- , -

.
, . ,
3-5 mm .
-
, a ,
.
:


()



,
:
( - ;
; .)


,


.
, .

(. 82):
o tuber maxillae
o foramina alveolaria
o rami alveolares superiores posteriores
:
o os zygomaticus
o crista zygomaticoalveolaris
o tuber maxillae

. 82. : tuber maxillae; foramina

alveolaria; rami alveolares superiores posteriors
109


- .

.
,
crista zygomaticoalveolaris (. 83):
o (, ., 1960; Hofer, 1969)
o (Fisher, G., 1955)
o - (, .,
1962; , ., 1969)
o (, ., 1953; , ., 1977)
o (, ., 1957)
, ,
. ,
. (
plexus venosus prerygoideus ),
:10 mm (Fisher, G., 1955);10-15 mm (, ., 1977); 20-25 mm
(, ., 1969); 25 mm (, ., 1959; , ., 1962); 25-30 mm (Hofer,
1969).
1.5 ml
7-8 (, .) 10-12 (, .),
,
ramus alveolaris superior mdius (Seldin,
1948).

. 83. -
-
ramus alveolaris superior mdius rami
alveolares superiores posteriors (. 84).

.
, .
1-1.5 m,
. .
1-2 , .
5-6
, 10-15 - , 15-20
- .

110

. 84. :

- .
:
, . ( 1962)
.
, :
o
,
.
(. 85). ,
, ,
.
2.0-2.5 cm.
o
,
.
. (. 85),
, ,
.
2.0-2.5 cm.

. 85.
. (1977)

, ,
111

 -
, 2-3 m.

(. 86).

. 86.
, . (1969)
,

. , ,
.


.

(rami
alveolares superiores anteriores), .
, , ,
, , (rami
palpebrales superiores,rami nasales externi, rami labiales superiores).
(. 87)
o foramen infraorbitalis
o fossa canina
o rami alveolares superiores anteriores

. 87. : foramen
infraorbitalis; fossa canina; rami alveolares superiores anteriores
112

:
o margo infraorbitalis
o foramen infraorbitalis
o fossa canina
- ;


:
,
,
.
, .
foramen infraorbitale margo
infraorbitalis 5mm . margo infraorbitalis
, sutura zygomaticomaxillaris, 5mm .

(foramen mentale).

( ).

, . (1962)

A .
( )

( 1.5-2 m) 0.5 ml .

7-10 mm, 0.5-1 ml (, C.; , M.;
, .; , .). , .
,
(. 88).
rami alveolares superiores anteriores,
rami alveolares superiores media
.

. 88.

-, . (1950)

A ( ).

, , ,
113

 - .

(. 89) ,
. 2 m (Jorgensen, ., 1983).

. 89. -
, . (1980) ,
,
. (, ., , ., , .)
,
. ,
,
(. 90).

. 90.

-
; .
:

.

. ,
, (. 91).
0.5 m .
.
114

 ( )
7-10 mm .
-, - -.
(
).

- , -
.
, - .
.

. 91.


. (. 92).

. 92.

n. incisivus n. palatuinus major

n. incisivus
papilla incisiva (. 93).
0.25.-0.5 ml .
.
.

115

. 93. n. incisivus

n. palatinus major. ,
,
,
1-1.5 m (. 94), -
.

. 94. n. palatinus major -

, (. 95).
,
processus palatinus maxillae lamina horisontalis os palatinum.

, - .

. 95. -
116


n. incisivus n. palatinus major (. 96).

. 96. E o n. incisivus n. palatinus major

.
:

()





( ).
,
, . , ,
.

1884 .
William Stewart Halsted n. mandibularis -
13 4% .
7 28 .
,
.

(. 97). (margo anterior
rami mandibulae) , linea
oblique. linea oblique crista temporalis fovea retromolaris. rista
temporalis, , ,
- crus medial crus laterale. trigonum retromolare.
, fovea retromolaris trigonum retromolare
.
117

 ,
, (foramen
mandibulae), (lingula mandibulae).
processus condylaris mandibulae
(crista colli mandibulae).
(sulcus colli mandibulae). ,
,
.
(Halsted-Braun ). processus condylaris mandibulae
processus muscularis mandibulae, incisura mandibulae
, torus mandibulae. n.
mandibularis (n. alveolaris inferior, lingualis buccalis) -
torus mandibulae, Gow-Gates
(sulcus colli mandibulae).

. 97.

Halsted, W. S., Braun, G. (1884-1905)
- foramen mandibulae
:
o trigonum retromolare
o lingula mandibulae
o ligamentum pterygomandibularae
:
fovea
retromolaris ( linea oblique crista temporalis).
,
, 1 m
plica pterygomandibularis (. 98).

. 98. Halsted-Braun
118

 0.5 m 0.5 .
n. lingualis. ,
,
.
1-2 m, . ,
lingula mandiblae foramen mandibulae.

. n. buccalis
.
foramen
mandibulae (. 99).

. 99. Halsted-Braun
Gow-Gates, G.A.F. (1973). .. .
:
o , m. pterygoideus lateralis
o sulcus coli mandibulae
. - .

(. 100).
.
o ( )
o
o

. 100. Gow-Gates

119

:

, plica pterygomandibularis
(. 101a). ,
, m. temporalis,
. ,

( ),
. (
25 mm) - . 1 mm,
, 1.8 ml .
1-2 ,
(. 101b).

. 101. Gow-Gates
.
25 mm , ,
. , (< 2%)
.
Akinosi, J.O. ( 1977)
.

, ,

o
o rysta temporalis m. temporalis
o
o rocessus muscularis (coronoideus) mandibulae

o , ,
o
:
,
( ,
).
.
rysta temporalis m. Temporalis (. 102).
(. 102b).

120

 , .
(. 102c)
().
rysta temporalis.
30 mm, .
. spatium
pterygomandibulare n. alveolaris inferior, n. lingualis, n. buccalis
.
4-6 2 1/2 5
(, ., , ., , ., 2002). n.
facialis , , .
1.65% .

. 102. Akinosi: ) ;
b) ; c)
:
; ;
; ,
:
;
; , .

o
Levit, B. (1924)

- foramen mandibulae
:
o plica pterygomandibularis
o
:
121

 plica
pterygomandibularis, 1 m
. , 2.5 m
1.5 . . n. alveolaris inferior.
, a 0.5 .
n. lingualis. n. buccalis
, .
1929 . Levit -
- (. 103),
1 m .
.

. 103. Levit
B, . . (1940)
,
lingula mandibulae, , torus mandibulae.
,
( processus condylaris processus coronoydeus
mandibulae).
.
- torus mandibulae (. 104)
:
o plica pterygomandibularis
o
o
:

. plica pterygomandibularis,
0.5 m (.
104b), - 1.5 m .
,
1.5 . . n. alveolaris inferior
bucallis.
n. lingualis.
n . mandibularis.

: 2 11 (), 5 7 (), 5 10 (
Berg), 10 15 (, ), 15 20 ().
30-40 .

122

. 104.

.
, . .
.
foramen mandibulae.
incisura mandibulae, ,
. , Klein B.,
Sicher, H. (1915), , . (1962), ,
22 mm, - 27 mm, 13 mm, - 15 mm (. 105).

. 105.

Berscher--

(Mayer, 1916; Berscher, 1922).
incisura mandibulae Berscher
,
. ,

.
- incisura mandibulae
:
o arcus zygomaticus
123

o tragus auricule
o processus condylaris mandibulae
:
,
o , , (.
106).
,
.
, , (.
106b).

. 106.

2 m ,
, (. 107), 2.0-2.5 m
(Bercher). 15
( n. alveolaris inferior).
, . (1947) 3.0-3.5 m,
m. pterygoideus lateralis.
,
( n. alveolaris inferior n. lingualis).
, . . (1929) 4.0-4.5
m foramen ovale
(n. alveolaris inferior, n. lingualis n. buccalis).
4.5 m
, m. pterygoideus lateralis,
a. meningea media.
.

. 107. --
124


Pehr Gadd (1913)
, a.
facialis m. masseter.
a. facialis ,
30 mm.
n. alveolaris inferior.
Klein, B., Sicher, H. (1915)
foramen
mandibulae 13 mm .
.

(. 108).
35-40 mm .
n. mandibularis.

. (1927)
.

. 108. Klein-Sicher
Berg (1940)
II, III, IV
, (. 109). 1.5 m

: 40 mm n. alveolaris inferior, 50
mm n. lingualis 60 mm n. buccalis.

. 109. Berg
125


Pekkert-Wustrow (1937)
processus mastoideus 1 m ,

2 m. lingula mandibulae,
.
- n. facialis, .

(1956)
.
. ,
.

.


-
. ,
- .
:
o ( 28 )
o / 28 - 12 )
o (1-7 .)
) (1-3 .)
) (4-7 .)
o (7-12 .)
o (12-18 .)
,

. 12-
. E
. ,
.
, , . .
. 7- -
.
:
o : > RR; ;

o
o

.
, ,
, , . ,
() .
.
126


,
. :
, ,
,
( ).
,
.
,
, .

(). 0.1
mg/kg. 4-6 . 2 mg , 30-40 min
. , 7-10 . 2-5 mg,
11-14 . - 4 mg, 15 . - 5 mg. ,
,
.

.

.
, ,
.
. ,
,
3-7- , .

.

. ,
,
.

-
-

- -
.
14-15- .

(Donohue, D. et al. 1993; Jastak, J.,
1995; , .. .,1997).

, :
, , .
. ,
- ,
.

127


( ,
, ).

foramen mandibulae .

, .
, ,
.
(150), - 105-110.
foramen mandibulae. 9 18 5 mm
. 3 1/2-4 1 mm
, 6-9 - 6 mm ,
12 - 10 mm (, .., ,
. ., 1989). 3.3 mm 4.5 mm (Fischer, G., 1938).
.
- ,
. -,
- .
15 mm, - .
. ,
10- (Maragakis, M.,
1987).
,
(-, 1989):
o 5 .
o 5 - 3-5 mm
, . (1975) :
o ( 7 .) -

o 7 12 . - 2-3 mm
o 12 . -
,
- -
.
.
,
.
, 6 12 . - , 12 . - .
, , -, .

. -
, - . 1969
. - .

- 5 mg/kg
30 kg = 150 mg
1 68 mg
150:68 = 2
()
= 5 mg/kg X kg.ml = 5 30 = 150 = 3.7 ml = 2
% X 10
128

4 10

40


Sanders, B. , ,
:
2 .
- 0.2 ml
3-4 .
- 0.25 ml
5-6 .
- 0.4 ml
7-9 .
- 0.5 ml
10-14 . - 0.75 ml
14 .
- 1.0 ml
, . (1988) 4-5-

.

,
:
-
-
-

-
, pH
,
,
:

, .
- .
.
- -.
10-15 , - 20-30 .
(, ., 1975)
(0.5-1%)
15-20 .
(, ,
, ,
, /
- .

(. 110), , .:
.
.
.
,
- .
- .
129

. 110.

(
, , )
,
, .

I.

- ,
.
, -
.
plexus
venosus pterygoideus (. 111a),
a.v. mandibularis, ,
, - a.a.,
v.v. infraorbitalis, angularis, facialis.
, ,
, , (. 111b)
.
. -
.

. .
(
).

o
3-5 .
o
10-15 .
.
o ,
.
130

 .
10-12 .
o
(, ) .
- , ,
-, . 5-7 .
o .

. 111. : )
plexus venosus pterygoideus; b)

o ,
.
o - ,
.
, .
.

.
-
.
(
). (. 112),
- .

, .
.

. 112. : ) ; b)

131

 n. facialis

, .
,
.
n. facialis
, (,
) .
n. facialis
,
(. 113).
ramus marginalis mandibulae
.

. 113. n. facials
.
rami zygomatici
, , , .

.

,
, ,
.
--.
chorda tympani
( n.
facialis n. trigeminus).
n. auriculotemporalis
, , ( n. Facialis).

o


( 1 1/2-2 ). ,
.
o

132

. ,
(Dibasolum tab. 0.02 g - 2x1; Nivalin tab. 0.005
g - ; Acidum glutaminicum tab. 0.5 g - 2x1)
(, , ).
. .

n. trigeminus

n. trigeminus
( )
,
.
, ,
,
.


n. linqualis n. alveolaris inferior. .
,
(, .)
(, ..).
, , (Fisher, G.).

, , , ,
.
n. alveolaris inferior
, .
,
,
.
.
, .

o 2-3
.
( ).
o , ,
(Chlorazin tab. 0.025 g ) (Promedol tab. 0.025g ,2 x
.), (Allergosan dr 0.025g , 2, 3 x 1; Tavegyl dr 0.001
g, 2 x 1). - . 1, 2, 12,
.
o ,
(, , . 1).
.

o .
o .

.
, -
m. pterygoideus medialis.
133

, , ,
.
- - , m. temporalis
(, ..).

.
(
) (
). ,
.
(, ,
.) (. 114).

o , (),
.
o
(, ) 3-4 ,
5- ,
, .
o , . . -
, ,
.
5-6 .

o
o ,
o
o

. 114. : ) ; b)
-

,
( ,
, , , ,
, , , ).

134


(. 113) .
, ,
.
- .
, , 5-8
.
.

, . , ,
.

.

.
.

o ,
.
0.25-0.5% (
) 5-6
.
o
, 0.5% .
o .
o ,
,
. Haemodex 500 l,
0.9% NaCl 500-1000ml i.v/24 h.

o .
o .
o - (1 10-15
ml ).
o , .

- .

(. 115).

o , .
o , .
,
.
o :

135


,
.

o , .
o 5-6 m - 2 m
, . . .
o ,
.

. 115.

.
.
.
.

o .

(. 205)
.
o
.
.

o .

, .


.

- , ,
,
.

, (Kloh, R.).
136

 ,
.
( ).

o .
48 ,
5-7 .
o
- , ,
, .
(Diazepam)
.

. -
(. 116).

. 116.

o
o
. .
.

, ,

.
.
, -
(Rood, I.).

canalis infraorbitalis .
( ).

, .

o , .
.
137

,
,
( ,
).
.

.
, , .

o - ,
, .
(, KJ).

o .
o .
o .
o ,
.

II.
O
(syncope)
. ,
.
.
( ),
- (
, ), , , ,
( ),
, .
.
. ,
- :
, , ;
, , ,
; ;
. -
, , ,
, , , .
, .
- 20-40 s, 30 s ( 5 min).

( ,
).
. , 3545/min, 80/40 60/30 mmHg.
138

. .
. -, -
( 10). - . - , , - .
.

10

.
-

-

- s..,i.m.
- 2
- i.m.,i.v.
-

. :
1.
- , -
(. 117).
( ), .

. 117.
2. -
. - ,
, .
3. - .
.
,
- .
139

 4. , ,
( 5-7cm).
5. , .
( 55 )
i.v. i.m. (Atropini sulfas, amp.0.1% 1 ml - 0.4-0.6 ml ).
10 min.

( ,
, ).
, 30 s,
, - i.v. Coffein natrio-benzoicum (apm.10%1
ml), Effortil (amp. 10mg 1 ml, Vasoton (amp. 6% 1ml), Mephin (amp. 15mg 1 ml).

(COLLAPSUS)
. ,
( ).
,
.
.
, .
(
). . ,
. .
, , . .
350 . .
. .
, e ,
. ,
,
.
. (, )
, .
:
1.
, -
(. 117).
( ), .
2. -
. - ,
, .
3. - .
.
,
- .
! . -
.
4. O ,
. i.v. 50-100 ml 40% Glucosa . , 1, 6,
140

 (0.9% NaCl,
Haemodex, Serum Glucosae).
Mephin (1-2 amp. i.v.), Coffein natrio-benzoicum (1-2 amp. s.c.), Effortil (5-10 mg i.v.),
Dopamin (50 mg 250ml i.v. - - 18 /min.).
5. ,
() -,
.
6. ,
, ( 3)
. , i.v. i.m. 0.4-0.6 ml
Atropini sulfas. 10 min.
7. , -
,
:
A (airway open) -
B (breathing) -
C (circulation) - ( )
1. .
:
( , )
(, )

Esmarch (. 118)
2. O
(
)
, .

. 118.

,
().
- ,
, .
(. 119) .
.
, .
.
5 s (12 ). ,
141

 - 1 .
15-17% ,
. 1 12/min, 12
l/min, . . 150%

. 119. :
) ( );
) ( )
3.
( a.carotis a. femoralis) -
12/min. ,
(Isoprenalin amp. 0.5 mg 1 ml - s.c.,i.m.,i.v.). 1 ml
1:5000 (0.02 mg) 0.5 10 ml
(0.01-0.2 mg).
,

(. 118).
o , . , .
o ,

.
o ,
4-6 cm. ,
,
(0.5 ).
60-80-100 ,

.

, , .
, 1-2 , 12-15
. ,
, 1-2 , 5
.
:
- - .
, , .
(, ), .
142

RR 60-70 mmHg .
.
,

.
1 min, - 5 s,
2-3 min. (,
).
,
(- 30 min).
8. .

A
IgE
, - 1% (Gall,H., Kaufmann, R.,
Calveram, C. M., 1996, Malanin, K., Kalimo, K., 2005).

.
,
. ,
, .
(DeSwarte, R. D.,
1980).
.
, , , ,
. .

1. ()
.
, .
2. : Allergosan
amp. 1% 2 ml (i.m., i.v.); Sandosten calcium amp. 10 ml.(i.v.); Dimedrolum tab. 0.05g;
Tavegyl tab. 0.001 g.
3.
(Urbason, Sopolcort )
.

. .
.
, ,
, ,
.
. ,
, .
, ,
.
, ().
. .
- (-), 10 cm .
143

 - ,
, (38-390 ), ,
.
. (, , )
:
1. ()
.
, .
2. s.c., i.m i.v. 0.3 ml 1:1000
0.3 ml 5 min, .
3. : Allergosan amp. 1% 2 ml
(i.m., i.v.); Sandosten calcium amp. 10 ml (i.v.); Dimedrolum tab. 0.05 g; Tavegyl tab. 0.001
g.
4. 1 .
5.
(Urbason, Sopolcort ),
.
(, , ,
):

i.v., i/m.
6

(edema Quincke)
. .
, , ,
. , ,
.
. Quincke 1882 .
,
. , - , ,
, , , . (. 120)
10-14 . .
.
, , ,
. .
, , -
.

. 120.
144

 .
lymphangioma Merkelson-RosenthalSchuermann.
, . - , .
--
, , , ,
. n. facialis ,
, . 10-14
, , , .

1. .
2. (0.1% 0.10.5 ml)
3. (
, , ) i.v i.m. 0.3 ml
1:1000, (i.v. Sopolcort H, Methylprednisolon
20 ml 40% Glucosa).
4. ( ).
5. .
5.

.

( )
. -
( , , ,
) .
, ,
-.
. -
, . . ,
, , .
20 , -
, , , .
, ,

.
.
30 min .
- .
: ;
, , , ; ,
, . ,
, , , , .
,
- .
, ,
.



145

,
, , . -
, -
. -
3- 10- (, . ., , . ., , . .,
1984). ,

( 30-40 min.).
. - .
- , .

(, ), -
( , ).
, - .
.

(). :
( ) , , , .
, . ,
. - .

, ,
,

,
,

( )
( )
( )
( )
. ,
, (, . ., , . .,
1976; Blanca M. et al., 1997). ,
, , 3%
.
1.
(. 116 )
.
2. -
. 0.3-0.5 ml
. (0.5 ml 10-50 ml
0.9% NaCl.) i.v. ( ) i.m., -
.
.
146

 3. (RR, , ).
.
.
4. 2 ml 10% Coffein natrio-benzoicum
.
5.
(. 121) 0.9% NaCl.

. 121. e
, , (
) i.v. - 0.5 ml 0.1% ,
10-20 ml 40% Glucosa .
i.v.-gutta ( 250 ml 5% Glucosa 2 ml 0.1% ).
.
,
. Urbason (1-3 mg/kg) Sopolcort H (510mg/kg) - i.v. i.v. gutta 500 ml .

(-
)
, , , B, 60/min, :
0.5 mg - 1 mg i.v. (max. 2 mg) 2-10 mkg/min 1-10 mg i.v.
, .
6.
Salbutamol - i.v. (5 mg 500 ml 5% glucosa),
(5 gutta 5 ml 0.9% NaCl 15 min).
7. 1-2 ml Droperidol (2.5 mg).
8.
, - , ..
( ).
9.
.
- .

147



K

,
. (,
) .
.
:
,
, .
.

( ),
().
.
()
. ,

(Altenburger, K., 1984; Neugut A .I. et al., 2001):
- - 7-14

,
()
( )
- , -
() -,
()
, ,
2-3
-
:
Patch test ( ) -
. ,
( 700 )
2.5-3cm
. , , .
Scratch test ( ) -
. -
,
700 2-4 cm
, 0.1% .
, 5 mm 3 mm,
.
.
20 min 24 h .
,

148

 .
:
+ ,
+ , 2-3 mm
++ 5mm
+++ 10 mm
++++ 10 mm ,
Prick test ( ) -
1 mm ( ), .
,
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, ., . (1996)
:

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151

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153

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, .
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: Acetysal, Analgin, Ibuprofen,
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-2
o Meloxicam
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163

COX-2
Celecoxib (Celebrex)
Valdecoxib (Bextra)
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,
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Paracetamol
Aspirin
Ibuprofen
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Ibuprofen 2-12 .
12 .
Nimesulide(Enetra, Aulin)
12 .

(mg)

500-1,000
325-1,000
400
25-50
75
100
50

46 h
46 h
46 h
68 h
12-24 h
12 h

10-15 mg/kg
10 mg/kg
200-400 mg

46 h
6-8 h
4h

100

12 h

11
(mg)

4,000
4,000
2,400
300
150
400
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o Tinctura opii simplex
o Omnopon
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o Codeini phosphas
o Dionin

o Lydol (Pethidinum)
o Dipidolor (Piritramid)
o Fentanyl (Fentanyli citras)
o Lexir (Fortral)
o Valoron (Tilidini hydrochloridum)
o Probon (Rimazolii methylsulfas)

Codeini
Acetaminophen

Codeine
acetaminophen

(mg)

3060

0.51 mg/kg

12
(mg)

46 h

200

46 h

3 mg/kg

(Haas, D.A.,2002):
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165

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Fentanyl.
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.
.
, ,
, .

, ,
.
: Xanax (Alprazolam); Rivotril (Clonazepam); Valium (Diazepam); Lexotan
(Bromazepam); Dormicum (Midazolam); Radedorm (Nitrazepam); Rudotel (Medazepam);
Tranquilan; Tempidon; Lonetil.
:
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, ., , . .,, .., , , 1991, 309-19.
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. , ., Quintessence BG ,Sofia, 1994, 200-208. 1., ., , .
, . - , , .,
, . , . , 1996.
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anesthesia, Anesth. Prog., 39, 1992, 87-89.
72. Waldhausen, E. Anaphylactic shock, Anaesthesist, 47, 1998, 10, 884-6.
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168

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225


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Antilpasmin 2

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Factor IV - Calcium
Factor V - Accelerator globulin
Factor VI -
Factor VII - Proconvertin,Co-thromboplastin
Factor VIII - Antihaemophilen factor;vonWilebrand factor
Factor IX - Plasma thromboplastin component (PTC; Christmans factor)
Factor X - Stewart-Power fctor
Factor XI- Plasma thromboplastin antecedent (PTA)
Factor XII - Hageman factor
Factor XIII - Fibrin stab. Factor
Fitzgerald Factor -
Fletcher Factor -
:
1.
2.
3.

226

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1 10 mg/kg 20 ml serum 20 ).
1.0 g 5 . 20 mg/kg (Kasper, 2000). - ,
6 ; .
, .
Franchini, et al. (2005)
1 F VIII IX ,
30% . , 50%
! : 1.0 g Tranexamiuc acid
4 7 ; 4 ( 2 ) 7 10 l
5% Tranexamiuc acid; ;
; 50% ; , 6 ; .

.
.
,
, .. .
. Filho, A.M.B., et al.
(2006) Beriplast P (Aventis Berhring Gmb, Marburg,
Germany), 2 : 1 Aprotinin, Fibrinogen F VIII; 2
CaCl trombin.

, F VIII. , ,

. Aprotinin ,
. .
, -
AHG 7-10 ,
.

o von Wilebrand
,
, von Wilebrand factor (vWF).
F VIII
. :
o F VIII
o
:
1 - vWF ( ),
, FVIII
228

 2 - vWF ( ,
FVIII ,
, FVIII .

, FVIII vWF.
() tranexamic acid .
20 mg/kg 8 ,
, (Protet at al.,
2002).

o - Factor IX
- (1/300 000).
, -, .
Factor IX, .
- Factor IX. 2 .

.
F IX (60U/kg),
10 (Djulbegovic, B., 1994).
Factor IX , ..
- . - (II, VII, IX, X
S). trtanexamic aciud
.
o Factor XI - (1/1000 000),..

FXI ( < 20-30% )
. - (FFP).
Factor XI 72 .

o

. .
.
,
.
.

. - . 2 .
o Factor XIII ( )
< 1.2% , .
, .
. .

, .
- 5-10% Factor XIII .
Factor XIII 2 , .. ,
.

o 2
.
, ,
( ,
. -
(Nakahara&Koyanen, 2003).
229

 , ,
.
3.3.2. ( )
, .
: Rendu-Osler,
Ehlers-Danlos, von Willebrand ( )
, .
3.3.4. ( )
(/
.
140T/l , 440T/l .
, Glanzmann,
.
-
.
- , , , ,
. .
.

.
.
50 000/mm
. 20 000/mm - 50 000/mm,
,
. ,
50 000/mm,
. 20 000/mm

. ,

,
.

, .
:
o , , ,
, , , .
o .
o ,
,
.
o 2 .
o ,
.
o .
o 50T/l .

3.3.5. ,
:

230

- (Heparin Natrium, Heparin Calcium,

Fraxiparin)
- (Syncumar, Sinthrom, Pelentan, Warfarin)

- .
(XII, XI, X), V
. (
),
. ,
(V, VIII, XIII).
i.v. (Na heparinat) s.c. (Ca Heparinat)
. .
( 2-6
2-3 ). 6 (
) 24 ( ) .
, ,
, . , ,
,
.
(Fraxiparin)
.
,
.
( )
(Protamini sulfas amp. 1% 5 ml, 10ml; amp. forte 0.25g 5 ml). 10
min ( ) i.v. 1 ml, 5 ml .
- .
(II, VII, IX, X).
(Pelentan), (Syncumar)
(Sinthrom). Warfarin.
INR.
. 1 (Kanavit) - amp. 1% 1 ml. i.v. .

( 15).

.
(Campbell, J., et al, 2000;
Glasse, S. P., 1997),
(Patton, L.L., Ship, J.A., 1994; Robert, H. L., 1996),
(Merha. P., et al., 2000)
, .

, (Harish, J., 1995) ( 15).
, ,
, ().
2-3- ,
. INR 2.0
, .
2-3 .
INR 2.0 3.0,
( ). INR
3.0, , 3.0.
231

 INR 1.6-1.9,
.
.
(Hupp, J.R ., 2008).

15

INR
/
2.0-3.0

2.0-3.0

2.0-3.0

2.0-3.0

2.0-3.0

2.0-3.0

2.0-3.0

2.0-3.0
( )
2.5-3.5


. JohnsonLeong, Ch., Rada, R.E. (2002) s.c.
enoxaparin 3 .
(INR 1.1). . 3
.

:
(INR)
, (.
)
,

, ,
,
, , ,
.
,
. ( )

,
.
, ,
.
, ,
(Barrero, M.V., 2002):
, - 5 (91.7%)
, 5 (7.9%)
, (0.4%)

3.3.6. ,

232

Acidum acetylsalicylicum (Acetysal, Aspirin)

Dipyridamole (Antistenocardin)
Clopidogrel (Plavix)
-
( )
( ,
), , ,
,
( 16).

().
, , e
.
. ,
, 3-7 ( 5 )
.
, - 24 .

-,

16

Clopidogrel Aspirin - 12
Aspirin; Clopidogrel; Aspirin
Dipyridamole
Clopidogrel ( Aspirin)

Clopidogrel
7 . , 5-7 .
- ,
, 7 . 5
.

4.

(Diabetes mellitus)

,
.
, .
(WHO, 1980) : - I,
- II ( ; ;
). (Slavkin, H.C., 1997)
- . ,
.
- II .
(IDF)
245 ,
3,8 .
.
,
.
.
,
( ).
233

 , .

.

, .
,
.
,
, ,
. ,
.
, .

, .
,
.

:
o - . 10 mmol/l
. .
o .
o .
( ), - - 1-1.30
( ).
.
o .
o .
.
.
.
(1:50 000) .
o , , , , .
o .
o , (
).
( , ).
o .
- .
.
o . ,
, . ,
, ,
.

.

,
. ,
, , , , ,
, , , ,
, .

234


, , ,
, , ,
, ,
. : , ,
, , , .
.

.
, ,
. ,
,
.
, .
:



.
,
(
)

( ). (
) ,
. -
.
.

, , ,
, , , , , ,
. ,
.

()
. : ,
, , . -
( ).
, , ,
.

, , -
.
,

. ( )

(). .
( ) (Hupp,
J.R., 2008):

()
235

, ,
,


, - 20
mg ( ) 2
, :
()
,
60 mg ( )
( i.v. i.m. 60 mg
)
40 mg prer os
20 mg, 6-

5.

,
- , , . -
- .
o .
o ,
.
o - 3
.

,
. ,
. :
; ()
; .
:
o
o
o 2
5-7
()
,
, .
, ( 50%)
. - ,
, , (,
, ), , .
4 ,
- , - .

, : , ,
.
,
:

236

:
,

(IV
).
, , , , (
, , ,
.).
:
o
o (-
), (
)
o
o
o
o ,
o 2 - 5-7
o ()
o

,
.
.
.

(Hupp, J.R., 2008):
,

6.
, ,
.
, . ,
, .

6 .
:


1

237

7.
- (HEPATITIS)
(/; )
(, , ).
Hepatitis A - A (HAV),
Picornaviridae. - ().
6 . .
, : , , , ,
, / .
: o
IgM HAV Ig G HAV.
( ,
,
(Gillcrist, J., 1999). : Harvix (Smith Kline
Beecham) Vaqta (Merck).
Hepatitis B - (HBV).
, , .
, HBsAg
. (3-4 ,
).
. ,
,
. 90% HBV
, 5-10% ,
.
: - HBV DNA, HBsAg .
- Engerix B (Merck) Recombibax (GlaxoSmith Kline).
3 6- .
Twinrix.
Hepatitis C - HCV . :
, , ,
. , , .
. .
, / .
.
.
, .
40 . 85%
. -
.
Hepatitis D - HDV .
. ,
, , . :
HDV.
Hepatitis E - HEV . - (). : , , /

238

. .
.
Hepatitis G - HGV . .
, , .
- HCV.

.
. - :
.
:
.
- (6 1 ),
(). .
, .
.
-
, , , /
. .
.
: , , , , ,
, , , .
.
(. 17).
.
.

, .
PT, PTT, INR, ,
( 17). ,
.
,
- .

17



o (Er, Lev., Tr., Hg, Haematokrit)
o
o
o INR
o
o
,
/ .
o (, , )
o
()
()
o (, )
239

o ()
o ( , )
.
-
.
(, ) ()
.
, , ,
, ,
, (, , ).

. -
. ,

.
,
, .

8. ,
, ,
,
( ).
,
Glick:
o , 30 ,

.
o , , 30 ,
.
o , ,
, ,
.
.
o , , - 10 mg
Prednisolon (8 mg Medrol),
.
,
.
, , , ,
, , , , ,
.

9.
,
, ,
.
- 1
.
.
7-10
.

240

10.
, ,
,
. -
, , ,
.
,
, .
( ), .

, , .
,
.
(Bamber, J. H., Dresner, M.,
2003):
,
.
, -
, .
5-
( ).
( ).
.
( ).
(. . 1:200 000).
(Hupp, J.R,
Duddleston, D. N., 2004):
o ( , )
o Carbamazepine
o Chloral hydrate ( )
o Chlordiazepoxide
o Corticosteroides
o Diazepam
o Diphenhydramine hydrochloride ( )
o ( - 50%)
o Morphine
o Phenobarbital
o Tetracyclines ( )
o Promethazine hydrochloride
,
, , .
, .
,
(Hupp, J. R., 2008):

241



Acetaminophen; Antihistamines
Cephalexin; Codeine
Erythromycin; Fluoride
Lidocaine; Meperidine
Oxacillin; Pentazocine

Ampicillin; Aspirin
Atropine; Barbiturates
Chloral hydrate; Corticosteroides
Diazepam; Metronidazole
Penicillin; Propoxyphene
Tetracyclines

- .
( ;
;
) ( ; )
, -
, ,
( , ,
).

o ,
, .
o .
, ,
,
- - (, .).

, ,
(, )
.

o
o

-
.
.

o
, .

-
, .

242

o .
.

.
.

o (
),
. .

, .
,
, , , .
- .

.

o , ,
,
.
o
.
o
.

()

,
.

.

.
.

o ()
-
. ,

.

, ,
. .

.
.

o
(, , ) .
o
-
243

 .
.

.

.
,
. ,
.

o .

, - .
, (, ,
, ).
,
, , .

o
.

.

(Perforatio

sinus

maxillaris)
. /
. :
o - (. . sinus
procedans) .
,
.
o - ,
, , , .
o -
.
. :
;
;
; ; (Walsalva) ;
;
.
, ,
(, ) .
. .

. :
Walsalva -
( ) (. 198a)
;
(. 198b); -
244

 ,

.

. 198. :
) Walsalva; b)
,
.
.

(, , , , ),
.
.

( ).
. :
) .
; ,
;
, .
) , .
, ,
. ,
.
.
.
,

.

.
.
) ( ) -

. Zange,

,
.
) (
,
245

 ) - Rehermann
Pichler. ,
.
Rehermann, A. -
.
.

,
1-2 cm.
- (. 199).

. 199. Rehermann:
)
; b)
Pichler, H. -

.
, ,
.
, -
(. 200).
, .
(. 200).

. 200. Pichler:
) ; b) ,

246


Amoxicillin, Amoxiklav, Augmentin), (Aulin, Enetra, Paracetamol) 5-7 . 7- ,

. 1-2
.


.
.

.


. Coldwell-Luc
, - .
() (. 201)
,
. ,
. ,
(fossa canina) .
. .

.

. 201. - 16

, ,
.
.

o ,
.
.
o
,
.
.
247

 ()

,
- ,
( ).

()

. .
(. 202).

. 202.

, 3-5 . -
:
o - ,
o
o (. ),

o
o ()
o
o (, ,
v.Wilebrand, )

248

.
a. palatina acessoria.
()
( , , ).
.
(
) , , ,
, .
,
,
.
, ,

.

 , a. carotis
externa - .

.
,
: (syncope);
(collapsus); ; ; ;
; ; (insultus cerebri);
; .
:

()
()
,
, ,
-
.
. :
o
o (20%)
o
o , (35-50%)
o (, , )
o - (15%)
o - , (1%)
o - , (5%)
o -
o (15-30%)
. .
, , ,
, , . , ( Kussmaul).
- (120-200/min),
, .
, ,
. ,
. . , ,
, ( bulbi).
. ,
:
o 15 50 mmol/l
o - 7.3
o , , -
o
o -
o 3-27mmol/l (+/ ++++)
o 310-380 mosm/kg
o - 15 mmol/l

249

 .
( 19 )
(), , ,
( 18).
:

-

, ,

, ,

, ,

(,
Kussmaul)
,

18

+++

+++

+++

+/-

+++

++

.
:
1. ( )
.
2.
.
3.
.
(0.9% NaCl).
4.
(1/2 i.v. 1/2 i.m.). Insulin
Alt , .
20-30 ,
- . 30 min s.c.
- ( 30 min).
, , , t 0
-
.
2-20% (, .,
, .., 1991).

250


- Whipple:
o - 2.5 mmol/l
o
o
.
2-3 mmol/l, - 4-5 mmol/l.
:
o
o
o
o
o ( )
. -
(, , , ),
- (, , ,
, , ).
. .
:
( ):
, ,
, ,

, ,
( ):

(),

:
o
o ,
( )
o ,
o , RR
o
o -
.
( , ,
).
!
: ,
- 8 mmol/l; - 15 mmol/l ( ,
), 4-6 h
.

.
.
( 19) i.v. - 20%
251

Glucosa. , ,
.

19

,
,

+++
+ /-/

+++
+/-/

, : - , , ,
(, ., , . ., 1991).
. , ,
:
1. , 15 g (3 ) 150 ml ( ).
2. (), i.v. 16 g
(40 ml 40%) Glucosa. ( ),
i.m, s.c., 10 .
3. , i.v 30 ml 40%
Glucosa. , .
4.
, .

.
, , , (
, ),
. ,
.
. , , .
.
, .

.
252

.
5 ,
.
1.
.
2.
, ,
.
3. ,

( ).
4. :

Heimlich - 6-10
, (
) (. 203).
- . .
, .
, .
.
a .

. 203. Heimlich
5. , .

ligamentum intercricothyreoideum, .
900,
.
, (. 204)
10-12 (. 204b)
.
, .
6.
-
. ,
.
253

. 204. :
a) ; b)

- ,
, , , (Matocha, D., 2000).

e .
() ().
( 75%
) (25%) - Sakarnoto, E., et al., 1975.
. -
, ,
(. ), .
- ,
(4:1), .
.
.
, :
o (, v.Wilebrand)
o /
o ( - )
o
o
o

.

, .
,
. .
, .
254

 , , .
, , .
.
- (a. lingualis, a. facialis, a. Maxillaris)

.
,
, .
,
.
,
. ,
, .
, ,
(EAC) 4-- - Tranexamic acid
(yklokapron; Transamin) .

(Dolor posr extractionem)

.
,
, .
, , ,
.
, - -
, .
.
.

,
.
o
. -
.
(,
) , (,
). , ,
.
. - ,
, , ,
. ,
, .
. 24
5 .
o

.

,
.

(Alveolitis postextractionem)

.
255

- ,
Alveolitis postextractionem, (dry socket).
Crawford, J.I. 1986 .
: alveolar osteitis (AO), localized osteitis,
postoperative alveolitis, alveolalgia, alveolitis sicca dolorosa, septic socket, necrotic socket,
localized osteomyelitis, and fibrinolytic alveolitis (Blum, I. R., 2002).
-
, ,
0.24-28% (, ., 1980; , ., 1994).
3-4% 145% (Barclay, J.., 1987;
Fridrich, K. L; Flson, R.A.J., 1990).
.
( - 63.6%, - 27.3%,
- 9.1%/) (Krekmanov, L., Hallander, H., 1980; , . ., , . .,
, . , 1991; Adeyemo, W.Z., Ladeinde, A.L.K., Ogunlewe, M.O., 2007),
:
-

( , )

(
, , , , , )

( , ,
).

( )

: - (31.69%),
(20.76%), (18.24%), (12.34%),
, ,
(
)
,
, 2-3 2-3
,
(, , )



.

(, ., 1982):
Alveolitis acuta ( ):
Alveolitis acuta simplex ( )
Alveolitis acuta purulenta ( )
Alveolitis subacuta ( )
Alveolitis chronica ( )
Alveolitis chronica simplex ( )
Alveolitis chronica hyperplastica ( )
256

Alveolitis chronica exacerbata ( )

. 2-3
(, .,
, ., , ., 1980).
, , ,
, .
, - , ,
, , , , ,
( ). ,
.
,
. (dry
socket), - ,
. ,
. ,
. , , .
,
380 . , .
. ,
, .
,
.
,
37.2-37.30 . ,
, .
.
.
.
,
( - . 205)
, ,
( ).

, -
(. 205b).

. 205. Alveolitis chronica: a) simplex; b) exacerbata

257

. (
2-3 )
( ,
, ; , ,
, ,
).
.
, ,
. ,
()
, (3% , ,
0.5% ) :
:
- (chlorphenolcamphor-tripaflavin)

(Anesthesin)
(Indecstol)

:
( Acetysal, Grisaldon)

(Alvogyl)
c (Solcoseryl)
, 30-50% ,
, (Clindamycin, )
- (100-200 Vt/2, 3-5 min, 2-3
)
-
(.
206).

. 206. (alveolitis sicca): )

; b)

.
.
(
, ).
258


, 50-70%
.
, , - .

. -

. ,
( 7-10 ).
2-4 .
.

(Trismus)

,
.
, (lock-jaw).

,
(, , ).
. :
, , , , , ,
(, ), (, .
, ), (
, ).
- m.
pterygoideus medialis ,
.
.
- 3-4 mm.
, ,
.
.
. (. )

.
. three finger test,

(. 8).
.
. ( ,
), (, , ),
. , ,
- ().
()
:
o
o
o
o
o (
)

259


().
( ).
(
)
:
1. , . . , .,
, 72, 1993, 3, 71-2.
2. , . ., , . ., , . . ,
., , 67, 1988, 2, 27-9.
3. , . . , . .,,1991.
4. , . . , ., , 73, 1994, 3, 83-4.
5. , ., , . , .,
, 1980, 6, 417-9.
6.,.. , ., , 1971.
7. , ., , ., , . ,
., .,1980, 5, 32-34.
8. , . / /, .
., , 1980.
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multiple supernumerary teeth: a retrospective study. Dentomaxillofac Radiol. 35, 2006, 3, 185-90.
10. Asanami, S., Kasazaki, Y. Expert third molar extractions, Quintessence Publ. Co. Inc., Chicago,
1993.
11. Chaparro-Anvendano, A. et al. Morbidity of third molar extraction in patient between 12 and 18
years of age, Med. Oral. Pathol. Oral Cir. Bucal, 10, 2005, 422-431.
12. Castro, D. R. et al. Multiple supernumerary teeth in non-syndrome patients.Report of 5 clinical
cases. Braz. J. Oral Sci, 6, 2007, 22, 1415-1419.
13. Chu, F. C. S. et al. Prevalence of impacted teeth and associated pathologies - a radiographic study
of Hong Kong Chinese population, Hong Kong Med. J., 9, 2003, 158-163.
14. de Carvalho, P. S., Mariano, R. C., Okamoto, T. Treatment of fibrinolytic alveolitis with rifamycin B
diethylamide associated with gelfoam: a histological study, Braz. Dent. J., 8, 1997, 1, 3-8.

15. Fernandez-Montenegro, P. et al. Retrospective study of 145 supernumerary teeth. Med. Oral Patho.l
Oral Cir. Biol., 11, 2006, E 339-344.
16. Filho, A. M, B. et al. Oral surgery with fibrin selant in patients with bleeding disorders: Acase
report, J. Cont. Dent. Pract.,7, 2006, 1-5.
17. Garvey, M. T., Barry, H .J., Blake, M. Supernumerary teeth - An overview of classification,
Diagnosis and Management. J. Can. Dent. Assoc., 65, 1999, 612-6.
18. Gndz, K., Muglali, M. Non-syndrome multiple supernumerary teeth: A case report, J. Contem.
Dent. Pract., 8, 2004, 4, 81-87.
19. Hall, A., Onn, A. The development of supernumerary teeth in the mandible in cases with a history
of supernumeraries in the pre-maxillary region, J. Orthodont., 33, 2006, 250-255.
20. Krekmanov, L. Alveolitis after operative removal of third molars in the mandible, Int.J. Oral Surg.,
10, 1981, 3, 173-9.
21. Mettes, T. G. et al. Interventions for treating asymptomatic impacted wisdom teeth in adolescents
and adults, Australian Dent. J., 60, 2005, 3, 207-8.
20.Pell ,G. J., Gregory, G. T. Report on a ten-years study of a tooth division technique for the removal
of impacted teeth, Amer. J. Orthod. Oral Surg., 26, 1942, 6, 660-6.
21. Peterson ,L. J. Rationale for removing impacted teeth: when to extract or not to extract, J. Am.
Dent.Assoc., 123, 1992, 7, 198-204.
22. Pototski, M., Amenabar, J. M. Dental management of patients receiving anticoagulation or
antiplatelet treatment, J. Oral Sci., 49, 2007, 4, 253-8.
23. Rajab, L. D., Hamdan, M. A. Supernumerary teeth: review of the literature and a survey of 152
cases, Int. J. Paediatr. Dent., 12, 2002, 4, 244-54.
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prevention, J. Can. Dent. Assoc., 66, 2000, 497-501
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41, 1996, 3, 169-172.
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the upper and lower jaws, Australian Dent. J., 40, 1995, 4, 233-235.

, ,
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:
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4.

261

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. ,
(American
Association of Oral and Maxillofacial Surgery, 1998).
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3 - 18 32% (Andreasen, J.O., et al.,
1997; Kim, T.W., et al., 2003). 5.4% (92%
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. Archer,W.H. (1966)
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(1926), Pell, G.J., Gregory, G.T. (1933,1942); Archer,W.H.
(1975); Kruger, E. (1984) (. 181,182).
1993 . -
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208). (retinens)
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263

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, cleidocranialna dysplasia,
Gardner, Ehlers-Danlos, Fabry-Anderson, Down,
Hallermann Streiff, Elis van Grevelt, Crouzon.

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264

. 210.
, (adentia; anodontia)
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o
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1%
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(2002) 23% ,
0.5%.

265

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e 23%
(Lopes, V., et al., 1995).
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80% (Sasano, T., et al., 2003).
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Guven, ., et al. (2000) 0.79% , 0.77%
0.025% - .
.
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13.6% , - 35
(Batianeh, .., et al., 2002).
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266


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()
(National Institute of Health, 1979; Van der Linden, W., et al., 1993; Lytle,
J.J., 1993; Meisami, T., et al., 2002):
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267

o
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(Mercier, P., Precious, D., 1992):
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.
(Lytle, J.J., 1993; Van der
Linden, W., et al., 1993, Fuselier, J.C., et al., 2002).
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Song, F., et al., 2000, Pasqualini, D., et al., 2002).
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, (
).

(DENTITIO DIFFICILIS)

() ,
.
,
.
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. 55% 80%
(Knutsson, ., et al., 1996; Sasano, ., et al.,2003).
.
- .
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, (, A., 1966;
Gnass, C., et al.,1993; Hattab, F.N., et al., 1999).

,
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50-58 mm, 46 mm.

268

 , 70-
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) 29 mm,
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PELL-GREGORY
20.

- :

Clas II



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las I

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-

1.
2..
3..
4..
5..
6.
7.

269

.
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(. 216), .
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( 380 , , ).

270

. 216. Paracoronitis regionis 38

,
(. 217).

. 217. Paracoronitis 38 -

.
.
:
Pericoronitis Paracoronitis
,
.
,
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.
Paracoronitis Abscessus pterygomandibularis Abscessus sulci
mandibulolingualis

.
.
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.

271

 , ,
.
.
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)
. :
.
(3% ; 1:1000 ; 1:5000
Hibitan ( ) .
(, ) .
- Clas I,
Pell-Gregory.
- . ,
, (incisio)
(circumcisio).
,
(. 218a).
.
(7-10
).
,
(. 218b).
. Clas II,
Pell-Gregory,
( 18-25 ).

. 218. -
: a) incisio; b) circucisio
.
.
.
, ()
.
.
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Class II III Pell-Gregory, ..,
, ,
272

 .
, -
Pichler-Trauner-Thoma ( ).

Ward, T.G. (1956).
- , - ,
.

( ,
) .

()
:
o
.
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.

:
(heterotopia)
.
, - (. 219).
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,
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. 219. : ) ; b) e
o
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,
.
(heterotopia). (.
220).

273

. 220. 43 42
(ectopia). .
o
.
.
, ,
, .
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, .
(. 221).

. 221.
o

. (. 222) ( ).
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). (. 222b).
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,
.

274

. 222. : ) ;b)
o ()
,
.
- , , . -
, .
90 180,
. ,
, ,
, .
,
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.
.
,
.
:

1. ., -
. . , 91, 2009, 2, 172-175.
2. ., . , . . -
82 . , 91, 2009, 2 ,141-144.
3. , . . , . .,,1991.
4.,.. , ., , 1971.
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Hong Kong Chinese population, Hong Kong Med. J., 9, 2003, 158-163.
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Oral Cir. Biol., 11, 2006, E 339-344.
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Diagnosis and Management. J. Can. Dent. Assoc., 65, 1999, 612-6.
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Dent. Pract., 8, 2004, 4, 81-87.
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of supernumeraries in the pre-maxillary region, J. Orthodont., 33, 2006, 250-255.
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cases, Int. J. Paediatr. Dent., 12, 2002, 4, 244-54.
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prevention, J. Can. Dent. Assoc., 66, 2000, 497-501
15. Sixou, J. L. et al. Evaluation of the Mandibular third molar pericoronitis flora and its susceptibility
to different antibiotics prescribed in France, J. Clin. Microbiology, 41, 2003, 12, 5794-5797.
16. van der Sanden et al. Effectiveness of clinical practice guideline implementation on lower third
molar management in improving clinical decision-making :a randomized controlled trial, Eur. J. Oral Sci., 113,
2005,3 49-354.
17.Yamaoka, M., Furusawa, K., Yamamoto, M. Influence of adjacent teeth on impacted third molars in
the upper and lower jaws, J. Can. Dent.Assoc.,66, 2000, 497-501.
18.Yamaoka, M. et al. Completely impacted teeth in dentate and edentulous jaws, Australian Dent, J.,
41, 1996, 3, 169-172.
19. Yamaoka, M., Furusawa, K., Yamamoto, M. Influence of adjacent teeth on impacted third molars in
the upper and lower jaws, Australian Dent. J., 40, 1995, 4, 233-235.

276