Injection Videos

Maxillary Injections

Posterior Superior Alveolar

Teeth blocked:

1. Patient is in supine position while dentist sits at 9 o’clock for both sides.
2. Target is the infratemporal surface of the maxilla
3. Intraoral landmarks:

Zygomatic arch
Second maxillary molar
Height of maxillary vestibule

4. Patient closes mouth and moves mandible to the site of injection

5. Needle is aimed above and behind the second maxillary molar at a 45 degree
angle to the occlusal plane AND sagittal plane.
6. Palpate intraorally the zygomatic arch. Site of injection should be posterior to it in a
soft area. Firmly retract that area until taut
7. Insert 16mm of the needle. Angle should be towards inner corner of the eye
opposite to the injection
8. NO BONY CONTACT IS MADE
9. Perform multiple (At Least 3) aspirations because this area is well vasculated
10. inject 0.9-1.8 ml of solution

Anterior Superior Alveolar Nerve Block AKA Infraorbital Nerve Block

Blocks - Middle superior alveolar nerve, Anterior superior alveolar nerve
Teeth blocked: Incisors and canines (ASA), premolars and MB root of first molar (MSA)

1. Patient is supine with neck extended and chin lifted while dentist sits at 9 o’clock
2. Bony landmarks:

Infraorbital notch
Infraorbital foramen
Height of the vestibule adjacent to first premolar

3. Intraoral landmarks

height of vestibule adjacent to first premolar

4. Palpate the notch on the inferior rim of the orbit and go vertically down OR from
the pupil of the eye vertically down to the labial commissure. You will find the
orbital foramen here.
5. Place middle finger over the foramen and retract the buccal mucosa with your
 thumb and index finger. Secure retraction is CRITICAL.
6. Apply topical anesthesia to the height of the vestibule adjacent to the first
premolar.
7. Syringe is directed towards the foramen NOT to the apex of the tooth
8. Use a 25 gauge needle (long) and inject towards the infraorbital foramen (which is
being palpated extraorally) at this site for 16-25 mm until BONY CONTACT IS
ACHIEVED.
9. Retract the needle 1mm and inject 0.9-1.2 ml
10. Apply firm, extra extraoral pressure over the foramen for 1 minute to direct the
anesthesia into the canal

Greater Palatine
Teeth: Mesial aspect of 1st premolar to distal of 3rd molar. Also medial to midline suture

1. Patient is supine with neck extended while dentist sits at 9 o’clock

2. Target: Greater palatine foramen - adjacent to the second molar midway between
crestal bone and midline of the hard palate
3. Intraoral Landmarks:

Midline of palate
Junction of the soft and hard palate
Second maxillary molar

4. Palpate the greater palatine foramen with a cotton tip applicator along the line
halfway between the midline of the palate and the CEJ of the molars. IT will feel
like a soft depression. Occasionally the blood vessel exiting the foramen show a
blue spot which can indicate the correct insertion site.
5. Apply topical anesthesia for 2 minutes.
6. Use a 25 gauge short needle and insert 5-6mm inside. Deposit 0.45-0.6ml of
anesthesia. You may feel resistance because the tissue is keratinized and bound to
the periosteum
7. Tissues will blanch. Apply pressure to stop bleeding.

Nasopalatine nerve block

Teeth: Mesial of first premolar to mesial of first premolar

1. Patient is supine with neck extended while dentist sits at 9 o’clock. Patient will
move head depending on which side needs to be injected.
2. Target: incisive foramen -located below the papillae
3. Landmarks:

Central incisors
Incisor papillae

4. 25 or 27 gauge short needle is used. Needle is directed at a 45 degree angle

towards the papillae. Bevel is directed against the palatal soft tissue (meaning you
will approach it 45* in the angle where the patient won't be able to see it). Needle is
 inserted 5mm and 0.45ml is released. CONTACT WITH BONE OCCURS.

________ injection
Teeth: Mandibular teeth and labial periodontum. Second premolar to midline

1. Patient is in a semi supine position. The dentist sits between 11 and 12 o’clock for
the right side. Between 1 and 2 o’clock for left injection.
2. Target: mental foramen - between the apex of the 1st and 2nd mandibular
premolars
3. Palpate the mental foramen at the depth of the buccal vestibule between the
premolars. Apply topical anesthesia for 1 minute.
4. Using a 25 or 27 gauge short needle angle the needle 45 degrees to the occlusal
plane. Insert 5mm and deposit 0.6-0.9mm. CONTACT WITH BONE MAY OCCUR,
if it does remove 1mm. Apply extra oral pressure for one minute so it goes into the
mandibular canal from the mental foramen.

Gow-Gates (OPEN MOUTH; 3 Trunks): The nerves anthesized are the IAN, Mental
Nerve, Incisive Nerve, Lingual Nerve, Mylohyoid Nerve, Auriculotemporal and the Buccal
Nerve (75% of Pts).

1. Target Tissue: The mandibular teeth to the midline of one half of the mandible,
body of mandible and inferior portion of the ramus.
2. Extraoral Landmarks: Center of the external auditory meatus.
3. Intraoral Landmarks: Below the mesial lingual / mesial palatal cusp of the second
maxillary molar.
4. Insertion: Long needle. Align needle on the plane from corner of the mouth to the
ala-tragus. Direct surging towards target area on tragus. Penetration happens
distal to the maxillary second molar at the mand. occlusal plane
i. Bone Contact (neck of condyle) must occur. If bone is not contacted,
withdraw and redirect (more distally), angulating the needle tip anteriorly
5. ORIENTATION OF BEVEL IS NOT CRITICAL. 25 gauge long needle is used and
inserted 25mm.
Unit 3 Local Anesthesia 1 (Maria)

1. Syringe

The Yutil Syringe was the first syringe. There was no possible aspiration, difficult to clean, sterilize. The
needle removal was not easy, and they were reusable (with no autoclave at that time à boiled to be
sterilized).
The only advantage it that is was easy to inject intravascular

The Dental Cartridge Syringe has a cylindrical metallic body, a needle adaptor, piston and cartridge
placement

2. Needles

They have 2 parts:

Short end has a Bevel 45 degree, to perforate cartridges

Long end: to penetrate soft tissues

There are short and long needles: the long ones are for blocking techniques in oral cavity; the short ones
are for all techniques in oral cavity, and the very short ones are for periodontal ligament, intrapulpar, or
papillary techniques

3. Cartridges

The cartridge is made of the Rubber diaphragm surrounded by an aluminum cap, that should be
perforated by the short bottom of the needle. The body is a glass tube; the bottom is a plunger in silicon
that should be perforated by the piston.
It contains anesthetic drug or vasoconstrictor with type and concentration written on it. Important to do
an aspiration to provoke vasoconstriction, so that the effect lasts longer (vessels are closed off).
 4. Local Anesthesia Techniques

A. General advice
We should clean the area with chlorhexidine, preheat the anesthesia, use disposable needles, and pull
the lip to inject in soft tissues.

The bevel should always be towards the bone and the injection should be slow and gentle. ALWAYS
ASPIRATE AND NEVER LEAVE THE PATIENT UNATENDED.

B. Techniques
Topic Anesthesia
Presentation can be in cotton tip with gel, ointment, spray cryoanesthesia (liquid nitrogen), mouth rinse…

And even though they are not injected, they are absorbed and can have toxic effects. They are applied
on dry mucosa and have a shallow and short duration.

Infiltrative Anesthesia
Does not have a very wide area, and has a DEEP ACTION.
There are different types:

Periapical or Supraperiosteal: (MOST USED) Near apex, does not perforate periosteum, at
bottom of sulcus, slowly. USED FOR EXTRACTION (something about maxilla??)

Intraligamentary or Periodontal Ligament Injection: SHOULD NOT BE USED IN periodontal

disease or periapical acute pathology because there is always a risk of bacteremia. It is painful,
and the injection should be under pressure

Subperiosteal: the site of injection is the attached gingiva, there is only mucosa and
periodontium, and then we directly touch the bone. Therefore, it will be painful and we need it to
be under pressure and at a slow pace. In palatine, needle is perpendicular, 1 cm to margin and
there might be a risk of necrosis.

Intraosseous: Through cortical bone and should perforate with trephine. It is deep, there will be
 less amount of anesthetic drug and no numbness. Not very used

Papillar: used for small procedures Extirpate papilla, remove foreign object, temporary root à
biopsies

Intrapulpal: 2nd choice anesthesia, in endodontics, when there is a failure of the Supraperiosteal
or block technique. Here we do not need to do an aspiration because it will be too painful.Once
the pulp has been exposed, anaesthesia may be placed directly into the pulp

5. Anatomy of 2nd division

Trigeminal Nerve is a mixed nerve, has 3 trunks: Ophthalmic, Maxillary, and Mandibular. From the pons,
the two roots divide, pass through the petrous part of the temporal bone and reach the middle cranial
fossa to the Gasser Ganglion where they are separated.

ANATOMY IN PDF ***

6. Block Technique Anesthesia

A. Maxillary Block Technique

Anterior Superior Alveolar nerve

It is indicated when we want to remove several teeth, implants. In this case we do not use the
Supraperiosteal technique.

It will anaesthetise the PDL, alveolar bone, periosteum, buccal soft tissue, and teeth from
canine to midline. The penetration is over the maxillary canine.

The infraorbital technique: it is very close to the lower rim of the orbit. We ask the patient to look at you,
not move his eyes and with my middle finger, I locate 1cm below the lower rim of the orbit. We should
not remove the finger because when we inject, the anaesthesia can be versed in the eye resulting in
diplopia.

Posterior Superior Alveolar nerve

Need of a long needle and it needs to be introduced at least 2 cm inside, we locate the zygomatic
process on top of the 1st molar.
We need to use all of the cartridge and this will allow to anaesthetise all 3 molars, except
for the mesiobuccal aspect of the first molar.

Middle Superior Alveolar

The middle superior alveolar injection will anaesthetise the mesiobuccal aspect of the
maxillary first molar, both premolars, PDL, buccal bone and periosteum, along with the
soft tissue lateral to this area.

The needle is inserted at the height of the buccal vestibule lateral to the maxillary second
premolar.

If the MSA is absent, the anterior superior alveolar nerve injection will anaesthetise the premolar region

Nasopalatine nerve

In the midline, it will anaesthetise the tissues of the palatal aspect of the maxilla
We do not introduce the bevel inside any foramen, the anesthesia is released in the surrounding areas.
When released the area becomes white (ischemic). The palatine anesthesia is painful

Greater Palatine Nerve

It will anaesthetise the tissues of the hard palate.

Foramen located 1 cm away from the midline, btw the 2nd and 3rd molar, it is between the hard and soft
palate.
It may be palpated as a depression or soft spot in the posterior area of the hard palate.
Needle inserted until bone is contacted

B. Maxillary Trunk
It is very uncomfortable for the patient, feels like he is suffocating. It is done in the pterygomaxillary fossa
or palatine canal (these are the 2 possibilities). Complicated, better to do general anesthesia.
Unit 3: Local anesthesia 1 (Alberto)
Surgery Block 2: Anesthesia

Yutil syringe – Old model, no longer in use.

Caused trauma to the tissues

IMPORTANT: aspiration - pull the needle out a bit from the tissue. Why? Most
anesthesia had vasoconstrictors (shuts down the vessels, produces less
irrigation/blood in the tissue) – this is useful because:
1. we want the anesthesia in the tissue for as long as possible because most
surgical treatments need atleast one hour. This allows a higher concentration
of anesthesia in the tissue.
2. The other effect is that there is less blood flow to the tissue, which casues
less bleeding and less blood loss for the patient
Vasoconstrictor is usually adrenaline. Adrenaline causes tachycardia. You need to
aspirate before you inject because if you inject adrenaline into the blood vessel, it
can cause, a stroke, a _______ & ________
If you aspirate and you do NOT see blood, then you may inject the anesthesia
Needles go into the YELLOW bin

Dental cartridge syringe

Needles:

objective is mainly not to touch bone because it will be painful and may cause
bone inflammation
large needle is used for the inferior trunk
the side of the bevel that goes near the bone is …. The part that has the 45 degree
angel needs to go against the bone. Meaning the needle should not be going in
perpendicular.

Techniques

1. TOPIC

Anesthesia is preheated to prevent pain cause by the temperature difference, since the
anesthesia is stored at a colder temperature than body temperature

You can cause a trismus or a lesion if you ______

Perioapical supraperiosteal

In apex of tooth

Periodontal ligament injection

More trauma, hurts more, because disrupts the periodontal ligament fibers
With a normal syringle your hand can shake because you need a lot of strength to
be able to inject
There is a special syrgine for this type of injection that looks like a pen
Used when trunk or infiltrative does not work
Never used as a first technique

SUbperiosteal

Slow
Don’t use it usually because more risk of touching bone

Intraosseous

Through cortical bone

Cortical bone is very strong. Spongy bone has blood supply.

Papillar

Listen
Only for lesions

Intrapulpar

Very painful
No aspiration (as well with the intraligamental )

Anatomy V cranial nerve

Cranial nerve V MOTORY AND SENSORY COMPONENTS

2nd division – Maxilar

It leaves the skull through the foramen rotundum

§ It then crosses the pterygopalatine fossa, inclines lateralward on the back of the maxilla,
and enters the orbit through the inferior orbital fissure
§ It traverses the infraorbital groove and canal in the floor of the orbit, and appears upon
the face at the infraorbital foramen.
§ At its termination, the nerve lies beneath the Quadratus labii superioris, and divides into
a leash of branches which spread out upon the side of the nose, the lower eyelid, and the
upper lip, joining with filaments of the facial nerve.

Branches
Know where the middle meningeal nerve is
Posterior superior alveolar – used in daily practice. Molars. Buccal mucosa and buccal ….
Anterior superior alveolar – canine and incisors
Middle superior alveolar – premolars , MB root of 6 and

Nasoplatine nerve – canine to canine

Greater palatine nerve – is divided into middle posterior and posterior superior

Infraorbital technique

Blocks these branches:

Terminal part of trigeminal nerve
Part of the vallax points
Use a longer needle
Follow the canine up to the infraortibal foramen

Posterior superioer alveolar

Not used anymore

NAsoplatine nerve

Innervtes canine to canine and palatal mucosa

In the mucosa.
Sometimes used as a placebo
Used in children
Short duration ~15 mins just to be able to inject. Toxic effects. Takes 5 mins to
work (?)

1. Infiltrative
Difference between infiltrative and trunk.
Infiltrative doesn’t numb the whole trunk / multiple teeth. It will be on the
area where we need to work.
2. Trunk
Block the whole nerve in the roots. Cannot do infiltrative due to anatomy or
need multiple teeth numbed due to the type of technique
Unit 4: Local Anesthesia 2 (Maria)

1. Anatomy 3rd division

In PDF

2. Anaesthesia technique of 3rd division

Inferior Alveolar Nerve

The inferior alveolar injection will anaesthetise the mandibular teeth from the third molar to the midline,
the buccal soft tissue from the premolars anteriorly, the body of the mandible, the periosteum, the PDL,
and the skin and subcutaneous tissues of the chin and lower lip, all on the ipsilateral side

Landmarks: Lingula of mandible, mandibular foramen, retromolar area, pterygomandibular raphe

a. Direct or Standard
The operator's thumb or index finger is placed over the anterior border of ramus that helps in retraction
of tissues mildly.
The point of insertion is determined by carefully palpating the mucobuccal fold using the index finger,
until the external oblique ridge is felt by reaching for the retromolar triangle.

A long needle is positioned between canine and premolars of contra lateral side of extraction

The mucosa is pierced at a point between the pterygomandibular raphe and the deep tendon of the
temporalis muscle, and the needle is advanced until bone is contacted

Once the needle is advanced and bone contacted, the tip should now be just superior to the lingula.

The needle should be withdrawn 1–2 mm so it is no longer under the periosteum. As the needle is being
removed, when it is approximately halfway out, the lingual nerve is injected with the remaining solution

b. Indirect
The anatomical landmarks are carefully palpated and needle is inserted at the point bisecting the
fingernail into the retromolar triangle

1st position: the syringe is placed on the occlusal surfaces of the premolars on the opposite side. The
solution is deposited slowly anaesthetising the long buccal nerve

2nd position: syringe barrel is retracted back and directed to the same side of the arch, into the internal
oblique ridge. Needle is further advanced and solution is injected anaesthetising the lingual nerve

3rd position: syringe is repositioned on the opposite side at first premolar region and the needle is further
inserted deeper until bone is contacted. The solution is injected anaesthetising the inferior alveolar nerve

c. Gow-Gates (3 trunks)
The injection is performed by having the patient open the mouth as widely as possible to rotate and
translate the condyle forward: the patient needs to keep the mouth open for 2 min, then inject
The condyle is palpated with the fingers of the nondominant hand while the cheek is retracted with the
thumb.

Beginning from the contralateral corner of the mouth, the needle is positioned so that a puncture point is
made approximately at the location of the palatine cuspid of the 2nd upper molar.

The injection must not be performed unless bone is contacted to ensure proper needle placement

This injection is unique among intraoral injections because the operator does not attempt to get as close
as possible to the nerve to be anesthetized

d. Akinosi-Shield (3 trunks)
This form of injection, also known as the closed-mouth mandibular block, is useful for patients with
trismus because it is performed while the jaw is in the physiologic rest position

A long needle is inserted parallel to the maxillary occlusal plane at the height of the maxillary buccal
vestibule.

Buccal Nerve

Complementary to Alveolar Inferior in posterior gingival mucosa. It is always done after alveolar inferior
nerve. The buccal injection will anesthetize the buccal soft tissue lateral to the mandibular molars

Injection sites: Bottom of sulcus, anterior rim of the ramus, 1cm behind and below Stensen Duct.

Lingual Nerve

Simultaneously with Inferior Alveolar Nerve. The lingual nerve block will anesthetize the lingual gingiva,
floor of the mouth, and tongue from the third molar anteriorly to the midline
Done in lingual rim of the buttress (protecting wall), in lingual gingival margin opposite each tooth

Mental Nerve

The mental nerve exits the mental foramen at or near the apices of the mandibular premolars.

3. Accidents and complications

General

Toxicity, hypersensitivity, bacteraemia, hepatitis, AIDS

Fainting: more frequent. Benign and more frequent after injection: pallor, cold swear, muscle laxity, dry
mouth, bradycardia

Local

Infection (inflamed region), Dry socket, temporary ischema, necrosis, pain (trismus due to injection in
medial pterygoid muscle), facial palsy, diplopia, neuralgia, parenthesis, hematomas…

Prophylaxis

Suitable premedication, medical records, topic anaesthesia, warm to 37 degrees, new needles and
cartridges, injection in soft tissues that are not inflamed, bevel towards periosteum
Always supraperiosteal injection
Slow flow rate without pressure
Previous aspiration
Unit 5: Local anesthesia 3
intermediate chain more important because…
Three components : aromatic ring, intermediate linkage, terminal amine

NON ionized form enters the cell

Anethesia —> ionized and nonionized —> non ionized enters cell and divides into ionized
and non ionized again.

Therefore the ionized part of the non-ionized form that is active.

Henderson haselback formula - don’t need to study it. just know that each anesthesia has
a different pKa. pKa is a constant.

The more lip soluble = works better

More powerful protein binding = more powerful and longer it stays in the body

onset times: larger pKa = ______ onset. Low

anesthesia used are bases (therefore pH of more than 7). Normal tissue has a basic pH.

When a tissue has infection the pH is lower than usual (Acidic). Anesthesia on an acute
infection doesn’t work because the pHs are too different (acid and base). Do not inject
anesthesia on these patients because ____. Perscribe antibiotics and on the 4th day you
can do something because you will control the infection. IF you do a treatment on
someone with an infection, it can spread

Chart with anesthesia:

procaine low potency (not powerful) because unites very little with the body
tetracaine (not normally used) because very powerful. It unites a lot (lip solubility)
therefore it has higher toxicity

Normally use lidocaine mepivacaine and articaine

and normally use medium duration action and potency

Mechanism of action:

objective:

Classification and features of nerve fibers:

know about myelin - recovers the fiber and helps the impulse travel faster
diameter - first fibers to become numb are the B Fibers because of their small
diameter and myelin
then C fibers because no myelin
 Then A fibers - because of myelin and larger diameter
First thing that happens with anesthesia is vasoconstriction and then loss of
sensation of pain / temperature
we never numb Alpha A (motor)

Then recovery goes ih the sequence of ACB

Absorption:

End motor plate is not our objective

In normal doses we have excitation symptoms on the CNS

Larger doses induce CNS depression

Hyperthyroidism - high amounts of ACTH - higher metabolism (therefore can be very thin)

Vasoconstricotrs chart:

anesthesia works where there are alpha receptors and beta receptors (ex.
epithelium doesn’t have these receptors therefore it doesn’t work there)
Sympathomimetics - Adrenaline vs noradrenaline
More anesthesias have adrenaline to vasoconstrict - increasing intensity,
duration, and less bleeding and less toxic effects
vasopressin derived

Allergies with esters common (?)

Unit 6: Exodontia I
Winter’s definition of exodontia: part of oral surgery using special techniques and
equipment to avulse or extract the tooth from the alveolus

Xrays - We do not need a recent x-ray unless the tooth has an open apex. The roots are
already developed so the shape will be the same

if the root has a 90 degree curve it has a high chance of fracturing

Indications
I. Decay
Can be subjective. If the restoration will not last very long, an extraction would be
preferred.

main consideration is what amount of the tooth is left to rebuild

Dental abscesses can be due to caries or fractures
extract if the crown is non-restorable
extract after multiple rootcanal failures (more than twice)
after acute infection from odontologic origin: cellulitis, sinusitis, dental abscesses

Types of fractures:

1. Vertical - crown to apex - ALWAYS extract - because there is no way of sealing the
tooth in the bone and apex

Patient will complain of a very acute pain when biting

Diagnosed by elimination of other problems (ex. periodontal, caries, check for
overloaded occlusion, gum inflammation, etc). Exodontia is the LAST thing we
should think of because it is an aggressive treatment.
Most of the time you cannot see the fracture. Sometimes you can see it or feel it.
In the X-ray (periapical) you may be able to see an infection, but not a typical cyst
infection (rounded bubble in the apex), you will see more of an ovalic shape that
goes to the side.
The most definite sign, is probing depth, it will be 13 or 14 or more, the probe will
go all the way down (normal probing depth is 0-3. pathological is 4-8)

2. Horizontal - treatment depends on where the fracture is.

If it is quite deep, enters the gum or close to the bone, you extract because the
tooth prognosis is low because you will have to remove bone or gum to expose the
caries/fracture to reconstruct the tooth to get the correct seal of the caries/fracture
if it is coronal or a cusp, you do a filling
II. Periodontal disease
Mobility type 2 or 3, advanced furcation: better to extract
It is better not to wait because the situation will not improve. The longer you wait
the more bone you will lose, and the treatment later
(reconstruction/treatment/implant) will be harder

III. Impacted teeth

Do NOT extract every impacted tooth. We need a combination of factors
If the patient has pain, infection, causing problems for the patient, causing caries
on another tooth (7 if its the wisdom tooth), causing reabsorption of the root (of the
second molar), if we need to do an implant and it is interfering, then YES extract
CBCT needed

IV. Supernumeraries
usually diagnosed by orthodontist
Mesiodens - is more common - one extracentral insciors
usually there is not enough space for the adult tooth to erupt = indicated to
extract
usually mesiodens is removed
Distomolars - more than 3 molars
removed if there is a pathology to the 3rd molar
all supernumeraries do NOT have to be removed
if they affect eruption or patient is doing a treatment and it interferes you will
extract it

V. Malpositioned teeth
Will not have enough space to erupt in the arch and will erupt either palatally
lingually, etc
If it interferes with treatment = extract
ex. doing a bridge from 4 to 6 and the 5 is out of plane, you have to extract it
Patient has lost 1st inferior molar and 47 has moved to its place (mesialized). You
do not remove it especially if the patient has adapted
If it hurts the patient and is causing TMJ issues then you could extract it
If you need to put an implant and a tooth is below, extract
Premolars are usually the most frequent tooth that erupts abnormally.
upper arch palatally or buccally
lower arch lingual
In adults it is a clear indication of extraction because they cannot brush the
neighbouring, normally positioned tooth, properly
 In children, they can use orthodontic treatment. It takes a long time and a lot of
money. The orthodontic can decide to extract both teeth symmetrically to speed
up the treatment

VI. Temporary teeth

Normally we do need to remove unless they fall out by themselves
the mucosa can be fibrous that the tooth doesnt even move or the roots are very
big and cannot be absorbed: if you dont extract it the tooth will stay there
Pulpotomy fail a lot. if it fails after 2 treatments then we extract
When you remove it: you dont cause agressions to the tooth germ
must install a space maintainer
Temporary tooth restoration
if there is no tooth replacement = agenesia of the adult germ
Must keep the space if the patient is young until they are an adult and
are able to have a fixed prothesis or implant to replace the agenesia
most frequent spot with agenesia is premolars
Secondary retention
second temporal molars are not at the height of the other teeth
they have been in at the height of occlusion but after the eruption of the 1st
molar and due to a lack of arch space, the 1st molars erupt tilited mesially
with the force of the eruption fo the 1st molar the second premolar will
become retained
indicated to extract the second temporary molar because otherwise the
second premolar will never erupt by itself.
it is a surgical procedure to remove it
after the patient is sent to orthodontist to fix the arch space and alow
second molar to erupt

VII. Teeth associated with cysts

Needs to be treated because the cyst is only going to get bigger and cause more
issues
big risk of fracturing the jaw
IF there is a risk of fracturing the madnible the patient needs to be refered to the
hospital
most frequent cyst: inflammatory cyst
provoked by odontogenic infection - chronic periodontitis
ends in a granuloma and then the cyst formation begins
if we want to preserve the tooth, we should do a root canal procedure and
follow it by a surgical apicectomy
cut the end of the apex where the infectious process has started and
remove the whole cyst
Follicular cysts
formed after the different embyrological layers of ameloblast (cells that form
 tooth enamel)
associated with any tooth
3rd molars: remove the cyst and third molar
if it is any other tooth and the patient is not an adult (teenager): we try to
preserve the tooth and elimante the cyst
with orthodontic surgical traction we pull out of the bone the retained tooth
and the content of the cyst will go away on its own when exposed to the oral
cavity. Only indicated for adolescents

VIII. Teeth associated with Tumours

Do not touch the tooth
The maxilofacial surgeons will need to remove the tumor and probably bone
The oncologist needs to see this

IX. Teeth exposed to radiotherapy/Chemotherapy

WE need to consider when the patient will be recieving the therapy and how long it
takes for the socket to heal
You can extract before the 2nd month of radiotherapy but after it is not possible.
you will have to wait a year
there is still some blood supply to permit the recovery of the socket
if you do it not within this time you can have osteoradionecrosis - the bone
will not regenerate
Advice - if its not urgent just wait a year
so either you can extract right after or wait a year
Radiotherapy stops blood supply to malignant cells to cause the cells to kill
themselves
if you do a treatment and the tooth has an abcess later, you cannot do anything for
a whole year

X. Teeth included in fractures

If the patient has a mandible fracture (ex. in a car accident), all the teeth in the area
will be affected by either the trauma or the fracture
necrosis, reabsorption, other problems
It could have happened years ago
Important to check up on traumas years to decades after
You can do a root canal or exodontia depending on the tooth and the issues
The most frequently fractures are:
symphysis
paralateral symphysis
angle of the mandible
condyle
 Leave them if they are stabilised and without infection

XI. Teeth as a focal infection

we must treat the infection because it can migrate and cause sepsis/endocarditis
large infection, or abcess you give antibiotics
if you see pus, prescribe antibiotics
teeth suspected of focal infection - theory in 19th century
distant areas in head and neck with certain pathologies (ex kidneys nephfitis
or eyes uveitis) will get inflammated (NOT INFECTED), from unknown origins
the physican sends the patient for you to check for chronic infection in the
oral cavity. Because problems in the oral cavity can cause distant
pathologies in other parts of the bodies
If you remove a tooth, the distant pathology cures itself
Periodontal disease is related to cardiac diseases

XII. Prothesis
we do not leave anything that will be susceptible of giving problems in the future
Ex if you need to do a bridge on the 7 and you extract the 8 because it could give
problems in the future (if the tooth has an issue)

XIII. Orthodontic
Third molars can shift teeth and therefore can be extracted. Controversy though
and therefore up to judgement
in some cases it is permitted to do a symmetric extraction instead of doing a
longer orthodontic treatment
anytime you will extract a healthy tooth you need the written prescription form the
orthodontist. dont just take the patients word
supernumerary: also needs written prescription
Orthodontist can ask you to remove an unerupted third molar, or any or teeth, if
there is not enough space in the arch and you need to distalize the other teeth
(again we need the written prescription)

XIV. Esthetics
if the patient doesnt want orthodontic treatment
The patient needs to sign a confirmed consent form

XV. Social
 IF the patient cannot afford a treatment and prefers an extraction

Local Contraindications
Dental Infection

Never during an acute infection because anaesthesia does not work and the infection can
become systemic. Ex: Periodontitis, abscesses, cellulitis

the patient needs to be under control. Antibiotics for 2-4 days

WE do not do an infiltrative technique because we must avoid the infected
area
you can’t put an injection into pus because of the risk of spreading the
infection

3rd molar infection

MUST avoid in acute infections because it is risky and dangerous:

- In lower third molars: it can go to the neck and suffocate patient by pressure of the pus
collection.
- In upper it can go to the foramen of the skull and its dangerous because there is a risk of
meningitis and encephalitis

After 4 days of antibiotics you can extract the tooth and the patient will continue to take
the antibiotics for the recommended time

gingival tissues / gums infection

- ANUG (acute necrotizing ulcerative gingivitis): do not do the exodontia. give antibiotics
and do SRP = disinfect the tissues and remove inflammation

After treating the periodontal problem you can do the exodontia otherwise the necrosis
will spread

- Viral (ex. gingivostomatisis): that affects the mucosa of the oral cavity. MUST AVOID
EXTRACTION UNTIL HEALED: can decrease immunocompetence which is already
decreased due to this infection

malignant tumors
never treat
you can take a biopsy or send to the hospital (better)
if a patient doesn't smoke and you see a tumor it has probably metastasized
 to the mouth
avoid extracting teeth around this area because when the malignant tumor is
removed a large section of bone including teeth surrounding are removed.
radiation

General Contraindications
Diabetes

Have a chronic vasculopathy because they have low insulin - increases the risk of
infections after extractions. Impairs wound healing increased risk of bleeding and
high glycemia
check that their blood is controlled
diabetes infereferes with coagulation factors
their healing time will be slower

Cardiac hypertensive disease

check their blood pressure

If they had a heart attack less than 6 months ago you cannot proceed because
there is a risk of starting arythmias in the patient
Valvulopathies - always give antibiotic prophylaxis - 2grams of amoxicillin an hour
before the extraction, root scaling, any procedure that exposes blood

Hepatic disease

Risk of transmission of hep C

coagulation will be compromised - have a lack of cooagulation factors- clot
formation damaged or stopped
higher risk of haemorrhage in the patient
if you dont know their coagulation, need to talk to the hemotologist/doctor
check INR

Kidney /thyroid/epilepsy/Addison

do not do anything unless it is controlled

chronic patients need antibiotic prophylaxis
epilepsy: increase risk of crisis because you are increasing their adrenaline

Haematological

leukemia/mylomas/lymphomas can provoke severe haemorrhages or complex

infections due to immunocompromised system
always talk to doctor
UOF /general asthenia: will impair the condition of the patient so its better to delay the
extraction

Psychosis: make sure they are controlled

pregnancy

do not do anything in the first trimester because it is the period of formation of the
baby
second trimester is more indicated to do extractions
third trimester only if really necessary

Elderly: sometimes not worth doing an invasive procedure

Biphosphonates

stay in the body for decades. 'radioactive drug'

high risk of necrosis of bone
they are bone modifiers: indicated in cases of alteration of bone metabolism for
bone conditions - osteoporosis or bone metastasis
calcium content released into bones- therefore they are decalcified
adminsitration of the drugs by IV: meaning that they are in high doses
completely contraindicated to extract any tooth during this treatment
if it is required by infection or nonviabale tooth - do a conservative approach.
eliminate the caries, keep the roots and do a root canal. this preserves some of the
area and maintain the root in the socket until along time after the drugs are
stopped.
otherwise there is a risk of osteochemical necrosis
with oral administration the risk is MUCH lower
if you MUST extract check that the gingiva is completely closed, systemic
antibiotics for 10 days and mouth rinses with chlorhexidine

ONM = osteonecrosis

Anatomy
PDF
Alveolar bone - is the part of the bone that is related to the tooth itself (the cementum and
PDL)

doesnt exist if thereis not masticatory function

the alveolar bone is atrophied if there is an extraction
there us onyl the basal part left (which is on top of the alveolar bone)
the external cortical plate
internal cortical plate
between the external cortical plate and the internal cortical palte, there is
spongeous bones with hematopoeitic cells
 lamina dura
alveolar crest is the top of alveolar bone
in some patients it is 1mm beyond the Cmentoenamel junction
2mm or more it is a pathology - peridontal disease
Thickness of cortical plate in both maxillars
related with the spreading of infection
in the upper maxilla the buccal cortical plate is much thinner than the
palatal. it is specifcally much thinner at the side of the upper canine, central
incisor and buccal roots of the upper premolar. the more distal we go, the
external cortical plate gets thicker
Thickness in the mandible of the cortial plate
very thin in the lingual part of the lower back molars are located comapred
to buccal which is VERY thick
in the area of the central incisors, canines and premolars it is equally as thin,
lingual and buccal
premolars to molars is increasingly thicker external compared to internal
What side drains each tooth according to the thickness of each tooth?
attachment of muscles of maxilla and mandible
masticatory muscles : temporal, internal pterygoidal, and masseter, all are
inserted in both arches
other masticatory inserted in mandible and upper maxilla : external
pytergoidal
supplementary mastication msucles
genioglossus inserted into internal part of ___ of madible
mylohyoid inserted into oblique internal line/mylohyoid line
mimic muscles
inserted over the bone of the chin for themaidnble and ver the bone
of the upper maxilar
in between the ____ of those msucles all the odontogenic muscles
can spread
so it is importqant that you know the exact attachment of those
muscles to see where it can spread and what muscle it can affect by
pus collection. the patient wil jave htat muscle sort of paralyzed/cant
move it properly because of the infection
Soft connective tissue with fascia and ___ is a vector to spread infection from one
side to a distant area
anatomic areas in head and neck
cervicofacial areas

Bone

type 1 - cortical -
type 4 - spongy -
type 1 and 4 are not good for extractions or implants

Cortical walls exist buccally, palatally and around each root (maxilla)
when a tooth is removed from a socket (there is coritcal bone surrounding the tooth
mesially, distally, buccal and palatally). Blood (w/osteocytes) in this area will later become
filled with bone. if any of the walls are broken, all that bone will be lost. The socket will be
filled with cells from the gum. Contour of the bone will be lost and there will be a
concavity and it can look bad aesthetically. you have to press to be able to _____

Instruments
Forceps

Beaks (on top of the valves)

Hinge can be tight but permits some free movement
handles are long enough to be adapted on your palm. have a serrated part to avoid
slipping when grabbing it

Classification of forceps

depends on size for children vs adults

upper arch features: beaks, hinge and handle are in a straight line
lower arch: 90 degrees beaks to handle
shape of the beak is related to how long the crown is
long crowns (premolars and molars) the beaks are larger and broader
incisors are much thinner
Beaks are convex and end separated from eachother to control the crown
are serrated internally to avoid gliding of the beaks around the crown

I. Upper forceps

1. Incisors and canines: use the same forceps - completely straight

2. premolars use the same- not as straight. a little curve on the handle of the forceps
to place the concavity of the curve on your hand. rounded beak is adapted to the
upper premolar perfectly
3. upper left molars - larger angulation because you are trying to avoid the mesial
teeth. concavity placed on top of your palm. Has a sharp point to be inserted in
the area of the furcation. in between the two buccal. WIth that you will know which
one is right versus left
4. upper right moalrs
5. third upper molars for both left and right - has a bigger curvation. both ends are
equally rounded at the bottom of the beaks. They are broad enough to contour a
well erupted third molar
6. upper roots - called beyonette - beaks are very narrow and close together. they
grab fractured roots only for the upper

II. Lower forceps

1. Incisors and lower roots - completely closed bulb. Related to cervical diameter of
 the incisors and roots
2. canine and premolars - a bit separated. related to bigger cervical diameter
3. Molars - Cow horn - does not work if the molar doesnt have a furcation.
Sometimes second molars do not have a furcation and have fused roots.
4. Parrot beak - Both sharp beaks. Must be introduced below the CEJ. More
indicated for molars without furcation or when the crown is severely destroyed
5. Frontal molar approach/frontal approach parrot beak - Quite similar to upper third
molar forceps. The difference is in the beaks.
Upper: both beaks are completely rounded
Lower: Has a sharp part/beak
indicated in patients that cannot open their mouth widely for extractions of
2nd and third molars
can damage skin of the corner of the mouth but hitting. We can burn the
corner of the mouth in patients that cant open their mouth therefore we use
the frontal approach

All the rest of the mandible forceps are lateral approach: with one bulb you grab the
buccal part of crown and with other bulb you grab lingually

Lateral approach is much more common in Europe.

Elevators
Are made of blade (active part, very sharp), shaft, handle

Straight Elevators

cut like a knife

can use them upper and lower for any teeth

Winter Elevator: handle shaft and very long active part

Both are interchangeable because they are indicated for extraction of 3rd molars
and roots left of the back lower molars

Surgical bone curette

indicated as the last step of extraction to scoop out debris to avoid post operative
infection
lucas one - black and the best
others have a spoon shape
Unit 7: Exodontia II
Techniques of Exodontia
Head of the patient should be at the level of the dentist elbow, dentist is positioned next
to patient (8-9), for maxillary procedures the occlusal plane is 60 to 90 degrees to the
floor, for mandibular procedures the occlusal plane parallel to the floor

The non-dominant or free hand will separate and protect soft tissues, enlarges surgical
area, palpate and control movements, hold head and mandible

1. Syndesmotomy: separate periodontal ligament from gingival crevice, can be done

with periosteal elevator or straight elevator
2. Application: Grasp the crown
3. Consolidation: avoid sliding of the beaks
4. Intrusion ??
push the tooth towards apex with forceps
Decreases one of the arms of the lever
we are using second lever load to use the forceps
to decrease the arm of the lever between the fulcrum and area of resistance
- decreases risk of fracture
EVERY TOOTH must be intruded until the last moment of extraction (pulling
it out)
when doing luxation you are also doing intrusion
you must constantly have force towards the apex when doing other
movements
5. Luxation - to break PDL and expand socket
should also be intruding at the same time
Should be moving back and forth
place the beaks beyond the CEJ in a straight line along the long axis of the
tooth
Lateral - buccal to palatal/lingual
can be done on every tooth
always start with lateral movements
indicated for expansion of the socket
start with short motions and small angles
then we proceed enlarging slowly with bigger movements motions
and angles
rotation
clockwise and anticlockwise along the long axis of the tooth
cannot be in biradicular or multiradiuclar teeth
only single rooted teeth
to break PDL fibers - circumferential and oblique fibers
circumferation
to enlarge and expand the 3 sockets of the MOLARS and permit the
break of the periodontal ligament of each root
 indicated for upper molars ONLY
6. Pull the tooth/Traction
when it is loose you stop intruding and finally pull it out
it should be as loose as a grade 3 or 4 tooth

Maxillary Techniques
- Central, lateral incisor and upper canine

laterality and rotation

- Premolar 1st

has two roots: buccal and palatine root

laterality
do NOT rotate or do circumferential rotation
roots are very narrow: crystal roots: very delicate and fracture easily

- Upper molars

3 roots: round palatine root

the beak goes into the furcation of the buccal roots
laterality and circumferential, because the roots are arranged in a tripod way
circumferential is indicated
harder to extract upper molars because roots are curved, thicker periodontal
ligament, very close to the bone
alternate between laterality and circumferential movements

- 3rd upper molar

needs a plan for the movements depending on shape and size

always move buccal palatal (laterallity)
if there is a cyst previously in the xray and roots are fused: dont do a complete
rotation because the PDL is not broken enough yet and you will rotate beyond the
limit of the resistance of the twist and will fracture the bone or the root
therefore you should always hold the bone to avoid fracture

Mandibular Techniques
- Lower teeth: all of them are single rooted except molars, laterality and rotation for these
teeth

- Lower molars
 1st always has a furcation: indicated forceps is cow horn
Only laterality movements
has mesial root and one or two roots distal
you can put the tips of the beaks in the furcation on vestibular and lingual
side.
when you close the forceps beaks it exerts pressure below the furcation and
the tooth comes out of the socket - sometimes just squeezing extracts the
whole tooth or the roots are luxated halfway out of the socket: if that
happens we switch to the parrot beak to end the extraction
2nd: 50% furcation 50% fused
if furcation - start with cow and end with parrot
if there is no furcation start with parrot
one bulb bucally and one lingually
only laterality movements
IF the root is COMPLETE fused then you can rotate
never start with rotation at the beginning

Elevators
Principle of use of Elevators

follows principles of Axel and Wheel = rotation

Lever Principle: avoid lever action with elevator because you can damage other
tooth
Wedge Principle: but you can wedge it into the wall of the socket and root
cementum - with wedge action you are expanding the socket and breaking PDL
fibres as deep as you can

Index finger is always on the shaft of the elevator and tip of finger close to the blade

Blade

2 parts: 1 is flat or concave and directed to the tooth/root

convex posterior part - towards the soft tissue and gingiva - the convex shape
protects
the bottom is very sharp it is used to break /cut the PDL and for syndesmotomy
Always use the nondominant hand because it will protect the soft tissues if the
elevator slips out

Elevator can be used everywhere in the upper maxilla: buccal/mesial/distal/palatal

Mandible cannot be used LINGUALLY

if it slides it can perforate the floor of the mouth and its dangerous because of all
the vessels
 mesial and distal are the more efficient sides
buccal you just use it as a wedge action
axial rotation of elevator is more efficient mesially and distally

Straight elevator

used everywhere in the oral cavity: upper and lower, mesial and distal
should be used before the forceps
must start mesial/distal and buccal/palatal
rotation should not be very wide because you will damage the neighbouring
tooth
when applying in the distal side you can be as wide as you want if there is no
tooth behind
mandible: mesial distal buccal rotational or wedge action

Tip:

dont use the elevator at very straight angle to the long axis of the tooth (like in
forceps
they should be more oblique or even compleely horizontal (mandible)
upper molars: if a root breaks and you apply the straight elevator vertically in the
direction you may be able to push the root into the maxillary sinus. therefore use
oblique direction instead of vertical

Winter (curved elevator):

the active part is so narrow cannot be applied with wedge action or do

syndesmotomy because the active part is so small
only axial principle
dont use during beginning of career because with rotational movement you can
fracture the maxillary tuberosity or fracture the mandible
can be used in third molar, impacted teeth, fractured roots of lower molars

Temporary teeth

use topical anaesthesia

dont need to use blocking techniques because there is no cortical bone (much
more spongy) and the elasticity of the bone
will be able to extract with infiltrative
dont use the cow horn because it can damage the germ under the temporary
tooth
always take x-rays
we use a space maintainer afterwards
 Specific forceps: handles and bulbs are much smaller: possible to use adult
forceps (not the molar ones) on children

Post extraction advice

look in the socket for guttapercha /amalgam/gold chips and remove with bone
curette to avoid infections and alveolitis/infalmmatory cysts
after using elevator part of the alveolar ridge can have sharp areas (small fractures
of alveolar ridge) and we need to smooth the edges with a bur or bone file
squeezing cortical plates after extraction because we have expanded them. This is
to readapt the shape of the corticals
we do not squeeze for implants: because we prefer it stays expanded and it
will be regenerated and the bone will be wider than its original even though it
has been atrophied ??
gauze for 30-60 minutes
sutures only if necessary
in older patients we used to suture because they bleed much more or are
more anticoagulated
patients must be sutured if they are under anticoagualnts
x ray to check if the socket is empty only if there were several fractures with tiny
fractures
only need antibiotics in compromised patients and if the technique was
complicated (lots of fractures bone/tooth and need to do a flap)
pain if killers needed

Advice for patient

bite on gauze for an hour

no mouth rinses for 24 hours to prevent clot formation/destruction
smooth and cold diet
rest. no gym. but can walk
if bleeding, try not to spit alot.
Unit 8: Exodontia III - Complications
We need x-rays and clinical history to be able to plan properly.

I. Early
A. General
B. Local
Happens right away to a few hours later

1. Dental structures

- Root fractures or fracture in the tooth = main complication that we will have. They can
usually be prevented. Always do a previous x ray (periapical) or CBCT: CBCT is quite
cheap, does exploration of the oral cavity and prevents complications.
Need it to plan because we need to know the shape of the root: commonly seen in long,
curved, divergent roots that lie in dense bone
It can happen due to poor technique or because it has a root canal/the root is fragile
Must be removed with either open or closed technique: to remove all the infected
tissue/granuloma tissue, root left that can provoke bone damages

- Fracture or dislodgement of adjacent tooth - warn patient that this can happen

wrong use of straight elevator: Can be due to the large active part, an inadequate
extraction movement, inadequate use of force with elevators forceps

The use of the elevator in the interdental areas (mesial and distal movements) can
damage the PDL of adjacent teeth. Mesial-Distal movements do NOT EXIST.

Start with narrow elevator and turn the blade, firstly in short movements, then larger and
larger. Then when it loose enough use the larger elevator

the larger elevator is much more dangerous. if you turn it slightly you can damage
the neighbouring tooth. only use it when you are able to introduce it deeply in the
socket: because then you wont damage the neighbouring tooth
aim is to break the PDL fibres and expand socket with elevator

- Fracture or luxation of the adjacent tooth

If tooth is luxated: we need to check the vitality. In a lot of cases we will require a
root canal.
Reposition the tooth into its original position, check to see if there are any
premature occlusal contacts on top of the subluxation that could cause traumatical
damages in the PDL due to the hyper occlusion
If the luxated tooth is mobile, you can split the tooth in the socket (stabilised with
hemi-rigid fixation to maintain tooth in position)

If you remove the neighbouring tooth, you can do an evulsion/avulsion (a forcible

separation), do a root canal and replant it and ferulize (treatment that consists in uniting 2
or more teeth, with the aim of stabilising them and avoiding mobility)

the other option is _______

Once you do an evulsion, you remove the blood supply and the pulp will become
necrotic later. Therefore, you do the root canal. If you do not luxate/evulse it, you
leave the tooth and ferulize and check the vitality. if there are signs of necrosis then
you do a root canal

- Injury to neighbouring tooth or restoration

fillings and prostetical crowns can be dislodged during an extraction; you need to
warn the patient preoperatively and use the elevators judiciously
just need to replace the crown or filling
always extract with an assistant because they can tell you if you are touching the
neighbouring tooth

- Extraction of the wrong tooth

always recheck which tooth needs to be extracted

2. Injuries to osseous structures

2nd most frequent immediate complication

Important to put fingers around the tooth to protect the lingual and buccal wall: this
will minimise 99% of fractures to the cortical bone

- Fracture of alveolar processes - occurs in maxillary and mandibular

Happens with ankylosed teeth, that are extremely attached to the socket and that lack
PDL in many areas of socket. Must be confirmed in Periapical XRAY.
There is no lamina dura or the cement is attached completely to surrounding bone

instead of using forceps we do a open surgical technique to be able to conserve

bone and without fracturing the whole alveolar process
fracture of alveolar process due to misuse of forceps requires splinting to
sabilize the loose bone fragment and promote healing in the fracture for 6-8
weeks because bone healing is longer than PDL healing

If the buccal wall fractures, place it back and put a bit of bone graft so that there is
osteoconduction

Prevention of fracture of alveolar process by conducting thorough preoperative clinical

and radiographic examinations, not using excessive forces (expand the socket, but if
there is resistance, do not rush), and using an open surgical extraction technique to
reduce force required
- Fracture of cortical plates
common in buccal plate of 1st and 3rd upper molar and canines, lingual plate in lower 3rd
molar

Buccal Plate of Upper Canines

Some upper canines are very close to the external cortical plane. not ankylosed but have
a lack of PDL between external cortical plate and the roots
If you are not gentle enough you can fracture a large fragment of this plate attached to the
canine
This has an aesthetic complication - severe atrophy in the area and it will not be the same.
To place an implant we need Bone regeneration in this fractured area.

Lingual Plate of Lower 3rd Molar

The internal cortical plate can be highly attached to the radicular cement of the 3rd molar
When using the winter elevator, you can fracture when using from buccal to lingual

if its a large fragment, and completely loose it will require osteosynthesis and
screws
if it is not a loose fragment from the periosteum you can suture the occlusal part
(or if it is an area of no bone movement, ex lingually) and permit bone regeneration
on its own. absorbable sutures
if its a small fragment we need to remove it

Risk of bone fracture on the lingual side = lingual nerve damage on top of the bone
fracture
Do not use the forceps and elevators past the point of flexibility.

- Fracture of the maxillary tuberosity

Results from 3rd upper molar erupted and not erupted, extraction of the second molar, if it
is the last tooth in the arch, firmly inserted or retained molar, poor technique

it is rare to happen after the 2nd upper molar extraction

the bone is a lot softer than the root: mainly pure spongy bone, very few cortical
bone

If the maxillary tuberosity breaks, the stability of a retentive denture can be compromised,
post operative state more painful, more haemorrhage, have a big hole communicating
with the sinus

Preventable? It Very difficult to prevent from happening if bone is fused to the roots. But
also because, most 3rd molars have divergent root, when you pull, the tuberosity will
break. You will apply too much force and break the maxillary tuberosity.

In case of fracture:

Must drill to smooth the edges of the bone remaining

 Small fracture and no oroantral communication: close mucosa as symmetrically as
possible
Small fracture and orantral communication: flap procedure and close hermetically
the mucosa. The patient should not pinch the nose, blow strongly, do the valsalva
maneuver (closing mouth, pinching the nose, and blowing out), diving or fly for one
month because might get a tear and even enlarge the perforation
Extended fracture: try to dissect the bone from the tooth and remove the tooth
Extended fracture and excessive mobility of tuberosity: 2 options
Dissect the tooth being extracted from the surrounding bone, and splint the
fracture from the tuberosity to adjacent teeth for 6-8 weeks, allowing time for
bone to heal
Section the crown of the tooth from the roots, and allow the tuberosity and
tooth root section to heal (splint to neighbouring teeth if needed). 6-8 weeks
later remove the tooth roots in the usual fashion.

For the Diagnosis of oroantral communication:

There is a perforation in the schneider membrane, if you ask the patient to do the valsalva
maneuver (bubble will come out of the alveolar if there is a communication), this might
enlarge the perforation.
You need to introduce probe, bone curette, metallic object to check the bottom of the
socket and see that there is no ending: The bottom of the socket goes up to 3mm, no
socket is larger than that.

Treatment:

Less than 7 mm perforation - close hermetically: important to suture the mucosa

and socket for 2 things: close the communication and avoid haemorrhages. And
put a blood promoting agent into the socket: oxidised cellulose or collagen
sponges, to start the bone regeneration
More than 7mm: repair the oroantral communication with a flap

If you are not aware of the communication, later on the patient arrives with chronic
sinusitis, chronic oroantral fistula and months or years with many symptoms, or will
notice liquid coming out of the oral cavity to the nose

- Mandible fracture
Occurs when the bone is weak (amount and quality), due to:

misuse of winter elevator, poor technique

after a surgical procedure for third impacted molar that requires a large ostectomy
distal angulation of impacted third molar - disto inclination of crowns will require a
larger ostectomy
shape of roots can be complicated and require more manipulation and ostectomy
macrodontia - big size of any tooth- crown,roots etc will require more manipulation
of the area
cyst will need to remove third molar and cyst and requires an ostectomy
fracture can also happen when the patient starts biting normal food after a few
 days because the internal pytergoidal is attached to this area: recommended that
the patient does not eat hard food after extraction, for a month

- TMJ luxation
Condyle will go out of the glenoid cavity and goes in front of the atricular eminence. The
patient will not be able to close the mouth in any moment.

This can happen due to the hyperlaxicity of the ligaments of the joints, or due to the
elevators or forceps.
Tell the assistant to hold the condyles (or with non-domiant hand) to permit lateral motions
with forceps and prevent TMJ luxation

Nelaton procedure: stand in front of the patient and with the 2 thumbs you push
downwards, backward and upward to fix the luxation

Anilateral luxation: another technique: be on the sie and the head of the patient is on our
chest, we do the same movements by anilaterally.

A patient with a frequent TMJ luxation, needs to have shorter appointments so that their
mouth is not open for too long to cause inflammation in the TMJ

Very important to write down the luxation in their patient history

3. Soft tissues

- Tear of muscosal flap

Mucoperiosteal flap badly torn due to inadequate care during its reflection.

cut with scalpel and reflect with periosteum

cut soft tissue flap to the bottom of the sulcus
when we use a lot of forces, you must release the pressure that acts over the flap
with a retractor to permit the blood supply to go to the bottom of the
flap; otherwise you will get necrosis of the tissue
Small size flaps: we try to stretch the soft tissue and tear the bottom of the tissue
by poor plannification of the flap
pay strict attention to soft tissue injuries, develop adequate sized flaps, use
minimal force for retraction of soft tissue

- Puncture wound
Instruments such as straight elevators or periosteal elevators may slip from the surgical
field and puncture
Therefore, the non dominant hand should be protecting the tissue

patient needs an esthetic suture to avoid a scar in the surface of the skin of the lip
dangerous for lips, tongue and floor of the mouth
- Abrasion or burns of lips
Represents a combination of friction and heat damage. The wound should be kept
covered with antibiotic ointment or vaseline until a scare is formed

use of forceps becomes hot due to the friction, patient is numb by the block
technique and cannot feel heat and then there will be swelling, burn and ulcer
Surgical procedure burns: ostectomy around root and using burs - the handpiece
becomes hot by the rotation and it rests on the lower lip

- Haemorrhage
Occurs usually on tissues with infection. There will be a tears or sections of vessels in the
soft tissue.
Need to clamp the vessels or making ligatures of the vessels. You can also use an
electrical scalpel to stop the bleeding

- Prolapse of the Bichat’s fat pad

It is a brown fat tissue, highly metabolic. It is located behind the buccinator muscle and
area of upper maxilla posterior molars. The first layer is oral mucosa, second layer is the
buccinator layer and the third deeper layer is the fat pad.

If you see it, eliminate it because we dont want fat in contact with blood, to reduce
thrombosis risk. This doesn’t affect aesthetics because this fat is in the tuberosity

Occurs due to a poor technique: When you apply elevators in this area (back upper
molars or surgical 3rd upper molar. Or when you have a bad design of the flap:

if the flap is very extended to the cheek area

Need to fix it by putting it back into its cavity and suturing the fibers of the muscle with a
resorbing suture and suturing the flap immediately

4. Nerve injury

- Inferior alveolar/dental nerve

Can be damaged because its too close to the roots or the crown of the impacted 3rd
molar
Occurs even with proper planning and CBCT, you may still have nerve damage in some
cases, for instance, with the extraction of 3rd impacted molars that have a cyst, or when
roots are on the canal. Even if you divie the moalr to separate the roots you must always
ask for informed consent

The patient can suffer numbness in the area, for a while, because every time you touch a
nerve this occurs

- Mental
Rarely damaged, happens during lower canine and premolar impactions in surgical
procedure
Never put a vertical incision (relieving incision) in the side of the mental foramen
Plan with xrays and CT scans to know exactly where the nerve is located the mental
foramen. You will plan the procedure mesially or distally depending on it's location

- Lingual nerve
Close to the lingual plate, it is damaged when you are doing movements with elevators or
incisions with scalpel

To protect it, during 3rd lower molar extraction, you will put a metallic instrument
(periosteal elevator) to know exactly where its located to avoid it

- Greater palatine nerve

Along the greater palatine foramen, it is damaged when you need to reflect the fibre
mucosa palatine to continue with difficult extraction of a second upper molar or third
upper molar
Recommended not to reflect it much; nothing happens if you damage this nerve

Beside the greater palatine nerve is the greater palatine artery. This is a problem because
then the palate will be without blood supply and causes a huge necrosis. very painful for
several weeks

- Infraorbital nerve
It is damaged if you go through the foramen therefore DO NOT GO IN THE FORAMEN
Can occur during a surgical procedure in upper maxilla, the retractors, with a lot of
pressure over the flap can damage the infraorbital with the metallic part. Or can be due to
the misuse of the anaesthesia.

3 types of nerve damage:

Compression

Recovery is immediate: few days when you remove the compressive agent or swelling
above the nerve. it is called neuropraxia: mild-grade lesion, the neurological deficit is
transient

Tear by stretching

The nerve has already been touched, the myelin sheath and nerve is already damaged,
needs 6 weeks - 6 months to be fixed. Called Axonotmesis.

Section of nerve

Take years to recover or never, might require micro surgery because a section of the nerve
and the nerve sheath is damaged. With an CBCT, we can prevent this from happening.
NEUROTMESIS

These traumatic nerve damages can have legal consequences due to Traumatic neuralgia.
The patient will be in a lot of pain for patient for months - years, and can sue you
 4. Other complications

- Displacement of root or full tooth to a neighbouring area/unfavorable anatomic

space
To submucosa, nasal fossa, maxillary sinus, mandibular canal, pterygomanidbula fossa,
buccal space and more

mild or severe consequences

The patient can inhale the fragment, and if it finds it's way to the respiratory tract, can
cause suffocation
Happens with poor technique, surgical procedures that are not simple, or if patient is
moving

Solution: remove the fragment/tooth

- Shift to submucosal area

Between mucosa and vestibular plate (periosteum and external plate), underneath
periosteum. More frequent in Buccal roots or premolars and upper Molars
Treatment: Incision in the depth of the sulcus, at the bottom of the vestibule, will allow us
to find the fragment and easily remove it

- Fragments in the maxillary sinus

Poor use of straight elevator: NEVER apply vertically the elevator. ALWAYS OBLIQUE

If the floor of the maxillary sinus is thin or the floor is damaged by previous infection from
the tooth to be extracted, the fragment will shift easily with a push to the maxillary sinus

Solutions:

Retrieve root fragment with instrument or irrigate with saline solution and with the
flow of the irrigation it could come out (Rare)
The best is to open a window in the anterior wall of the maxillary sinus and retrieve
the fragment with open surgery, called the CALDWELL-LUC procedure.
If it is the third upper molar you will require open procedure. Happens when the
3rd molar is very close to ptyerygomaxillary fossa (impacted). Using elevator here
you cannot see anything (blind movement) - there can be a fracture of the maxillary
sinus wall and the tooth is dislodged in the maxillary sinus. Best to check with an
axial cut and CT scan so you know where to look for it when you open up the wall

- Nasal fossa
Can be perforated (floor) when we are doing extraction of supernumerary tooth, or due to
an impacted Cental Inscior or canine (rare)

1st: try to blow the nasal fossa and with pressure the tooth can go behind the back
opening area of nasal fossa, from the coahna comes down the nasopahrynx and
then to the mouth - oropharynx
2nd: open a flap in the bottom of the upper sulcus: dissect, separate, reflect the
 floor of the nasal fossa, retrieve and suture the floor. High risk of infection

- Floor of the mouth

Some fragments of the root of 2nd or 3rd lower molar can go to floor of the mouth.

Must be opened with a lingual flap in the palatine gingival margin.The mylohyoid muscle
must be disinserted from the internal oblique line of the mandible to be able to retrieve
fragement. Suture afterwards the muscle and mucosa

- Inferior alveolar N canal

Sometimes require large ostectomy to remove root in the canal in the area of the 2nd or
3rd lower molars
May provoke paresthesia, anaesthesia or neuralgia; vessel injury and haemorrhages

- Pterygomaxillary and Zygomatic Area

Occurs in high retained upper 3rd molars or retained supernummerary molars. When the
PDL is loose, the tooth can go backwards to the pterygomaxillary area

Need to go to the hospital and open from the tuberosity to anterior pilar of the isthmus of
the fauces. High risk of damaging the important vascular structure

- Buccal Area
Retained upper 3rd molar. There will be a displacement over, through the buccinator.
Need to do an oral incision. There is a risk of damaging the facial vessels

- Tooth lost in the Pharynx

If this occurs, the patient should be turned toward the suregon and placed into a position
with the mouth facing the floor as much as possible, The patient should be encouraged to
cough and spit the tooth out onto the floor.

If in the digestive Tract: there is a high probability it will pass through the GI tract within 2
to 4 days. Recommended to eat vegetable and fibers

If in the respiractory tract:

Heimlich Maneuver: abdominal thrusts

Fibrobroncoscopy

- Subcutaneous Emphysema
Air collection around connective tissues due to the use of turbines or micromotors. There
will be immediate swelling, Cracking sensation.
It does not require antibiotics and does not hurt. It will resolve on its own.

- Death
Myocardial alterations, edema, asphyxia, anaphylactic reaction, septicemia...

II. Delayed
A. Local
 1. Infections

- Alveolitis
Very common, it is an inflammatory process in some sockets, mainly mandibular, related
in the alteration of clot formation. It happens 48-72h after extraction

Triggers - Pathogeny: traumatic procedures, periapical infections, postanesthetic

ischemia, imbalance germ host, immunosuppression, frequent mouthrinses
can occur due to bad technique or leaving a piece of tooth in the alveolus or because the
patient smokes after the procedure

There are different types of Alveolitis:

Dry socket
Suppurated alveolitis
Margin Alveolitis
Phlegmon Alveolitis

Treatment: does not require anything more than painkillers. Do not prescribe antibiotics
unless there is suppuration around socket or if the patient is immunosuppressed.
Clean the socket with saline or chlorehexidin and put Alvogyl (made of components that
will relieve the pain, calm the neural pain).
Revise the socket from time to time, but the pain will last 1 week

- Abscesses and cellulitis

Are Due to Chronic infections, foreign bodies or because the patient does not follow the
indications given.

Cellulitis Over the soft tissue of the face: it is an extended complication of an extraction

DO NOT CONFUSE WITH INFLAMMATORY POST OPERATIVE EDEMA WHICH ARE

NORMAL.

- Trismus
If of infectious origin: prescribe antibiotics
If not: Analgesics or Benzodiazepines

- Emphysema
Vascularisation that needs to be evacuated because gives a lot of pain

2. Haemorrhages

- Bleeding
- Hematomas: Aged patients have a higher chances of getting hematomas and bruises.
Patients with capillary fragility

3. Traumatic
- Traumatic Periodontitis: Inappropriate contact (2nd lower molar), follow up: healing or
pulp necrosis. Relieving occlusion by selective preparation/bone regeneration ??

- Oronantral Fistula: If you have not hermetically closed the oroantrum communication,
the patient will have chronic fistula, he will perceive that he will have liquid in nose, when
drinking. Treatment: advancement flap: ??

- Gingival Recession: Poor flap design, tears or inadequate suture. Esthetic

consequences or dentine hyperesthesia

- TMJ Dysfunction: Movement limitation, TMJ soft tissues, and delayed will result in
occlusion disorder.

4. Reflex reactions

- Herpes
- Aphthous Stomatitis

5. Tumorals

- Inflammatory Cysts: if we remove a tooth in the oral cavity, and do not perform the
bone curatage, we will leave fibers that can grow and become inflammatory cyts
- Ameloblastoma: can come from retained 3rd lower molar (follicular cyst)

III. Generals

Haemorrhages

Can be due to Local or General factors, and can be immediate or delayed

Immediate

1. Local

- Hyperaemia and inflammation: can lead to haemorrhage

- Bone chips and sequestrum
- Wounds and Tears
- Blood vessel damage
- Inappropriate suction use: the use of excessive suction is bad
- Vascular wounds

2. General

- Hemorrhagic diseases
- Drugs
- Liver and diabetic patients
Never suspend a drug before consulting the physician of the patient
Delayed

1. Local

- Mouthrinses with hydrogen peroxyde: it alters the clot formation

- Vasoconstriction stop: we can have a hemorrhage 2-3h after extraction due to
vasodilation
- Secondary infection
- Eroded vessel by inflamed tissue

2. General

- Coagulation failure

Management
Wound examination, medical records, drugs, features of extraction procedure, remove
foreign bodies and suture, hemostatic agents, blood test, 112

Need to look at the socket, mucosa, eliminate fragments, clots that are around it. If there
is a tear in the mucosa, suture it up.

Local measures: Gauze packing, collagen sponge, oxidised cellulose, bone wax, surgical
dressing, pressure over blood vessel, clamping, suture, tranexamic acid

General measures: hemostatic drugs: desmopresin, tranexamic acid, vitamin K,

blood products
Unit 9: Basic oral surgical techniques
Blood tests

required according to the drug intake of the patient for systemic diseases

Coagulation tests

Prothrombin time (PT): extrinsic pathway INR

Thromplastine partial T (aPTT) - Intrisinic
Thrombine - shortage of fibringogen
gylecemia
uremai - for chonric renal insufficeny
BUN

Premedication

sedatives
benzodiazepine is the most frequently prescribed for patients anxious about
the surigcal procedures
short action:midazolam
medium action: diazepam
can be intramuscular injection or oral (?)
Cannot be used by children because they can provoke paradoxal
reactions: causes hyperexcitation instead of relaxing them
do not provoke hangovers like oher sedative drugs
Anterograde amnesia - the patient will not remember much from the
procedure
Barbiturates: thiopental and Propofol (barbiturate-like sedative, ultrashort
acting anaesthetic)
Post operative have adverse effects/big hangover
anesthesiologist should be adminsitering (? which ones can dentists
administer)
react with anterograd anesthesia
antianalgesic post operative effect - when the relaxing effect is over
from benzodiazepiene, the pain can be felt. But the barbiutates have
some analgesic effect, therefore you do not need analgesic a few
hours after administering because the analgesic effect stays for a few
hours
Antihistaminics Ketamine
increases blood pressure and causes hallucinations
most used for children (?)
Major tranquillizers also used by anesthesiologists

antiinfective
 Not in ASA I
low risk does not need prophylaxis : also schemic cardiac pathologies ex.
angina
You dont need prophylaxis for fillings and (what other procedures??)
2 g of amoxicillin in adults 1 hour before the treatment. if they cannot do it
orally you can administer injection of ampicillin IM or IV 2 g before procedure
Allergies to amoxicillin : 500 mg of azithromycin or 600 mg of
clindamycin or 500 mg of clarithromycin
Children:
50 mg of amoxicilin / kg in a single dose
IF allergies: 20mg/kg of clindamycin not exceeding 600mg
anticoagulation
anti-inflammatories
Corticosteroids/NSAIDS
we do not pre-prescribe: it is controversial

Operative Stage

use sterilized scrubs in the sterilized area

the eye protection protects laterally as well
must scrub in all the way before the elbow
You must keep your hand angled upwards so the dirty soap does not go back over
the scrubbed area
Then someone gives you a sterilized cloth
Now youre ready to put on the sterilized gown
Someone will tie the gown and face mask for you because you cannot touch those
areas
Always tied in front of you not behind you
Last thing to put on is the sterilized gloves
When putting the gloves on you try not to touch the fingertips and they are folded
in a way so you can roll them up after
Patient is already anesthetized
The patient wears long sterilized clothes so that you dont touch anything
unsterilized

Instrument and equipment

Simple:

1 or 2 components handled by surgeon

Mainly steel with another metallic component to increase the properties of them
titanium: makes the instruments lighter and resists heat more
Nickle: makes them harder
Tungsten: duration under friction. Burs are made of tungsten for the friction
chromium stainless
Complex: need an electrical source

Surgical table:

Trays are prepared differently and then can be swapped when needed
prepared from left to right
Anesthesia —> retractors —> scalpel —> tweezers —> (finish up the order)
Must be in order for time management under emegencies

Lighting:

very intense/concentrated
3:1 ratio compared to the surrounding area. If you need to remove your eyes to
outside the light field if the ratio is more than 3:1 you will not be able to see

Dental chair/surgical table

dental chair is much more comfortable

Aspiration

has nothing to do with the saliva (?)

What is surgical aspiration??

Rotatory

we usually use low speed for bone etc

high speed can make osteocytes necrotic because they die above 45 degrees.
Friction from high speed can cause this heat
Therefore we also need water
NOT above 40,000 RPM

Sterilisation
Antiseptic and Disinfectant: both terms refer to substances that can prevent the
multiplication of organisms capable of causing infections. Antiseptic: Living, Disinfection:
inanimate objects.
Sterilisation: Freedom from viable forms of microorganisms. Sterility represents an
absolute state, there are no degrees of sterility

Heat: Dry air (flame, dry air, glass spheres), Moist Heat air (boiling, autoclave)
Chemical Agents: liquids for disinfection of the mouth previous to surgery, infected
cavities, equipments. For equipments we use Glutaraldehyde and Formaldehyde;
Clorhexidine as mouth rise. Gaseous: Formaldehyde (bactericide, irritant, slow
action) and ethylene oxide (high effectiveness, rapid action, flammable, toxic,
carcinogenic, for plastic ONLY)
Radiation
rare for sterilization
used in industry
 gamma is very dangerous and requires a lot of isolation
Ultra-violet: less aggressive. doesn't work if the instrument is not transparent

Instruments to improve vision

Retractors: acrylic/plastic/stainless steel, different shapes and lengths, all are

reusable
Langenbeck retractor
active part - 5-6 length with a bland bottom to protect the retracted
soft tissue
the long part with the hole for the index finger to hold it
indicated for operation for premolars - molars mxillary and
mandibular
Farabeuf
indicated for anterior surgeries
upper and lower
Cheek retractors
2 sides must be held bilaterally in the corner of the mouth
Austin retractor
short active part
used by periodontists
Minesota retractor
for the tongue
can also use a spoon to retract the tongue
Mouth prop
For patients who cannot open their mouth widely or when the patient is
fatigued and cannot open the mouth
Suction
prefer not to use large suction tips because they can pinch the mucosa

Instrument to cut (Dieresis)

Scalpels
Handles can be flat or rounded
always hold it like a pen with thumb and index finger
Blades
#15 is the most frequent
#10 if for general surgery
Can use 15, 12, 11 for dental
use a needle holder to mount the blade
the scissors need to be long to be able to reach the third molars
Periosteal elevators
can be double ended/single/ narrow/broad
Molt type: one side is narrow and one side is completely rounded
cannot use one that is 1 cm for oral surgery because the site of use is at the
 gingiva

Instruments to Grasp and Fix

tweezers
Dissection/simple: the closure is made by our index and thumb fingers. Must
be closed manually
Forceps tweezer: With a latch ratchet: mechanism that maintains it being
closed. To release you have to use your fingers to press it again.
Some have teeth at the end to hold the soft tissue better
(ask which tweezers are used for what exactly)
Adson Tissue Forceps: used to gently stabilise soft tissue for suturing or
dissection
Mosquito Forceps: is most common for homeostasis. Can be curved
Pean is stronger, used for clamping larger tissue and vessels for
homeostasis
Allis tweezers : have a Forcipresion, meaning they have a forcipressure,
stop circulation

Equipment for Haemostasis

Need to see the exact site

Hemostatic agents : drop of biological material oxided, swabs and gauzes. Gauzes
must be folded and put into the site of bleeding
Hemostatic sponge made of collagen and fibrin, used to stop the bleeding

Instruments to Exersis
Removing something from somewhere. ex cysts, roots, impacted tooth

Soft tissue
scissor, scalpel, bone curettes
periapical curette removes soft tissue from bony cavities and can also
remove contents of the cyst
Hard tissue
elevators, bone rongeur (like forceps that must be closed manually and has
sharp edges that can cut fragments of bone. It does the same action as the
bur but more delicately and manually) Bone files (smoothing bones/alveolar
ridge) and chisels (to remove bone. Can be used to remove torus).
Burs: Tapered for sharp edges of bone. Rounded/staight fissued: area of
pathology to remove some cortical plate/bone

Instruments for Synthesis (suturing)

needles, needle holder

straight needles: cannot be used in the oral cavity because there is no room
 curved needle: used in oral caivty. You can choose the curvature of the needle
Triangular or rounded cut can be used
triangular cut preferred because stabilising the round needle is more unstable and
can fall off the holder
Prefer reverse-cut-triangle because the flat surface is closer to the wound edges
therefore it will not tear it. The regular one’s triangle tip can tear the soft tissue
when you tie the suture
The needle holder grabs the curved needle two thirds of the distance from the tip
of the needle closer to the thread. Never frontally to middle part.
The threads type: Absorbable (poly - something), Non absorbable (silk B, Nylon M,
polyester, polypropylene, teflon, monorail)
absorbale: dissolved by enzymatic action from the saliva in 3-4 weeks
all are synthetic
nonabsorable must be removed a week - 10 days after the installation of the
suture
most common are silk
B means braided
M means monofilament
cons of braided:
Have adverse capillary action. in moist enivornment in oral cavity they
become very dirty. it suctions all the liquids coming into the area
therefore the suture becomes very dirty and needs ot be cleaned 3-4
times a day
Cons of monofilament
they are hard to tie. must be tied with two hands and can untie very
easily
takes longer to get used to the monofilament versus braided
always listed as “#-0"
we never use -0 or 2-0 in the oral cavity. we start at 3 and the highest is 0.
you use 3 when less skilled and 4 when more skilled. these are the most
used in the oral cavity
we choose the thinnest type of suture in cases of aesthetic requirements -
anterior area of oral cavity, lip or skin of the face. therefore choose 5,6,7-0
to suture with more tension or msucle attachment (lik ein the oral cavity) 3,4-
0 is okay
Atraumatic needle: No eye and are swaged. the line coming from the soft tissue is
very straight and not double. Doesn't have holes that become scars (?)
Beaks of needle holder are shorter compared to mosquitos
groove in the middle of the needle holder to permit the needle going into that
position
mosquitos do not have this groove. they only have serration
everything that has two rings: you use the thumb and ring finger in both rings
(sicors, mosquitos, needle holder)

In some cases you cannot suture therefore you use peridontal dressings
 it avoids bleeding, acts as a antimicrobial barrier
made of different components like eugenol
we use cyanacrylates in araes we cannot suture and in little children (? what
exactly do we use this)
it is like super glue for the oral cavity/biological tissue
can also be used for sutures of the skin of the superficial layers of the skin

Wire

0.4 diameter
nonelastic
used for splinting, fractures tooth, after a full luxation, partial subluxation, to split
the oral ridgesl. any spliting
single use or in cominbation with maxillary bars after a fracture

Resins and acrylics

cement:mineraltrioxide aggregate : sealing in periapical surgeries

mathacrylate plates for post operative stages to avoid swelling after a palatine
proceure (?Palatine?)

Surgical stages of the Operation

1. Incision: Mucoperiosteal Flap

2. Reflection- soft tissue. with the periosteum elevators. used exactly like straight
elevator. Use it like we do with the scalpel (so like a pencil) with index and thumb
finger. The straight elevator is used differently. There is a flat surface and a convex
surface. the flat surface is always towards the bone and convex towards soft
tissue. to spearate the soft tissue : with short movements you will rotate the
attachement from the periosteium to the bone. we separate mucosa plus
periosteum to approach the cortical. The flap is mucosa and periosteium. this is
retracted. from time to time we lose pressure on the sfot tissue to allow the blood
uspply to come into the flap. the retractor always lays onto the BONE. NEVER lay
on the flap.
3. Osteotomy: extract or cut bone to permit access. It is done with rotatory
instruments (bur on handpiece), rongeur (manual), chisel and mallet.
permits access to the internal pathology
always start with a rounded bur in concentrical movements. by the cnetre of
the pathology and we enlarge it concentrically the window made on the
cortical palte
we use saline solution with refridgeration or running water & ___ (?)
objective: reach the pathology or have a site to use forceps/elevators.
Sometimes the tooth retained or root left is completely attached to the
surrounding bone. Therefore we need to use the burs to do an ostecotomy
Can do it with ulrtasound and laser devicies as well.
4. Exeresis, evacutation, delivery, bone demodulation: clean up the cavity of
granulations; smooth sharp crests (to avoid pressure damages in mucose).
 Checking up with curettage, mosquito forceps, smooth bone edges
smoothing edges to permit healing of ghe mucosa overlying after.
we can smooth with a rounded bur
clean the cavity with currettes, mosquitos
may require grafting. but usually do not put anythign in the cavity to allow
bone regeneration by its self. could require blood promoting agents
(hemostatic sponges or bone wax (?)) to promotoe hemostastia
5. Haemostasis: bone compression over bone trabeculae with blunt instrument or
clamp on a vessel
1. put a blint instrument and press towrards the bone that bleeding
2. bone wax is natural wax from a bee that is sterilized. it is put into a ball
shape and remains there. It has natural lipids that help boen regenration (?)
6. Suture: reunite tisses, start with the most difficult area. Cut end thread not longer
than 1 cm
put the flap back in its original position
reunite both wound edges previously cutt
requires needle holder, threads, siscors, tweexers
do not recommend at first to pass both wound edges together (when
starting out suturing)
We always require double knots. The second knot is to be sure the suture
stays shut
first clockwise second counterclockwise

7. Check up

Postoperative stage

Local measures: clean wound, bite gently a damp gauze, compression for 30 min,
ice on skin, no mouth-rinses in first 12-24h, after that mouth-rinse with antiseptics
or saline solution, smooth diet. brush gently with special tooth brush
Systemic measures: antibiotics, analgesic (mild pain: aspirin, paracetamol; medium
pain: aspirin or paracetamol + codeine ; severe pain: opioids - pentazocine,
tramadol), antiflammatorie measures (NSAIDS, STEROIDS)
depends on the patient and type of surgery
if the patient is compromised then yes prescribe.
combination of pain killers works better than just one type of pain killer.
Alternating perscription of them
steroids: single dose in post operative in one single injection. high dose does
not provoke separation of cortical _____ . can relieve alot of swymptoms liek
edema or swelling. indicated in complicated surgeries
Suture removal: up to 7-10 days if nonabsorable

Healing Types

1. Primary (by first intention): both edges and planes come together, quick repair
under the suture. suture replaces its self in its original site
 very thin aesthetic scar because of early healing
2. Secondary (by second intention): both edges and planes do not come together.
First granulation tissue followed by epithelization, more sensitive and fragile bigger
and unaesthetic scar
No suture between both edges because you cannot suture it
much longer time to heal because the wound will heal from the bottom and
periphery to the middle. will take several months.
3. Tertiary (delayed): suture of wounds after a 2nd intention starting. More esthetic
outcome but less functional
combination of both
without suture healing
at a certain moment a suture will be required for the shallow part
medium esthetic and more stable than the 2nd but less then the first

Scarring process:

Exudative stage: with plasma exit, loss of fibrine clot, leucocytes migration and
edema
immediately after wound formation in the first few hours
exit of plasmatic cells from vessels that go into the wound area. leukocytes,
macrophages, plasma cells that clean and remodel the wound
lasts a few hours: 6-12 h
Proliferative stage: vascular neoformation, phagocytosis and connective tissue
formation
wound is already cleaned before thie stage starts
blood vessel and endothelial cells
tiny capilary formation promoting precursors of fibroblasts and producing
collagen
stabliizes scar
12h - 15 days
cicatricial stage: collagen and elastic fibers
15 days - several months
promotion of collagen fibers and elastic fibers are added to the scar
consolidates scar and makes it stable
Unit 10: Surgical Root Extraction
Surgical Extraction: It is the extraction of a complete tooth or part of one, using some
steps of surgical basic procedure:

incision
reflection (separating soft tissue from bone)
osteotomy
tooth division
smoothing of bone edges: clean socket and remove bone fragments to avoid
cyts forming. IF the edge (crest espcially) can be left sharp like a knife. if a
prothesis later needs to go there, the prothesis will compress the gum towards
the bone and it will hurt the patient. Therefore take a drill and smooth it out for
the future treatments so the patient does not have this continuous trauma
against the soft tissue
suture

Open vs closed surgical procedure

open = surgical extraction/complicated exodontia. All three names mean the same
thing

Advantages of surgery:

less resistance: better to divide and extract

less post op complications: sometimes is not because of the extraction . it can be
because of removing a lot of bone or from the retractors on the soft tissue
if you do the surgery too fast the post operative stage can be bad
if you try to be conservative (close procedures), sometimes you cannot see,
and with a surgical procedure we obtain a wider vision/field
Wider surgical area: better field/vision to work and remove the tooth

Indications:

impacted teeth/erupted in a poor position: either to collaborate with the

orthodontist
sometimes need a tiny flap to be able to grab the crown better
fractured roots
root canal tooth will not react the same way: when you apply forceps and elevator
they will wear off and break easier. VERY FRAGILE. Therefore they need a surgical
procedure when this happens
the longer the root canal has been there the drier it can be or it can be
ankyloses
therefore its harder and we need the clinical history and x ray
crown can separate from the root as well: can be a closed extraction or
surgical extraction
 Crown with alot of damage: if you grab the crown it'll break off

Materials: Have 2 tables

1. straight elevator, indicated forceps (bayonette or lower root forceps), bone curette
2. For if it gets complicated

Radicular rest: will not be able to work in that space. might need a surgery
interproximal caries: if the molar is impacted and the 7 has a huge caries, you
cannot access it, therefore__(?)
tooth with a crown: crown breaks off and the root stays inside
dentin resorption: inernal or external resorption. The weaknd area will be fractured
when grabbed. More difficult to extract, the tooth is too weak and will fracture
Root abnormalities: dilaceration of the root, dilaceratioon of the apex, abrnomal
shapes that prevent extraction
Osteosclerosis or hyper dense bone disease or bruxism ( Paget syndrome): the
width of the PDL is decreased, it will be very difficult to extract the tooth because it
is on the way to becoming ankylosed. Need to prepare for a complicated
extraction
peripathological wide areas: infection of cystic tissue around

Stages:

1. Reflection and few bone removal: we start by using an elevator, but the tissue
will bleed and we cannot see the site for level/application of the elevator/ OR try to
grab the crown and the bulb slides because we cannot place it further than the
CEJ. Iin this case, we will do an envelop flap (buccal or palatine/lingual), that goes
from the pathological side to distal or mesial bottoms (the length as much as
required). Have to introduce scalpel into the sulcus
2. # and cut the attachment. Place the periosteium elevator and separate from the
middle of the envelope flap to the bottom of the flap. Then, parts of the cortical
plates are going to be seen when you use the elevator. You need to start removing
a few mm of bone to be able to see with the rotatory instruments with a rounded
bur. Remove 1mm from the external cortical plate, occlusal ridge of bone to get
enough room to applicate the elevator in mesial and distal. Usually extract from
buccal side. This is the easier way to remove a root with a fracture.

If the root with rotational movement, with elevator, goes out, we do not need to use the
bayonnet forceps.

with the little ostectomy you have space to place things

In the mandible if the portion that is fractured is in lingual you can do a LITTLE envelope
flap lingaully and remove 1-2mm. in this procedure you must be VERY careful to avoid
slidiing to the floor of the mouth. 4-5 is NOT allowed. to allow the forceps to grab the
crown straight

*an envelope flap is “almost nothing” of a procedure.

if a fragment gets deeper and deeper as you try to remove it then you move onto
the second stage

*remember not to use elevator lingually

2. Mucoperiosteal , Partial Neumann, or 3 corner Flap: this technique is used in

case we are not able to remove the root with the previous technique. The flap can
be done in both upper and lower but ONLY IN BUCCAL. It contains 2 incisions: 1
envelope and a vertical relieving incision. This will allow us to obtain a wider
surgical area. hold the flap with a retractor (anterior with parid, and posterior
langerman). start with handpiece and round bur from occlusal side. Can go up to
3-4mm on the buccal side.

We can remove 2-3 mm of external cortical plate (easily replaced by a graft with
biomaterials or membranes, or regenerated). Each time we remove 1mm, we need to
luxate mesially and distally with the straight elevator, with slight rotation, and try to remove
the bone. We remove the soft tissue around the bone cavity (that is infected) then smooth
edges and if its required you can graft or not.

Can be done upper and lower but ONLY buccal. Never have the relieving in the papilla

3. Tooth Section

All are done with handpeice and bur. NOT with turbine or high speed.
we dont use the round bur we use the straight fissure bur and ALWAYS use with
running water or saline solution

Important to use the elevator, preluxate and destroy as much PDL as possible before any
sections.
If a single Root: we use a straight fissure burr with running water or saline solution. We
section the root vertically (mesial/distal or buccal/lingual fragments) with the rotatory
instruments.

this is if we need to place an implant right away and do not want to damage the
socket walls
if it has a curved root: must separate the straight fragment from the curve
fragement. do it horizonatally with the straight fissure bur
before using burs to do a section we MUST preluxate
It is indicated for:

Impacted teeth
Weakened Crowns:
cervical section: straight fissure burr, below the weakened crown in the
cervical area, cut the crown and grab the rest of the root with forceps
Always use the elevator before that. You can split the roots if needed. If the
roots have not been removed, we will need to separate them with the
handpiece and fissure burr: we divide the root into mesial and distal. Then
we can use the elevator and the forceps. The movements will be much
easier, we can luxate mesially, distally and do slight rotations.
Occlusal section:
Destroyed Crowns: Vertical section. Use elevator or forceps to split roots. In lowe
molars, use of cowhorn forceps. do not need to remove the crown separately. For
upper premolar use mesiodistal section. upper molar T shaped section for 3
fragments. Lower molar ___.
Curved roots: separate the curved part from the non curved part, with the straight
fissure burr. The burr is inserted horizontally
Temporary tooth with roots biconvex: we cannot use the cowhorn to fracture the
crown like we do in adults, because we might damage the germ. We use the
Handpiece and burr and separate the tooth into 2, and remove each separately.

If a straight elevator is used, surgeon should remember that the maxillary sinus might be
close to these roots, so apically directed forces must be kept to a minimum and carefully
controlled. The entire force of the straight elevator should be in a mesiodistal direction or
toward the palate; NEVER PRESS LEFT APICALLY

4. Surgical Flap: with osteotomy and tooth section, this technique is used for
impacted teeth (procedure is more complicated) or if everything else fails

Always start with a closed procedure: we use the straight elevator and bayonet or root
forceps and if after 10 min we do not succeed, we need to do an open procedure.
Indicated for:

Roots fractured immediately and deep (inside the socket): There are 2 options:
1) Surgical Flap, faster and less traumatic 2) Through the socket, without a flap.
more dangerous: we make room by removing bone around the root/socket, and
then with a straight and narrow elevator, we luxate inside (Requires a skilled
surgeon) the aim is to have room to be able to put the elevator into the socket. In a
multi-rooted tooth, we need to eliminate the interradicular septum. usually after
extraction this bone is already damaged. Can break with elevator or bur If the
apical part of the tooth is loose in the socket : we can use a rounded bur and
remove 2mm of bone. We can introduce an hedstrom endodontic file into the root
canal, rotate clockwise to stick to the root and anticlockwise and remove the root.
doesnt work if the apex isnt ALREADY loose
Can use winter for the lower posterior teeth impactions
Roots included into bone:
Submucosa Roots: easier to remove. do a flap, retreat the remaining root
 with elevator or bayonnet forceps
Deeper, always flap
Roots under a fixed prosthesis: abandoned roots that happen by poor
treatment plan. It is not necessary to remove the prosthesis, we just need to do a
three corner flap (partial Neumann) Can use boyentte or straight elevator. Spoon
out any pathologies. Use single uninterupted to suture (can use in anywherein the
oral cavity). Fracture can be:
Submucosa: buccal flap
Deep inside bone retained

*if the abandoned root is in an edentulous area you should put a metallic instrument when
taking an xray to be able to see how far it is from the metallic object.
Lateral incisors: abandoned roots in upper maxilla

use elevator or forceps (what type) with or without ostectomy in the buccal side

Suture order: maxilla and mandible

for a lineal/envelope incision: start in the middle and go mesial to distal (?)
3 corner:
4 corner: start on the corner of the flap. second one is on the area of the pathology
(site of the envelope). third is relieving incision

Extraction of teeth in a Poorly position: teeth that have erupted in buccal or palatine,
these teeth are normally single rooted. iT IS NOT A SIMPLE EXTRACTION BECAUSE
THE VALVES CAN NO BE PLACED NORMALLY and we can not luxate bucco-lingually.
Central incisors and canines are usually erupted bucally If a tooth is erupted palatally, you
preform a incision and remove a bit of bone on the palatine side and continue to apply
mesial and distal the elevators. in the buccal side you can do 3 corner but in palatine you
can NEVER do this flap. You can only do envelope or something similar to envelope flap in
palatine side.

Incisors: beaks in mesial and distal, without damaging the well erupted tooth. We
use an elevator to lever, but if the movements of luxation are not sufficient to
remove the tooth, we do a mini flap, and remove 1mm of cortical bone, allowing us
to remove more efficiently the tooth. The deeper the elevator can go the more
efficient the luxation
Canines: Apply mesial and distal. If the tooth is erupted into the palatine, we can
only do an envelop flap (only possible flap). If it is erupted in a buccal site, we can
do a 3 corner flap. We then proceed to remove cervical and root bone and finally
apply the forceps in mesial or distal. Palatine: biconvex
Premolars: in lingual palate, same procedure as in canaines with the use of frontal
approach forceps (beaks in mesial and distal)
mandible: you cannot do a 3 corner or 4 corner. You can do an envelope flap
around the cervical part of the crown. Can use straight or rounded fissure
bur to remove 1mm to place bulbs at CEJ. Can rotate because they are
single rooted.
Unit 11: Complications in Oral Surgery
I. Local Complication
A. Buccal haemorrhages
This is the most frequent complication.
Hemostasis is bleeding control. It involves:
-the blood itself
Vascular endothelium (vessel walls)
- Platelets
- Coagulation and anti-coagulation
- Fibrinolysis and anti-fibrinolysis

The stages:

Primary Haemostasis : involved vessels and plateltes. (vascular and platelet

steps): when there is a damage in the vessel wall, there will be a reflex
vasoconstriction and then several platelets come to the wound site and form
platelet-vessel adhesion. Interaction and aggregation (screened by Bleeding Time).
Factors, such as Serotonin, platelet 3 factor, ADP , IV factor and Ca are
released initiating the coagulation cascade.
Secondary hemostasia / plasmatic stage/ the coagulation cascade:
Intrinsic pathway : created by ADP
Extrinsic pathway: thromboplastin from damaged vessel
Common pathway: both pathways are convergent into the activation of the
X factor which active, PROTHROMBINASE, and turn prothrombin into
thrombin. THROMBIN is the activator for Factor II. Thrombin will turn
fibrinogen (soluble) into fibrin (insoluble), allowing the formation of a clot

The most important coagulation factors we need to memorise are the following
Factor I: Fibrinogen
Factor II: Prothrombin
Factor III: Thromboplastin from tissue
Factor IV: Ca++
Factor VIII: Anthemophilic Factor A (Haemophilia and Von Willebrand)
Factor IX: Anthemophilic Factor B (Christmas)
Factor X: Stuart-power factor
Factor XII: Hageman or contact factor

Pathological conditions: Hemorrhagic Diatesis: when hemostasis is compromised/altered.

There are 3 different origins: Some have hypercoagulability and some others have
hemmoragia

1. Thrombopathic: thrombocytopenia (count of platelets), thrombopathies (function of

platelets)
2. Angiopatic: (Angio means vascular) mainly in the primary stage of the coagulation:
vessels are affected due to congenital or acquired reasons
3. Plasmatic: shortage of coagulation factors. Normally congenital (shortage) but can
sometimes be aquired after consumption (excessive use of them)
Etiology:

Local Causes: less dangerous, mild complications. Most frequent

Post extraction haemorrhages: inflammation, bone chips, fillings into the
sockets
Surgical injuries
Vessel (local) disorders: traumas, tumors
angiomas can provoke a HUGE hemmorage
Gingival haemorrhages due to irritative agents (ex. a filling can provoke
bleeding on the papilla), ginigval hyperplasia, vascular lesions, fillings ,
periodotntal treatment
always mild
just have to spit continuously
seems like a lot of volume because its mixed with spit
General Causes:
Diseases in Vascular Step:
Congenital disorders:
Rendu-osler or hereditary Haemorrhagic telangiectasia
affects tiny vessels/arties all around the body
you can see them easily above the mucosa (lips, tongue,
cheeks)
breakage of tiny vessels (?)
Elher-Danlos Syndrome: hyperlaxicity of joints (most common)
dominant or recessive
Very elastic skin
can have aneurysms, connective disorders
Marfan syndrome: autosomal dominant, heart valve prolapse,
long limbs, aortic aneurysm...
alteration in elastic fibers all around the body
very tall and long libs
heart valve prolaps, eyelens prolapse, aortic artiers
can lead to death if not diagnosted
elastic fiber disorer affects the walls of the vessels
Acquired Diseases:
Scurvy: Vitamin C deficiency, will damage the wall of small
vessels/capilaries
provokes continous hemmorage
Infectious diseases (smallpox, typhus)
affect several vessels
Vessel disorders (fragility) in elder people or cachectic's (very
skinny): these 2 patients get bruises/hematomas a lot because
of vessel fragility
Altered platelet stage:
Thrombocytopenia: ITP or Werlhof disease (autoimmune disease): the
platelet count of those patients is very low and will provoke
spontaneous haemorrhage
 thrombopathy: altered function
Sepsis: affects the cardiovascular system and the platelet count. The
number becomes so low that (reflex reaction is the oppsoite) hyper-
coagulability starts (diseminated intravascular coagulation). Starts
formation of clots all around the blood stream leading to multiple organ
failure.
SLE - systemic lupus erythromatous (kidney failure, joint arthritis,
myocardiopathy, increased PTT by low platelet count...):
can affect all the skin or skin + multiple organs
rash in butterfly shape is typical on the face
several ulcers in the oral cavity
Medulla invading neoplasia: leukemia. Can affect platelet count
Drugs
Allergies:
thrombopathies: hyperuricemia, hepatopathies, salicylates therapy
salicylate have alteration in coagulation due to taking the anti
aggregant drug
Disorders in Coagulation cascade (Plasmatic step):
Congenital disorders:
Hemophilia A (lack of Factor VIII) and B (lack of Factor IX):
common in men
Von Willebrand D (lack of VW Factor (associated with ___?) +
Platelet adhesion; decreased Factor VIII): common in women

Screening tests must be done on all patients before clinic, but usually the patients know
because the diseases are congenital

Hypoprothrombinemia
Fibrinolysis
Acquired Diseases:
Vitamin K decrease: severe liver disease will provoke vitamin K
decrease
Anticoagulant drugs: Coumarin: they will get bruises all around the
skin (Vit K anatagonist)
bruises due to gravity and can go to mandible, neck, clavicle

Diagnosis Test:

Test to measure the quality of blood vessels:

Rumpel Leede T: count petechiae in an area after release pressure of a
tourniquet above the arm. If there are a lot of petechiae, then the test is
more positive. There is no determined values, just +++ (the more you have
the more positive the test)
draw a circle above around 5cm in the forearm. Maintain pressure for
a while. When you release it if there is an alertation in the vessel wall
there will be petechiae and you have to count how many there are in
the circle. The more you have the more positive the test.
Platelet tests: Platelet count, platelet function test, Bleeding time
 Coagulation tests
Primary hemostasis: Bleeding Time
Common pathway: Lee white coagulation time
Intrinsic pathway: APTT
Extrinsic pathway: PT, INR (international normalize ratio)

Treatment for haemorrhages:

First of all, find the exact site of bleeding by pressing with gauze over, using light or using
the suction, clean up, irrigate and aspirate.

1. Post extraction Haemorrhages

Causes: bone chip, bone fracture, granulomas, foreign bodies
Action: Gauze compression (30-1min), filling with hemostatic agents, suture
of alveolus, alveoloplasty. clean bone area and smooth wound edges. Can
place oxidized cellulose, collagen sponge, etc.
Suture is the main measure to control the hemmorage
alveoloplasty: after extraction patient comes back with hemmorage. You
prevent this by removing part of the occlusal edges of the socket to permit
both wound edges closing and suturing them. This removes part of the
cortical plate which is fine because it will regenerate.
easier to treat
2. Soft Tissue Injuries:
Action: wound suture, diathermy coagulation (electric scalpel. Cuts and does
coagulation at the same time), clipping vessels (the heat can burn the edge
of the vessel and stop bleeding)
3. Bone Haemorrhages (bone marrow, the cortical bone never bleeds)
Action: compression with blunt instrument towards the side that is bleeding,
bone wax (you put it in as a plunger above the area bleeding and suture it in,
it is a type of lipid that can be absorbed by the body), diathermy
cortical bone never bleeds. bone marrow does bleed.
4. Gingival Haemorrhages
Action: Hygiene, periodontal dressing (in case we cannot suture),
periacrylicates (super glue for biological uses)

Clamping of vessel: it is not very common because the diameter of the facial arteries are
very small.
The only case where we might require clamping is when there is a big cut in the lip. Under
the mucosa because there is the presence of the radicular oris (check that i heard the
correct muscle name) muscle as well as vessels and veins. They may require ligatures of
the vessels always with resorbable sutures. The tongue and the lip bleed a lot. You then
need to suture in layers. First you suture the fibers and then after the mucosa stitches.
You must use 6-0 or 7-0 to get a more aesthetic scar.

Hemostatic agents:

Desmopresin: the hormone is a derivate from vasopressin (antidirectic hormone), it

prevents haemorrhages in plasmatic diseased patients (VW disease, hemophilia).
 In the hospital they give them a bag of fresh/frozen factor 8, 9 and desmopressin.
Then they are well prepared for the dental procedures
Antifibrinolytics:
Tranexamic Acid: Antifirbrnolytic agent. used in ampules, IV, pills or mouth-
rinses used by dentist to stop hemmorages right after a procedure after a
(every 4-6h for 24-48 hours), not toxic, therefore the patient can swallow.
Not only in the hospital
Aminocaproic Acid
Estrogens - Only in hospitals
Local hemostatic

B. Emphysema
The air collection into soft tissues by the spread of an external course. Ex. turbine air
spreading when doing a tooth section. Remains in the area of the accident and can
extend to the neck or compromise an airway. It can also descend to the mediastinum and
provoke mediastinitis

C. Pain
It is the most frequent complication in post-operative stage. Cytokines are immediately
released after any procedure, resulting in PAIN. Usually is mild to moderate: first 12-24h
referred to surgical area. Treatment would be Methamizol / paracetamol/ NSAID and local
ice to decrease edema. If the pain remains 3-5days post-op, then it could be an infection

D. Inflammation
It is a common reaction but is not a complication. It is due to:
- Vasodilation: increased local blood supply
- Increased capillarity: liquids coming to extra-vascular spaces
- Macrophages and neutrophils migration
- provkes Tumefaction
Treatment would be NSAIDS or Corticosteroids and ICE in early moments

E. Hematomas
Blood collection in between soft tissues or over the bone. As the haemoglobin degrades,
the colour will change from red wine, to violet, to yellow. last 8-9 days. When the
hematomas are deep in the bone or muscles, they can get infected but nothing really
happens, it is more aesthetic.
We can use an antivaricose ointment to speed up the colour changement.

F. Trismus
Difficulty to open mouth due to
- Inadequate anaesthesia block technique (medial pterygoid muscle)
- Muscle spasm due to inflammation
- Anti-algyc reflex
- TMJ disorders by inadequate forces above the mandible like subluxation/luxation of the
condyle
Treatment would be benxodiazepam (muscle relaxant), local dry heat on the masticatory
muscles, pain killers, and exercise daily with ____ to provide oposiion to the oral cavity

G. Infection
Not that frequent. Fever at 38-38.5 degrees (called fibricul (?)) in early 24h post operative
stage. If there is pain, trismus, and all the other signs of infilamation impair the patient
after 3rd day post surgery, this means that there will be an infection. (??)
Treatment: Antibiotics

H. BONM
Related to drug intake of the patient or cancer.
in cancer they prescribe antiosteoclastic drugs (biphosphonate and anti rank-L
denosumab)
can be perscribe in low doses for bone metabolic diseases or high doses (IV or ___) for
cancer.
high risk of bone osteonecrosis. These pathologies are included into a large amount of
drugs that can provoke MRONJ or ARONJ

II. General Complications

A. Chest pain
Angor pectoris, myocardial infarction, arrhythmia, aortic aneurism, pulmonary embolism
(very severe)...
Anxiety due to surgery can be a cardiovascular risk and cause pain

B. Respiratory Failure
Dyspnea, Cyanosis, wheezing
Hypoxemia: can impair wound healing, you should not put the patient backward, should
be seated)
Foreign bodies in the airway
Asthma and COPD - can be chronically hypoxemic. Impairs wound healing

C. Altered Mind State

It is important to know the origin of the drowsiness. It can be very simple: due to a
vasovagal, of parasympathetic origin; or of neurological origin: epilepsy,
seizures, haemorrhages. Need to call 112

D. Shock
- Hypovolemic: happens in big surgeries, not very frequent in small vessels.
- Cardiogenic (after heart arrest, DVT, pulmonary embolus...): release of thrombus in the
lower limb and a sudden decrease of blood pressure. Immediate chest pain
- Septic (GRAM - BACTERIA ENDOTOXINS): does not happen immediately, we need
to recognise alarming signs and send the patient to the hospital ASAP
- Lung failure
- Multiple organ failure: results in death

E. Bacteremia
Pathogens spread from initial site through blood stream. High risk
in immunosuppressed and cardiac diseased patients. Happens very often after surgical
procedures. Anytime you provoke bleeding in the oral cavity it can happen.

F. Septicaemia
Bacteraemia + sudden decreased blood pressure and large cardiac output to
compensate. This will lead to multiple organ failure and death. With the complication of
hypercoagubility Diseminated intravascular coagulation by consumption of all the
coagulation factors (Email. ??what is this/ what does it mean?)
III. Oral Surgery In Medically Compromised Patients

Pregnancy - can work in 2nd or 3rd semester’s

Wait 6 weeks after delivery, and if it is an emergency wait until the 2nd trimester.
Low risk drugs: Antibiotics: Penicillin, cephalosporin, spiramycin; Analgesics:
paracetamol; Anaesthesia: Lidocaine
Always a semi-supine left position or upright. NEVER RIGHT SEMI SUPINE because of
the blood vein return. If on the right side it will be compressed. The vein comes from the
IVC.

Heavy drinkers

These patients will have coagulation disorders (hepatopathy), high risk of bleeding,
impaired wound healing, infectious risk, high tolerance to sedatives and
general anaesthetics.
Drugs to avoid: Paracetamol and any anaesthesia with Amide because it
is metabolised by the liver. Use esters

Drug abusers

Will have high risk of haemorrhages, and postoperative infections. High tolerance to
sedatives and general&local anaesthetics Need extreme postop surgical care, always
prescribe endocarditis prophylaxis.
Do not inject local anaesthesia if the patient has recently taken cocaine; need to wait at
least 6h.

Liver Disease

Same as heavy drinkers. Avoid drugs that are metabolised in the liver, and take
preventative measures in patients with hepatitis B and C. May have hemostasia
alteration.

Diabetes

These patients have an impaired wound healing and more tendency to have infection
and haemorrhages and impaired wound healing. You must measure the values
of glycemia before the surgical treatment. If the glycemia is above 140, postpone the
surgery. Hyperglycemia increased by anxiety and stress of the surgical act.
Antibiotics are required

Hypertension

Surgery will increase the blood pressure. Therefore, if:

- Stress, anxiety: give Benzodiazepin
- Diastolic Pressure higher that 100mg: postpone the treatment
You need the patient to maintain medication unless he is taking MOAI:
monoaminooxidase inhibitors that interact with cathicolamines (why?)

Myocardial Ischemia

CONTRAINDICATION:
- MI (Cannot do anything until 3-6 months): b/c alot of disarrythmeias around the heart
walls because there is necrosed areas.
- Recent angor pectoris + narrowing of coronary arteries (vasoconstriction due to the
stress you caused, leading to chest pain): you need to give them sublingual nitroglycerin
(immediate vasodilator) and then call 112. You cannot tell if the person has this or a
cardiac arrest because can only be differentiated by electrocardiogram. Nitroglycerin can
also help in cardiac arrest, it will not harm the patient. You can give the patient oxygen
mask.
- Congestive cardiac failure: ankle oedema, pulmonary oedema and hepatic overload.
CAnnot recline the patient (?)
- Uncontrolled Hypertension
- Uncontrolled Arrhythmia: Beta blockers
- Pacemaker carriers: the use of electrical scalpel is contraindicated because the high
frequency energy can alter the battery of the pacemaker.

Hematologic Disorders

Ask the haematologist. You can give:

- Fresh frozen plasma or platelet concentrates
- Short life of coagulation factors will only last 8 hours therefore need to be treated that
day after coming from the hospital
- Tranexamic Acid (Amchafibrin)
- Desmopressin (Minurin) in VW and haemophilia and blood products (??)

Addison Disease

The patients have an adrenal insufficiency and will have a shortage of cortical hormones
and will be unable to handle the stress. Need to ask the endocrinologist if they should
increase the dose of the corticosteroids to be able to overpass the stress.

Adrenal glands have 2 parts:

medulla - creates and releases adrenaline

cortex: create and release corticosteroid hormones and minercorticoid hormones
(cortisol - controls stress and inflammation and leukemia (?? what) and many
functions around metabolism and aldosterone - controls ion balance in the blood
stream. poatassium and sodium balance.)
A shortage = cannot handle anxiety and stress
must ask the endocrinologist to increase the dose of horomes to allow the
operative stress.
 Myasthenia Gravis

Autoimminue. Anti-acetycholine affects the neuromuscular transmission, affects muscle

contractions. The patients feel weak when they walk, and have weakened respiratory
muscles, eyelids are not in the right position (called ___). Will have respiratory issues
because of weak diaphragm or intercostal muscles. You need to treat the patient in the
first or second hours after their intake of corticosteroids and actylcholinesterase inhibitors
to permit more amounts, or in a hospital due to risk of respiratory failure (not common
though). Ask at what time they take their drugs and make the appointment around this
time.
Do not use muscle relaxants such as Benzodiazepine; COMPLETELY
CONTRAINDIACTED
Avoid stress, systemic antibiotic
Hospitalisation if respiratory failure

Kidney Disorders (Dialysis)

CHRONIC RENAL FAILURE, creatine clearance can be very high. Normal is 1. Above 3 is
medium renal chronic failure. above 6 is severe renal failure. At 6 or above they must go to
dialysis. We can treat the day AFTER dialysis not the same day because they will be too
tired. Surgical treatments are done the day after hemodialysis and we need to prescribe
some antibiotics. They patient should take Cephalosporins, NEVER PENICILLINS because
they are nephrotoxic, and NSAID ARE FORBIDDEN.

Patients on dialysis have a arterial/pilmonary shunt(?) in the upper limbs for example, to
maintain the shunt they are anticoagulated. Therefore we need to manage their bleeding.
They cannot be under severe surgical procedures. 1-2 extractions or 1-2 implants is OK
and considered a mild procdure.

Patients under Dicoumarin treatments (SINTRON)

Antivitamin K, therefore, the patient must check the INR twice a month, and we can only
operate if it is below 3. They can give you the values a week before operating. If above 3
consult with their doctor

IV. Surgeries in patients with Anticoagulation drugs

A. Major Surgeries (1H20MIN IMPORTANT)

ex. Full arch extractions or full arch implants. the rest of procedures are considered
minor

If a patient is undergoing major surgeries, such as full arch extraction and rehabilitation
(implants), we need to stop the antivitamin K treatment and inject heparin 5000U, 1-2
days before.

On the same day of the surgery,need to check INR (needs to be below 3), resume
anticoagulant (dicourmarin orally) but we still go ahead with heparine injections (?) 1-2
days after the surgery. After 48 hours we can stop heparine and conintue with dicoumarin

B. Minor Oral surgeries

Below INR 3 we do not need to suspend anything.
Patients taking aspirin 100mg/day, should NOT suspend the drugs. Only suspend if 300
OR ABOVE. Should be suspended also 5-10 days
Patients taking CLOPIDOGREL (Antiaggregant) , should suspend 5-10 days BEFORE,
except in coronary stent. drugs cannot be suspended with stents, will bleed a lot.
Cannot be suspended in cardiovascular patients without consulting the cardiologist.
*is aspirin a antiaggregant?

C. Modern Drugs
New anticoagulants (not dicumarins and antivitamin K): until recently do not have any
antidote. Antifactor 10 or antifactor 2. If there was a severe hemmorage there were not
drugs to reverse the effects but the effects only lasted 12 hours (half-life). Needed to be
maintained with blood transfusion.

They act on Factor II (thrombine inhibitors) and Xa, and have an effect for 10h.
They do not require control of INR, or bleeding tests and do not have a lot of interactions
with food.
Exemples of these drungs: Rivaroxaban (10mg/day), Dabigatran (220mg/day)

D. Antibiotic Prophylaxis
- Patients with Hip or Knee prosthesis (are anticoagulated)
- Prophylaxis against endocarditis: Heart transplant is now included in High risk
- Granulocytopenia, systemic diseases, immunosuppressed
- Splenectomised

E. Prophylaxis of Endocarditis

1. No allergies to penicillin: Amoxicillin 2grs, 1h before, children 50mgs/kg

2. Allergic: Azithromycin or clarithromycin: 500mgs, 1h before, children 15mgs/kg
3. Clindamycin 600 mgs, 1h before, Children 20mgs/kg

*if the patient is taking amoxicilin for 10 days for a urinary tract infection and you must do
an extraction or root scaling, you must add a different antibiotic 2 hours before. (confirm
the specifics of this??)

Osteoclasia
Unit 12: Impacted Third Molars
Need an X-ray to check anatomy of roots (can have up to 6 roots sometimes), number of
roots, treatments, caries, position, erupted/semi erupted, angulation is important, most
complications can occur with its relation to other anatomic structures

Usually extracted when there is symptoms that cannot be treated and its causing
pathologies.
20% of wisdom teeth progress adequately, 70% have altered eruption and 10% are
missing

Of all the retained teeth, 3rd molars are more commonly seen.

Dental lamina
third lower molar and second lower molar germ have a common branch.
Therefore they compete and this is a cause of the retention.
Inferior third molar is the most retained out of all these
in the eruption process most 3rd molars are compromised
usually due to lack of space- last tooth that erupts in the mouth
therefore between the ascending ramus and 2nd molar is the only space it
has
If it is below the ramus, it will be retained.
During normal development, the lower third molar begins in an horizontal
angulation and as the tooth develops and the jaw grows, the angulation
changes from horizontal to mesioangular to vertical. The originally horizontal
germ turns itself.
Failure of rotation from the mesioangular to vertical direction is the most
common cause of lower third molars becoming impacted.
late calcification: at 20 for the roots, at 16 for the crown. 20-25 is the average
age of eruption
Upper maxilla is retained less commonly
doesnt have limited access
there is no distal margin. just has the tuberosity (Does the tuberosity ever
interefere with the erupting?/what can affect the upper third molar erupting?)

To extract a third molar you must consider many factors

Age
younger patients have better post operative / intraoperative phase
however you can leave time for proper eruption. Ex. at 24 vs 18, the tooth
would have erupted more.
Pathology
be conservative. only take it out if there is infection/traumatising the 2nd or if
it has a cyst

Mucosa over the retromolar area is not keritinized, it is free and very moveable. When the
third lower molar pressing can cause infection due to this.
 LOWER THIRD MOLARS
Lower third molar landmark complications

inferior alverolar nerve damage/parasthesia

orthopantomography and periapical we wont have the real relationship
between the third molar and the nerve. Theses scans are not enough to do
an extraction.
you will never know for sure if its touching or how without the
computertomagoraphy (CT or CBCT)
without computertomography the patient can sue

More parathesias of lingual nerve than IAN

The third molar’s relation with the IAN:

overlapping
loss of roof of canal
narrowing: it is for sure near the nerve
defelction:Root makes a sudden curve. for sure you are going to touch the nerve
dilaceration - Roots inclined, usually towards distal. need a crown section

Anatomy

normally conic with 3 roots

but ALOT of variability exists
must avoid root canals on 3rd molars and pilars for bridges
they can have 5 or 6 ducts

CBCT

cross sectional slice

axial slice
panoramic slice
frontal
not to be confused with cross sectional

*periapical considered just a complimentary. It is not important. CBCT and OPG are.

CT can be to check cysts or tumors

A third molar can affect the eruption of the second molar

Distoangular third molar

 (lower) inside and towards bone of ascending ramus . Check defelcction of IAN
if there is no pathology you do not need to extract it

I. Treatments
A. Abstention
Need to avoid complication and balance the risk and benefits.
Wont do anything to it now but maybe later it may need to be extracted

Permanent Abstention: Deep impacted position, there is a risk of mandibular

fracture, risk of displacement to neighbour areas or risk of nerve damage. If it
develops into a pathology, then you might need to extract.
Temporary Abstention:l
temporary contraindication-
acute infection: treat the infection and then maybe later they don't need to
extract the molars if it can be controlled. if the patient keeps coming back
with acute infections, then the patient and you can decide
Uncontrolled systemic pathology: can not touch
Cardiac arrest/cardiovascular accidents less than 6 months ago: risk of
happening again with the vasoconstrictor
Radiotherapy/biophosphonates: Increase risk of bone necrosis. Talk to a
specialist

Neurotmesis: severe nerve damage. requires microsurgery

Neuropraxis:
Axonotmesis
B. Prophylactic extraction
Extracting before it causes problems. When the tooth is VERY impacted: tooth is in a
submucosal position OR one or two cusps tearing the mucosa (?)

If they get many infections, extract

impacted on the second molar/touching its root. In the future it can give caries,
distal root reabsoprtion
removable prothesis. usually near the tuberosity. You will not put something
attached to the tuberosity if the third molar may give problems. First remove third
and then put the prosthesis on the 2nd molar.
IF the upper third molar does not have an antagonist. The molar will competely
erupt. Then the inferior gum will be traumatised because of the extruded tooth.
Continuous trauma that does not heal can malignisize
facilitation of orthodontic treatment: lack of space in arch
prevention of jaw fractures: the tooth can have a cyst and then it can destroy bone
and have the risk of fracture. therefore its better to do a large ostectomy rather than
take the risk for a cyst to grow
prevention of cysts and tumors: pathologies can occur due to the cyst.
if the third molar is erupted with buccal inclination, it can affect the cheek and
provoke continuous ulcers / mucosal damage

C. Extraction of symptomatic 3rd molars

 repeated infections
deep caries in 3rd or 2nd molar
periodontal alteration (localized periodontitis on 2nd molar due to food impaction or
reabsorption of bone because of the crown molar)
Can lose both 3rd and 2nd molar
pericoronary cysts
peritonitis happens at early 20’s where its erupting and breaking the gum
there is space between gum and the third molar where food can get stuck
and develop infection. Can occur due to bad hygiene
or can occur due to lower immunity (due to stress or other factors)
treatment: antibiotics because it is acute and chlorhexidine rinses between
the impaction place
NEVER cut the gum because the acute infection can have pus. You may do it
after the infection
dont cut the operculum: fragment of non kertinized mucosa covering
the tooth partially
pain or fever of unknown origin

Always delay the operation when we have an acute process!! In that moment do not cut
the gingival operculum (soft tissue covering a partially erupted tooth). You need to brush
strongly the operculum to transform the non-keratinazed mucosa into keratinazed
mucosa

Elderly patients vs young patients

Operative and post operative tolerated better by younger patients because bone is
less dense, root formation is incomplete and there is a better recovery if the never
is injured
Bone of a 50 year old is different: more cortical and more difficulty to treat. The
bone becomes highly calcified, less flexible and less likely to bend under the forces
of tooth extraction. The result is that MORE BONE must be surgically removed to
elevate the tooth from its socket
mineral component/hydroxyapetite increases in older patients
Best age to extract between 17-24 because recovery is almost perfect, bone is
more flexible, periodontal healing / regeneration can be achieved for 2nd molar

II. Surgical treatment (listen here ~53min)

Here are the following steps in 3rd molar extraction:

1. Incision

Most important flaps: envelope lineal, bayonette

2 other types: angular and envelope lineal with one relieving
envelope of bayonet flap: relieving incision in mesial to 7: selected when we have a
difficult case
envelope lineal flap: no relieving incision: intrasulcus cut +distal to 6
Easiest
 first lineal cut on retromolar area inclined towards buccal .
Following cut is envelop on the buccal side cutting the dental gingival fibers
in the sulcus
extend up to the second lower premolar
gives you a normal surgical field.
Indicated for easier positions. vertical position or mesioangular position
angular: 2 cuts: around 2nd molar and behind
Harder level 1
more complicated teeth: convergent tooth shape that needs spliting
Lineal cut the same as envelope lineal
relieving 2 cm behind the second lower molar. vertical. directly to bottom of
buccal vestibule
indicated: easy molars that are a bit submucos but with root shape more
difficult than the envelope lineal
bayonnet:
Harder level 2
Indicated: horizontal , distoangular
lineal cut above retromolar inclinated towards buccal
envelope cut at bottom of the sulcus buccally
1mm incision between 1st and second molar. divergent 2cm to bottom of
buccal vestibule (?)
envelope lineal with buccal relieving incision in mesial 6: case in which the 3rd
molar has a follicular cyst or a pathology
harder level 3
incision between 1st and second lower molar
large and extended surgical field
indicated: very difficult positions or follicular cyst around that requires
ostectomy and splinting/splitting(?) of the roots)

When suturing: suture first angles then main incision then relieving incisions

Don't understand??
*remember the long buccal nerve has to be anesthesized 1cm below and behind the
stenson duct.

when doing flaps to remove third molar, you will cut along the ramus

requires numbness of the long buccal and be careful not to cut it

*the lingual nerve is very close to the retromolar area
- lineal cut should be inclined to the ramus and never to the lingual side
Dont enter lingually becase there is a high chance of paralysis
no lineal incisions that are veritcal
IAN enters the linguala and then there is the buccal nerve near as well
you feel bone while doing the distal relieving. if you do not touch bone
then maybe you are in the wrong place
 2. Reflection of flap: need of an adequate flap for accessibility: do the
syndosmotomy and try to avoid ostectomy

With periostieum elevator is a full thickness reflection: meaning you reflect together the
mucosa plus periostuem in one layer. Apply periostuem elevator with sharp end towards
the bone. *dont break the periosteum* When you sperate properly the full thickness flap,
you will get almost no bleeding on the bone to go on with the ostectomy because the
blood vessels are all in those layers.

3. Osteotomy: Bone removal

Use handpiece with irrigation (water or saline) and big round burr because we are doing a
non-precise ostectomy (because it is large). Need to discover all the occlusal and buccal
part of the crown to the CEJ - this will give you an ostectomy of around 2cm of diameter.
When doing the osteotomy DO NOT INCLINE LINGUALLY.

4. Extraction or Tooth Disivion

Previously need to Luxate by applying the straight elevator in the mesial aspect between
the 3rd and 2nd molar; with or without making flaps
If the tooth extraction is complicated, we need to divide the tooth.

need to luxate before splitting because the final extraction will be easier
start with the narrow one in mesial between 3rd and 2nd
Be careful not to damage the 2nd molar with the convex part of the elevator. So do
not do a WIDE rotation when luxating when first starting
You can also apply bucally on the third molar. However it will slide. You can make
with a handpiece a groove/hole to stop the tip of your elevator from sliding.
Do slight by small strong rotations at first and then when it becomes loose, then
you can make wider movements.
Do NOT APPLY THE ELEVATOR IN DISTAL OR LINGUAL (? lingual for 3rd
molars??)

Classification

A erupted, B semi, C non erupted - more difficult: the crown of impaction below the
CEJ of the 2nd molar
class A/I mesial to ramus, class B/II between ramus, class C/III inside the ramus

Vertical: complicated roots, need to do a section of the root, osteotomy over the
crown in buccal, Divergent roots: split the roots into mesial and distal
 Mesioangular: Slice in the mesial cuspid facing the second molar and remove this
first
then extract the rest of the back of the tooth (roots)
if the roots are fused apply the elevator mesially
if they are separated roots, you must split the roots
Other option: distal ostectomy in the area of the ramus. Not preferred
because its not conservative.

Horizontal: osteotomy over crown + crown section, be careful to IAN

less difficult than distoangular
requires ostectomy overlying the crown and bucally up to CEJ
vertical crown section with fissure bur from occlusal to apical
remove with turn of the elevator (separating crown from root) and extract
crown first
is fused put a groove on occlusal side to apply elevator and press with
rotation towards mesial
separated roots: crown section and split upper root from lower and remove
separately

Distoangular:
one of the hardest
split vertically a large fragment in distal (to extract first) and then mesial
crown section. Firstly remove crown and then split the roots.
Ostectomy distally with crown section

Buccolingual: complicated because it can be touching the lingual nerve or go

across lingual cortical
Others: ex. upsidedown
Usually mesioangulated or horizontal
classifications are related to the crowns relation to the ramus
Easiets : vertical and mesioangular
Medium: horizontal
Higher difficulty: distoangular and inverted , buccolingual (?)

Never remove in distal, it will weaken the bone and the ramus of the mandible

Dental Follicles or Germs: When the patient is 15-16 years old, the root has not erupted
yet, the germ is in a ball shaped. we can remove the germ to avoid complications later.
The ostectomy will be adapted to the follicle diameter

make an incision and ostectomy

no tooth section
 hold the germ firmly towards one of the walls to avoid its rotation and make the
extraction easier
why do we do this?
can impede eruption of the 2nd molar or for orthodontic reasons affecting
the 2nd molar

Greater difficulty: bone depth, distoangular position, impacted in ramus, shape and root
number, elderly, higher bone density, no PDL evident

5. Checking up the cavity:

It is important to remove the rest of the follicle sac membrane with a mosquito and bone
curette scratch the walls. this avoids cyst formation. Any fragment forgotten in the socket
will lead to a bone sequestrum (infection). ALWAYS CHECK THE SOCKET. Check with
round instrument to see if the walls are stable

Also check the bone boundaries of the ostectomy. When we use elevators we can
damage the socket boundaries and the edges need to be smoothed with a rounded bur
and irrigation. Touch the bone edge with the fingertip to check to see if it is smooth.

6. Hemostasis and Suture

check socket and suture

when suturing we start at corners
for envelope lineal we start distal to the 2nd molar, the second stitch will be in the
papilla. The next stitches with be in the retromolar and can be simple continuous(?)
or one horizontal (?): check unit 9 bis
For bayonette and envelope: the last thing to suture is the relieving. start at the
corner

6. Post-operation care

Relative resting, physical measures (saline, mouthrinses), antibiotics, NSAID, Analgesics

ASA I - dont give antibiotics after extraction: (?) because these patients are in good
health

III. Complications

Bony
fracture of jaw: cysts or large ostectomy
TMJ Dislocation
 Plate fracture
harder to fracture the external cortical plates than the mandible
Dental
Root fracture
fracture or luxation of 2nd molar
displacement of an apex in lingual or buccal space
soft tissues
Tears: if you do not extend it enough the retractors tear the flap
burns on the lip for the inferior molars
cheeks will also suffer alot from retraction
nerve injuries
Lingual and IAN are equally as important
more paralysis occurs in lingual
Others
dry socket can occur if it does not bleed or if the patient smokes
cellulitis, bruising, trismus

Prophylaxis

good vision occurs with a good flap design, surgical suction, skilled assistant,
adequate anesthesia

Upper third molars

Their pathology is less abundant and the surgery is less complicated. Remove when
condition is not adequate to regular eruption: large caries, periodontal alteration in 2nd
molar, buccal eruption (cheek erosions and ulcers). If the follicle is still high, wait until a
more optimal position. The lack of space is usually not a problem.
The tooth is delivered in the distobuccal and occlusal directions and in most
circumstances, bone removal using a burr is not required when removing impacted
Maxillary 3rd molars.

Complications:
- Dental: fracture or 2nd molar luxation, Displacement to sinus, pterygomaxillar fossa or
buccal sp.
- Bone tissue: tuberosity fracture or fracture of pterygoid wings
- Other: mucosa tear (more fragile in maxilla) , injury to greater palatine artery (due to
necrosis of hard palate) , hematomas, abscess

heterotopic: erupts in a place where it should not be

Same 4 flaps as lower

Ostectomy: not as large of an amount as in the manible or splitting of the tooth because it
is low density bone
Suture first in the corners, second stitch ______. If you abel to you can make a horizontal
behind and if youre not able to ___
Unit 13: Impacted Teeth

Situation: retained tooth that is trying to erupt in a site close to the original/regular site
where it is expected to be.
3rd molar normal eruption should be behind 2nd molar in retromolar area
An ectopic 3rd molar would be close to where it should erupt.

Example: the angle of the mandible

Hetertopic, the tooth should never be erupted in that site, very far from the site of origin.

Example: Ramus, condyle (it is a possiblity), maxillary sinus (? or ectopic)

According to situation, the tooth can be:

1. Physiologically in eruption: retention/eruption cannot be used for a teenager (ex.

age 15). But we can say if there is a delay in eruption (probbaly a retention but we
need to wait to see)
2. Erupted
3. Retained: tooth that is not yet in the arch when it is expected to be
4. Impaction: retained teeth partially erupted. More superficial. Higher in lower
mandible, and lower when in maxilla. Can tear submucosa or mucosa.
5. Inclusion: Can be completely covered by bone and very close to the occlusal ridge
(very superficial). OR very deep - some retentions are very close to the basal
lamina

Position: the angulation of the tooth, it is related to the long axis of the neighbour tooth.
Winter classification: Not only applied to third molars. To all/any teeth that can be
retained.
- Vertical
- Mesioangular
- Distoangular
- Horizontal
- Inverted
- Linguoangular
- Bucco-angular
- Palato-angular

The frequency of retention: Lower third molar 68.4%, Upper third molar 24.6%, canines
4.2%

I. The etiology of retention

A. Local

1. Embryological hypothesis: the germ is in a far situation: the germ of the upper
canine is below the orbit, if it is too high, there will be a retention. As for the lower
3rd molar, the location of the germ is in (or near ?) the angle of the mandible, if is
too deep can cause retention. Or if the dental bud has a common origin for the 3rd
 and 2nd molar and both teeth compete for eruption

2. Mechanical theory: Molars or canines most frequent

Arch-length deficiency:

For 3rd Molars:

Lack of room due to boundaries and inferior alveolar canal
mandible growing area
rigid relationships
dentomaxillar disharmony: sometimes people inherit a small maxilla and
large crown size. This mismatches with the room you have to get the tooth
to erupt in the arch. Main goal for orthodontics is to expand the arch.
For Canines:
Chronic mouth breathers: babies have a narrow enlargement of the palate,
and there will be no room for the canine
Retruded incisors: decreases the arch length and canines are the last to
erupt therefore lack of room
Iatrogeny: the child lost the primary tooth early due to caries and the
orthodontic did not apply a spacer to conserve the place for the eruption of
the canine. Can happen in canines and sometimes premolars

Mechanical obstacles:
Tipping of the lateral incisors:
the lateral incisor: tips towards distally. get separated from central
during eruption. when canine tries to erupt there is no room.
Supernumerary teeth (usually mesiodens): they are in the midline, btw
centrals or btw central and lateral. impede normal eruption of adult tooth
Odontomas: frequent odontogenic benign tumors:
Two types: complex & compound
some of them are situated in the anterior part or distal. Impede the
normal eruption of any tooth
Prolongation deciduous tooth is still in the arch that will lead to the non
eruption of the permanent tooth.
Slipping forward of permanent molars : 1st upper molar and lower usually.
they erupt before the replacement of the temporary molar. Therefore its
unkown why they tip mesially. when its time for eruption of the premolar (to
replace the 1st temporary molar) there is no room.

3. Bone-condensing diseases

enostosis: high cortical bone consensation around cancellous bone.

normally doesnt affect the whole maxilla and is localized somewhere. Tooth
 is retained due to the highly corticalized bone. Can be of unknown origin or
linked to syndromes

4. Odontological or inflammatory cysts

5. Postinjury scar (after a trauma) that can affect lips and gums, impeding the
normal eruption
6. Inherited gingival fibromatosis: autosomal dominant disease, where the patient
has a much higher amount of collagen fibers in the gingiva, which not allow the
eruption of the one or many teeth.

B. General Factors

Delay in eruption: not related to any genes, or sex dominance or recessive

inhertiance; it common in the same family- frequent retention of the same tooth.
The most frequent ones are premolars, not important just need to check them /
know they exist to prevent the retention. The origin is unknown it is thought to be
because of environmental, ethnic, climate, diet... It is important to check if other
members of the family have the same retention.

Pathological Delay in Eruption

Hyperthyroidism
Family feature
Gardner Syndrome: systemic pathologies that causes intestinal polyps
(worst because can turn into adenocarcinoas), retentions, osteomas, fat
cysts all around the bodies, impacted teeth
Rickets Disease: Lack of Vitamin D: *dont need to know every symptom on
the slides* Know:
has alteration in formation of skeletal bone. Especially in the chest
and legs (bow legs)
enlargement of skull
Alteration in dentin and enamel formation: high frequency of caries,
retentions, agenesias and tooth deformities and defects
Cleido-Cranial Dysplasia: Also high frequency of retentions, agensias.
Autosomal dominant inheritance
alteration in skeletal bone and maxillofacial bone (ex. enlarged skull,
delayed close of fontanella, atresia/hypoplasia or atresia of both
clavicles)
no dental replacement, multiple teeth impacted
NO mental retardation
Inherited ectodermal Dysplasia:
Autosomal dominant
In children that lack sweat glands (therefore when they have a high
temperature they have a risk of shock), fat glands
 lots of retentions and anodoncia (same as agensia)
HYPOTRICHOSIS: fragile blond hair and skin. Those patients have an
appearance of an elderly person
they do not have any anterior tooth erupted and the placement of
implants is difficult because they do not have bone volume.
Anhidrosis (temperature shock)
Try to promote bone elargement with orthodontic appliances for
years but usually fails
Fibrous Dysplasia: can affect all bones of the skeleton or just the
maxilofacial bone:
Cherubism: multiple cysts inside the germ and impede the normal
eruption.. Affects only the Maxillary bone. The aspect of those
children would be enlarged cheeks because there are cysts in the
maxila and mandibule. The have altered bone growth, anodontia and
impactions.
Mandible or maxilla (?????? email and ask)
Osteopetrosis: Autosomal dominant.
Not enough osteoclasts: responsible for root resorption, hemostasis
balance.
lots of root resorptions and compressive processes
foremens: cranial and spinal nerves are compressed because
of lack of bone replacement tehrefroe many neurpathic
pathologies
Therefore there is no bone remodelling, they will have very dense
bone, there will be impacted teeth because no temporary root
resorption
in xrays: higher average of corticalized bone and low medulalar bone.
the boen is very hard and mineralized but extremely fragile because
theyre not flexible and very rigid

II. Third Molar Pathology

There is a main age for all pathological diseases detected. (MIN 34???)

average age for the pathologies: 18-25

origin: common dental bud with secondmolar
anthropological evolution: 10% agenesia
decrease of jaw size and teeth size + more in mandible - room (?? what
does this mean)
Calcification stages
8-10: crown
15-16: root
25: root calcification ends

III. Pathogeny
A. Infectious Origin
Operculum: mucosa obstacle normally causes infections related to the retained third
molar. Food is trapped below the operculum. Can make that area permanently infected.

( will attract oral germs ??)

B. Mechanical Origin
Lack of room, wrong position, teeth migration, TMJ alteration

C. Neurological Origin
Area with rich innervation and vascularisation of the third molar.
Related to trigeminal nerve with branches from internal maxillary artery and related to
vegetative nerual system.
siblingual, pterygoid palatine / maxiallry fossa are parasympathetic and sympathetic
ganglions (?)

IV. Clinic
In frequency we find:

1. Infectious accident

A. The mucosal pathologies

most frequent

Any mucosal infection is linked to lymphadenopathie ALWAYS.

There are 3 main types of mucosal infections:

1. Acute congestive pericoronitis: pain irradiating to the pharynx, ramus with

overlying mucosa (operculum, pain to palpation)

and always linked to one adenopathie usually in the mandible (neck)

submandibular .
It can heal on its own after strong tooth brushing without systemic antibiotics.
Mouthrises and tooth brushes to clean the operculum.

Relapsing pericoronitis while the molar tries to erupt. Can turn into suppurative depending
on the condition of the patient: imbalance btw germ and immunosystem of patient

2. Suppurative Acute pericoronitis: increasing pain and swelling. radiation to ear and
tonsilla, pus formation on palpation of internal mucosa, trismus, painful
adenopathies, pyrexia (fever).

Need systemic antibiotics.

If the patient does not remove the impaction, the episodes become chronic.

3. Chronic periocoronitis: reduced symptoms (ex. pain)

 Relapsing (unilateral) pharyngitis and intermittent, pain, halitosis, bleeding gums

Other types of mucosal infections:

Neuroptrophic stomatitis: entended inflammatory infection of oral mucosa all

around. not only where the third molar is. can be on the opposite side for example
(not as common).
painful, not very common, related with a regular eruption of the 3rd molars
as well (?? didnt hear this on the recording. need to confirm)
Localized lesions ulcers in cheeks. very painful and can be infected and can infect
the mucosa.

B. Lymph Nodes infectious disease: commonly associated with mucosal infection

Simple adenitis: slightly painful, palpable, little enlarged. Same as the pericoronitis,
it is able to turn into suppurative
Suppurative adenitis: sudden enlargement, very painful, swelling, sometimes need
of surgical drainage, and antibiotics. Will have fever, tachycardia and pus in the
lymph node. Uneven contours (no mobility)
Adenophlegmon: rare to see these days due to sysetmic antibiotic reatment.
lymphnode broken and there is a spread of infection out of the lymph node and
into the soft tissues of the neck. HARD to palpation. Mainly in the submandibular
area

C. Infection in Soft Tissues of the face

Cellulitis come mainly from odontogenic origin, come from infection of the 3rd lower
molar. They are considered as dissiminated infections: Not primary infections (the primary
infections being Pericoronitis).
Those that affect the lower 3rd molars are:

Submasseteric abscess
Abscess of escat: affects medial pterygoidal muscle
A mirgrans of Chompret
Supra or inframylohyodeal cellulitis

Those that affect the upper 3rd molars are: quite frequent

Terracol abscess
Pterygomaxillary fossa abscess

D. Bone Infection Accident (might be missing somethings??)

Acute osteitis: severe pain, fistulae in mucosa or skin, bone sequestrae, mobile
tooth around that area,
Subacute Osteitis :
Chronic Osteritis: fistula in mucosa and skin bone sequestre.
 Aborted Form: caused by misuse of systemic antibiotics, with or without
sequestraes. stop syptoms and permits strange ____ (? email asking what this is
exactly)

2. Mechanical

second most common

dental accidents: caries in distal part of second molar crown or root (which is
worse because th molar cannot be restorable and lose second and even third
molar). Root resoprtion due to wrong position of the third molar the distal root can
be resroped and again no chance to restore. Loss of periodontal attachment: due
to wrong position (horizontal for example) for several years. the distal side of the
second molar will lose the attachment. Crowding of lower inscior: it is NOT true,
secondary retention around 18 years is due to third molar muscle origin function.
the power of the oriciular and mental muscle retrude the central inscor and
decrease the arch length. this happens during eruption of third molar. it was
thought before that the eruption of the third molar caused this anterior crowding. It
only has enough strength to incliude the ssecond molar, not affect the anterior
teeth.
TMJ disorders: rare but can happen after the eruption of 3rd molars. prophlactic
extraction in people with TMJ disorders.
Mucosa: ulcers due to wrong position (normally buccal in the upper) because the
tuberosity is weak they usually erupt bucall instead of mesial. Then the cuspid
ulcerated the mucosa of the cheeks
bone: alveolar bone around eruption site.
septum syndrome: food trapped between 2 teeth. can occur due to loss of
contact point. IF happens with conservative dentsitry you replace the
contact point. between second and 3rd molar we do not expect any
conservative procedure. you remove the third molar to prevent the septum
syndrome because it provokes a local osetitis in the dental wall between
second and third molar
malocclusion: due to destbalization of fixed prothesis which has a pillar in the
second molar. when it erupts the third molar can displace the second molar and
affect the setting of the prothesis.
fracture: direct trauma to mandible (ex. car crash) weakend area due to retention
and can fracture. direct trauma over the symphysis and fracture over the 38 area.

3. Reflex accident

third most common

There are different types of algias and neualgias all around the area of the nonerupted 3rd
molar.
If a patients comes frequently and tells you has an algia, neuralgia (whihc runs frequently
in the 2nd division, numb area. You can observe that there is a retention -ex. inclusion:
can give you a reflexive accident. and if you remove the retention, it will heal on its own
- Sensitive alterations: Tinnitus (noise that the patients hear in the ear, it can be related to
an retained 3rd molar pathology), Alopecia: with third molars in occiptital area (with
canine it is in the frontotemporal area)
- Trophysm alteration: facial palsy, blepharospasmus.
- Neuralgia of Sluder: pain on the shoulder, arm, eye, ear nose itching, rhinrrhea: non
erruption of 3rd upper.

3. Tumoral

lesast frequent

Cysts: follicular or kertocyst odontogenic tumor (behaves like a cysts but with tumoral
markers): they happen around the crown of those third molars

follicular memberane with more than 2-3mm enlargement. if there is only a folicular
memebrane but not enlarged it is normal for a single tooth. if it enlarges it can form
a cyst.

- Granulomatous lesions: hyperplastic granulomatous lesions in the distal side of the 3rd
molars. There is an osteoclastic reaction trying to remove the part of the ramus to permit
complete the eruption of the crown. Can be seen in OPGs
- Pericoronary cysts
- Hyperplastic osteitis in mandible angle
Unit 14: Impacted Canines
Most frequently upper palatal canines are the ones to be retained. You may be able to
see it because there will be an increased volume palatally that looks like a torus.

Third molar is retained usually due to lack of space. Normally upper canines are the same
because they are the last to erupt after the lateral incisors and premolars. Lack of space
causes retention.

The inferior canine is less frequently retained because it erupts before the other teeth; it is
not the last to erupt therefore it has enough space.

Can be heterotopic (not close to the site of eruption. ex in the TMJ) or ectopic (mostly
ectopic - tooth not erupted yet but its in a normal/close by area)

Where are they found?

mostly found palatal (80%)

and mostly found mesioangulated
some found buccal (15%)
some found in a mixed position (crown in palatal and root in buccal - 5%)

40-50% of canines that are impacted or included (fully covered) are bilateral/symmetrical
in palatine, mesioangular position (Crown facing the midline and root apex facing the
arch)
Normally asymptotic, and if there are any symptoms, should be removed

I. Clinical assessment

1. Mechanical accidents (most common, unlike the 3rd molar, which is the
infectious),

a. Displacement of adjacent teeth (NOT the worst case scenario):

Tooth rotation: sometimes, we have the lateral incisors or central incisors that
rotate because of the action of the retention
Diastema: If the canine is btw the lateral and central incisors provoked by the
pressure (from distal to mesia) of the canine towards the root of the lateral incisor.
The canine is distal to the incisors, so if the canine presses the root, it will be
pushing it mesially. Therefore the crown is displaced distally.
Crown opposite to root: The crowns of Lateral incisors, central incisors goes
opposite to the direction of the root (??)

The consequences: malocclusion, aesthetic disorders, open bite, especially in bilateral

retention. Canine is important because it has a functional component, keys of occlusion.
Aesthetics is not as important as this

b. Bone or root destruction

 Root resorption: happens when the upper canine is so close to the lateral incisor
that the follicle membrane (that has a high osteoclastic activity to resorb the
temporary roots (normal)), will react against the root of the lateral /central
incisor, causing root resporption that can be accompanied by acute
periodontitis, pulpitis, necrosis and tooth mobility. The tooth can fall out due to
its extreme mobility.
You can check the resorption on a CT or CBCT

c. Prosthetic
Unstable denture: prosthetic accident, patient carriers of full dentures or removable
prothesis. By the action of the friction of the phlagens of that denture, above the mucosa,
after several years, the bone ridge is atrophied. If there is an abandoned impactions, it will
start erupting unexpectedly and the denture become unstable (due to undiagnosed
impaction before using the denture)

When erupting, it can become infected (like the operculum gets infected with food in
cases of 3rd molar impaction)

2. Neurological Accidents (equal to those of the 3rd molar)

a. Algias
Pain, somewhere around the body, related due the wrong stimulation of the branches of
the 2nd/3rd division: could be in the area of impaction or distant (eye, nose, ear, neck), or
frequent migraines

Make a differential diagnosis with acute pulpitis of some of the neighbouring tooth and
that reflect algia. How do we do the differential diagnosis?
Sometime there will be caries on the crowns of lateral incisors, as well as an reflex algia
coming from that impaction of the upper canine: the pain felt is different than the one in
acute pulpitis. Be careful with that.

b. trophic disorders (??)

Bone area in the occipital side for the 3rd molars
For the canines it will be the fronto-parietal area

c. Motorfiber disorders

blepharospasm
facial palsy: same as 3rd molar
nose itching, running eye, cheek edema: those are vegetative signs related with the
ganglions of the 2nd division

d. Sensitive disorders
Decrease of visual acuity or tinnitus

3. Tumoral Accidents
a. Follicular cysts/Dentigerous Cysts (frequent)
It is related to the crown of retention, more frequent to the 3rd molar (because are more
usually retained) compared to canines

All impacted teeth may develop into follicular cysts. Into the lining membrane of those
cysts, which have high osteoclastic activity related to the root of the level, there are some
cells called ameloblast (precursors of the enamel).
Those ameloblast can become tumor: ameloblastoma (can be benign ) very severe
locally.

any type of impaction, if we decide not to remove it, need to check the impaction very
closely because after several years can develop into tumor
Check around a retention, if there is an enlargement. more than 2.5mm enlargement
means that the follicular lining membrane has developed a cyst.

when taking an xray of a canine and you see a line above it - that is the NASAL FOSSA
NOT the maxillary sinus (found by premolars - molars) *remember this for the exam*

In children,if a canine is causing root resorption (once resorption starts it never stops even
with splinting and a root canal ) always pull the retention out into the arch, even if there is
a cyst. DO NOT EXTRACT, even if the lateral incisors is going to be lost. Its better to have
the canine there and lose the lateral than not having both teeth (because the lateral will
(maybe) eventually be lost due to the root reabsorption)

4. Infectious Accidents (quite rare)

Less frequent than 3rd molars, since they are included, sealed and not communicating
with the exterior environment.

Except if there is an infection of the adjacent tooth (periodontitis or pulpitis), it is a

retrograde infection coming from the apex of the neighbouring tooth. Not form a
caries or root canal
Root lysis, or any other exodontia with infection in neighbouring tooth
Normally not acute pericoronitis (like in the 3rd molar), it is just subacute, with less
clinical signs. Can be in buccal or palatal depending on the site of the retention.
Less common to have abscesses. Can develop into a fistula (infection that is
encapsulated that comes out into the oral cavity. By entering a probe you can
touch the crown of the impacted canine)

Infection spread:

through the bone: osteitis (like in 3rd molars)

to nasal fossa or maxillary sinus
Overlying soft tissue of face, will provoke buccal cellulitis: around the area of the
canine, below the orbit.
 UPPER CANINE

I. Clinical Assessment:
Check if there is or not, the temporary tooth, if the adult tooth is missing, if there is any
tooth displacement of any kind, fistula, abscess, unstable prosthesis, anilateral mal
occlusion, and palpate.
Why palpation: the palatine bold in concave, if we have a convexity, it means there
is something there: suspicious diagnosis, and might be the retained canine. (??)

Canines are usually included or retained, there is no agenesia. Agenesia happens more
frequently to premolars.

- X-ray: Conclusive Diagnosis: situation, position, shape, size, relationship with adjacent
tooth, with anatomical structure, any abnormality (bone alteration, bone condensation,
cyst) around the canine. Need to check that on the root, there is no dilaceration.
Will allow us to know the success rate of any orthodontical or surgical treatment (to drive
the tooth to the arch) we think of doing

- OPG: pretty good screening of population, not agreed in all clinics, but good for
screening the general population.

- Periapical: USE THE CLARK TECHNIQUE: allows us to know if a tooth is in the buccal
or the palatal side (same as endodontics)
Needs 3 projections: one orthogonal, one to mesial, and one to distal.
When an object is located in palatine and we move the xray to distal, the object follows
the xray.
When the object is located in buccal, and we move the xray to distal, the object moves to
the opposite direction

- Occlusal technique will help us to determine if the retention is in palatine or buccal

- CBCT: in difficult situations, allows us to assess retained canines

II. Surgical Treatment:

If the extraction is needed not:

if there is any tumor: direct extraction

follicular cysts around the crown, remind the patient that might develop into
ameloblastoma. (1/3 of amelblastomas come from follicular cysts)
A cyst does not have calcification. If there is calcification, we are talking about a
tumor, needs to be removed, as well as the retained canine

When we have an adult, we have 2 options: either extract the canine, if there is a cyst, or
drive the tooth to the arch

in children/teenagers, we always try to move the tooth to the arch

Orthodontics takes priority over surgical treatments EXCEPT when there is periodontal
problems. Then you stop orthodontic treatments to deal with the periodontal diseases.

A. Canines in palatal
More frequent and more difficult because of the approach and surgical field is narrow
compared to the buccal side. But less complication than in buccal.

The practitioner will be seated at 7-8, and the head of the patient in hyperextension for the
hard palate to be in front of your eye.

Anaesthesia
Superior anterior alveolar Nerve, in the infraorbital technique and nasopalatine and greater
palatine are to be anaesthetised. If it is bilateral, you inject both sides, if not, just one
side.

Can only do envelope flap in palatine (no relieving on palatal):

if anilateral: mesial 6 to contralateral lateral incisor / canine

if bilateral: mesial 6 to mesial 6

Tissue reflection: the fibrous mucosa is difficult to see because it is completely sticked to
the perioosteum and bone

Ostectomy
handpiece, large round burr, irrigation above the area, where xray assessment has told the
location of the crown of that retention. Around the crown start with concentric
ostectomy, Beyond the CEJ, and immediately start to luxate.
If it moves but you are damaging (or at risk of) the neighbouring tooth of the well erupted
teeth, you should directly move to a tooth section; but always PRELUXATE TO BREAK as
many periodontal fibers as possible. always end the tooth section with straight elevator,
never the bur.

ELEVATORS CAN ONLY BE USED IN PALATAL OR DISTAL SIDE BECAUSE RISK OF

DAMAGING THE NEIGHBOURING TOOTH

if you use it mesial you can dislocate the incisors

Extract firstly the crown section. Sometimes you only need to section the cuspid, not the
whole crown. Then the rest of the root with Winter (very useful in retained teeth because
of its angulation) or the straight elevator.
Make a groove or a hole to introduce the winter elevator so it does not slide. (how does
doing this stop the sliding?)

ALWAYS EXTRACTED FROM DISTAL TO MESIAL the rest of the roots.

Depending on the shape of apex might require several tooth section.

Check up
Always remove the follicular membrane (scratch with bone curette): NEVER FOUND IN the
bottom or top?? OF THE SOCKET. The follicular membrane are around the crown, close
to occlusal site of the ostectomy.

Horizontal Suture - frequent. between buccal and palatal sides

*knot should always be in the buccal side

B. Canines in buccal
Approach is much easier, but much more periodontal complication for that area.

Anesthesia
Will involve the infraoribtal technique but make sure that the middle alveolar nerve is also
numb. If its not numb inject above upper premolar.
Nasopalatine and greater palatine as well

Flap

partial neumann, relieving incision in distal, betwee. 1nd and 2nd upper premolar,
no vertical incision (can cause an aesthetic scare), and do not go to the medial
area because it is an aesthetic area. The reliving incision in distal, divergent!!!
Parsh: with a convexity upwards, incision done when the extraction is not that
difficult
Apical advanced flap: typical peridontal flap displaced apically. Mainly in cases of
orthodontical surgical treatments, not when you wish to remove the canine

Reflection
gently because we are talking about free & alveolar mucosa that can be easily teared.

Ostectomy
large round burr and irrigation, above the crown of the retention of the canine and beyond
the CEJ if we are talking tooth removal.

The flap is different in case of surgical extraction and orthodontic surgery.

In cases of surgical extraction the incision as big as the size of the crown and flap will be
bigger

Tooth section, if required, and luxation previous to that, and remove with any instrument
(elevator, forcep (bulb in mesial and distal), can do rotation)

check up with bone curette

Suture

C. Canines in a mixed position

Few of them, most of them crown in palatine and root in buccal

1. need to know where is the crown and the apex

2. ostectomy in palatine and the another ostectomy in buccal
FLAPS: need to do 2 flaps

Partsh buccal or partial Neumann in buccal with the relieving incision in between
the 1st and the 2nd premolar: divergent incision
Envelop in palatal side

First ostectomy in buccal side and then palatal side. We find the apex and we push from
buccal to palatal

III. Complications

Fibromucosa tear, it is easier in the buccal side

Subluxation of the neighbouring tooth, wrong application of the elevators
incomplete fracture or extraction of the canine
Perforation of nasal fossa: if the canines are quite high
Displacement to nasal fossa
Damages to the infraorbital nerve or to the greater palatine artery because of
wrong tissue reflection.

Prophylaxis of the complications:

Need to make a proper preparatory assessment with clinical assessment and radiological
test, Need to check the situation, size, root shape, boundaries, relationship with adjacent
teeth

LOWER CANINE
I. BUCCAL
More frequent in buccal, the clinical is the same: lack of space in the arch or persistence
of temporary.
There will also be a convexity in the buccal area, in the external cortical plate, swelling
which is palpable

Accurate assessement comes from the XRAY (periapical, CBCT...) to assess everything:
position, situation, size, root shape, bone, boundaries, relationship with adjacent teeth

Anesthesia:
Inferior alveolar technique block: IAL+ LINGUAL N in the same injection
Inject also Long buccal nerve (incision we will affect the area around the 1st and 2nd
premolar)
Not necessary for the mental (never answer that in questions: trap)

becomes anesthetized from the lingual nerve (??)

Incision

Partial Neumann: relieving incision can not be done like the upper because it is
next to the mental nerve. You do relieving in the middle line, in the area of the
 central and lateral incisors. Might be aesthetic area, but better to save the mental
nerve
partsh: concavity downwards

Reflection

Ostectomy
Above the bone area in buccal where is located the crown. Tooth section optional.
Elevator in distal or mesial, not as risky as the upper canine, because the cortical plate is
much stronger in the mandible.

Can use elevator or forceps to remove the rest of the root. It is acceptable to use the
bayonet forceps from the upper maxilla, because we are talking about surgical
procedure, no need to follow guideline of forceps.

Check up and suture

OTHER IMPACTION

2nd lower and upper molars: it is because of the 3rd molar is tilted towards that
2nd molar, leading to its abnormal eruption.
Treatment: remove the 3rd molar, and use a mini-screw for the 2nd molar to
put the tooth back in place. Reimplanting is less frequent.
upper central incisors: more frequent upper with mesiodens or sometimes a tumor
2nd lower premolar: more frequent in lingual, normally position is vertical, making it
easier to pull out into arch --> envelope incision with extension as long as you
need. I tneeds to be long enough to avoid tearing. tooth section may be required or
you can use the bayonette forceps
2nd upper premolar: more frequent in palatine, also more common vertical position
supernummary: more frequent in boys 2:1, 15% of population
Mesiodens: in middle line, more in upper anterior maxilla, they will provoke
diastema, migrations, cysts, and need to extract early and drive the right
tooth to the arch. (you need ot be able to differentiate between which is the
right / wrong tooth) No need for a tooth section, because they are usually
not fully formed because they are detected at an early age
distomolars if associated with the 3rd molars
can also sometimes happen with premolars
if all the other teeth are in the arch in proper position and there is no follicular
membrane /cyst around it, we do not need to treat. Just check up from time
to time.

Reimpaction: often associated with temporary molars. Temporary molars were perviously
in function, but because of the the tiltiing of the first molar can reimpact the temporary
tooth and puts the teeth not at the level of the biting plane (not back into bone though).
They must be removed surgically and need to obtain room for the replacement tooth, and
drive the premolar to the right position. double surgical and orthodontic treatment.

If the premolar is horizontally placed, Also can reimplant the tooth if its not in the
 right position and create artificial socket and splint the tooth. Permits normal
function of reimplanted molar. “trendy” surgery for teeth that cannot be driven to
the arch (do we do this with EVERY horizontally impacted tooth??) and for
teenagers since they cannot have an implant
more successful when apex is not formed. If apex is formed it will need a root
canal treatment.
not successful in all patients because there can also be an akylosis with impacted
tooth.

Argue with patient if they will drive the teeth out to the arch
if it is a child/teen, ALWAYS drive the teeth to eruption (no discussion): orthodontic
surgical treatment

SURGICAL ORTHODONTIC TREATMENT

A. Patient related factors

Motivation: for adults, it will take too much time, and we are not always successful.
Some will prefer implants because it is easier and faster
Family Finances: patient that can not affort a long orthodontical treatment

B. Related to surgery factors

Position and situation:

favorable when the site of retention is between lateral incisor
behind central incisors not favorable
tipping of the root, related to the long axis of the lateral incisor, higher than
30 degrees it is not favorable
Tooth condition
follicle membrane: child is recommended orthodontical treatment
Ligament with XRAY, to check if there is no bone ankylosis or apex
dilaceration because will result in the non sucess of the orthodontic
treatment

How do we do the Technique:

Firstly you have to obtain room for the retention. Therefore we start with braces and arch:
obtain room, more than required and then close it, if there is more space than needed.
Then the surgeon starts with the surgical procedure to eliminate mecaniscal obstacles: if
there is bone around crown, make a pathway with an ostectomy allowing the normal
eruption of the retained teeth.

close hermetically with suture

close approach: Better and more frequently used. Open the flap, do the ostectomy
aroudn the crown. Bind the brace on the surface of the retention. Add wire of
elastic ligature around the brace (to pull) and then close with sutures around the
ligature. The only thing outside of the suture is the ligature to be able to pull the
 tooth.
can use partial neuman in buccal
(dont know what other types of flaps we can use - email to ask)
open approach: Make a flap or gingivectomy (depening on site of retention). Put a
brace with elastic ligature and allow the wound to heal as secondary intention.
The orthodontist will pull the tooth with the wound opened
periodontal attachment has more complications in the open approach
sometimes the flap doesnt go back to its oritignal position..
Chosen in cases of buccal position
apical advanced flap: 2 relieving incisions, one cut above the crown and put
flap towards apical.
never periradicular anchorage because will lead to many periodontal problems
(loss of attachment)

How to do surgical uprighting on a molar:

The second molar is completely blocked by the 3rd molar. We need to remove the 3rd
molar and then upright the second molar. They used to use braces back in the day for
this. Now we use mini screws or mini implants that are linked with the ligature to the brace
of the tilted molar. mini screws are also used to pull a retention and not only used just in
the arch. This is a new technique that is very advanced.

surgical orthodontic treatment:

Traction a canine and pull out with brackets: is one of the easiest. You know
ehere it is, open a flap, expose (~5mins). The harder part is putting the actual
button/bracket on the tooth because you need everything clean to put the acid
and the bond. IT is hard to get everything clean enough to put these materials
on to bond it properly.

healing by 1st intention: Putting the flap exactly where it was. not possible with
canine traction because we need to expose the canine to be included in the
brackets
healing by 2nd intention: use for canine traction.