLY AFTER 2-4 DAYS. 2. ANTIBIOTIC CAN BE GIVEN IN SOME CASES. 3. INCISION, DRAINAGE AND AGGRESSIVE SUPPORTIVE TREATMENT ARE SOMETIMES NECESSARY.
  91. 91. EDEMA • OCCUR SECONDARY TO SOFT TISSUE TRAUMA. • IT IS THE RESULT OF EXTRAVASATION OF FLUID BY THE TRAUMATISED TISSUES BECAUSE OF DESTRUCTION AND OBSTRUCTION OF LYMPH VESSELS, RESULTING IN THE CESSATION OF THE DRAINAGE OF LYMPH,WHICH ACCUMULATES IN THE TISSUES. • SWELLING REACHES A MAXIMUM WITHIN 48-72 HOURS AFTER THE SURGICAL PROCEDURE AND BEGINS TO SUBSIDE ON THE THIRD OR FOURTH DAY POSTOPERATIVELY. • DEPENDING ON THE AMOUNT OF TISSUE INJURY IN THE AREA, THE EDEMA RANGES FROM SMALL TO MODERATE AND RARELY SEVERE.
  92. 92. TREATMENT • A SMALL SIZED EDEMA DOES NOT REQUIRED ANY THERAPEUTIC MANAGEMENT. FOR PREVENTIVE REASONS, COLD PACKS SHOULD BE APPLIED LOCALLY IMMEDIATELY AFTER SURGERY. • SEVER EDEMAS MUST BE TREATED CAREFULLY, BECAUSE IF EDEMAS PRESENT FOR A PROLONGED PERIOD MAY LEAD TO FIBROSIS, AND IF EXTEND TO FACIAL AND PHARYNGEAL SPACES MAY LEAD TO ASPHYXIA. TREATMENT HERE INCLUDE THE INTRAVENOUS ADMINISTRATION OF 250-500 MG HYDROCORTISONE AND BROAD SPECTRUM ANTIBIOTICS.
  93. 93. OROANTRAL FISTULA IS AN EPITHELIALIZED,PATHOLOGICAL, UNNATURAL COMMUNICATION BETWEEN ORAL CAVITY AND MAXILLARY SINUS. Clinical features- *In fresh communication - -ESCAPE OF FLUID -EPISTAXIS -ESCAPE OF AIR FROM MOUTH TO NOSE ON SUCKING,INHALING, SMOKING - ALTERATION OF VOCAL RESONANCE - EXCRUCIATING PAI
  94. 94. *In established communication - - MILD PAIN - PERSISTENT,PURULENT FOUL UNILATERAL DISCHARGE - POST NASAL DRIP - POPPING OUT OF ANTRAL POLYP - SYSTEMIC TOXEMIC CONDITION
  95. 95. Management - Preoperative: -WELL FITTED ACRYLIC BASE PLATE - INFECTED ANTRUM WASHED WITH WARM NORMAL SALINE - DECONGESTANT NASAL DROP - SYSTEMIC ANTIBIOTIC THERAPY Operative: - BUCCAL FLAP ADVANCEMENT OPERATION - MODIFIED REHRMAN'S BUCCAL ADVANCEMENT FLAP - PALATAL PEDICLE FLAP - ROTATIONAL ADVANCEMENT FLAP OPERATION - COMBINATION OF BUCCAL AND PALATAL FLAP - CALDWELL LUC OPERATION WITH INTRA NASAL ANTROSTOMY
  96. 96. Post operative: - INSTRUCTIONS TO PATIENT • AVOID SNEEZING • AVOID NOSE BLOWING • AVOID EXPLORE THE WOUND WITH TONGUE • AVOID DELIBERATELY SUCKING AIR OR FLUID - MEDICATIONS - REMOVAL OF SUTURE ON 7TH OR 10TH POST OPERATIVE DAY - FOLLOW UP
  97. 97. GENERAL PREVENTIVE MEASURES TO AVOID COMPLICATION OF TOOTH EXTRACTION : 1. CAREFUL MEDICAL HISTORY SHOULD BE TAKEN 2. PROPER TECHNIQUE SHOULD BE FOLLOWED 3. A DENTIST SHOULD ALWAYS CARRY AN EMERGENCY KIT 4. AFTER EXTRACTION ALWAYS GIVE PROPER INSTRUCTION TO THE PATIENT 5. DO NOT HURRY!

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