Oral Surgery

Management of Medical Conditions
Hemophilia: Characteristics
Prolon thrombo •„ Ll1,,fry Pit ryyutCL1
• Normal prothrombin time (PT)
tfyuttfl[: If#: PIEills>1`c,
• Normal platelet count
• Normal bleedingtime i,.U~oc
• Partial thrombopalstin time (PTT): detects coagulation defects of the intrinsic
system.
• Normal value 2536 sec.
___ _ _
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Management of Medical conditions ffigrng
Hemophilia
• Management:
• General dental procedures and simple restorative procedures are generally not
associated with bleeding.
• Dental procedures should be carried out in consultation with the hematologist.
• Avoid invasive dental procedures unless the patient has been prepared based on
consultation with the hematologist.
• Postextraction treatment for all forms of hemophilia
Antifibrinolytic agents (e.g., tranexamic acid, 25 mg/kg) 3 times daily for 57 days.
ha Soft diet for 7 days.
Examine patient 2448 hours after surgery to check on control of bleeding.
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Asthma
• ls a chronic inflammatory respiratory disease associated with increased airway
hyperresponsiveness. Patients are sensitive to a variety of stimuli
•_Management:
Avoid asthma precipitating factors such as Sulfite preservatives in LA, cou reflex and
TID supine posl

s) severe stress, beta blockers, NSAlDS and ASA
8lnate a nd
Look for the signs associated wlth

with one breath, coughing, chest|:gs#nme::I:nait;Chk::r,Cnhga€'cnvaiiEL°of,`qsh#5
To minimize the risk of an asthma attack, schedule late morning or the late afternoon
iiRH • appointments.
Pal]enTaHl=fa=prescTlbed lnhalatlonal agents as lnstTijcted by famil
Minimize stress of appointment with oral or intravenous sedation if nece
Keep emergency drug in hand (ex: salbutamol).
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Management of Medical Conditi.ons

ii= irin _, _ ngrtJfroul
chronic obstructive pulmonary Disease (copD) haefhd{dr.i
tw s,, • ls a general term for pulmonary disorders characterized by chronic airflow
sot,u limitation from the lungs. The most common diseases classified as COPD are
chronic bronchitis and emphysema.
• Management:
Co oj>
• Use semi supine or upright chair position for treatment
• lf patient displays shortness of breath at rest, a productive cough, upper
respiratory infection, or an oxygen saturation level less than 91% (as
determined by pulse oximetry), reschedule the appointment when the
patient is stable and breathing is adequate.
• Slowly change the chair position to avoid orthostatic hypotension.
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Chronic Renal Failure

• Management:
Tff gounttpraoij|:Etadnedn!3'ntsreeravtaTi3:t+Segd:cnairca!'ryesj3f:r¥vhja:5repatient'SdiseaseisweH
#¥:jadndo:#:ar'styrsetaet#i€ndtj!te:t:Eg#emn:Lsj8}::ai?¥a::eetesxt:ageMS,°hfyrpeen£:fna!!:#ior
bfhej:i:i:3'¥aenjFeb:tannscuit:Sd'::Sdetnrt:act°mn:LdtecradnefeergrogvqdeendtiLcaaLeo:B,ttj!,a.,ike
sett ing, or postpone until after hemodia|
• Dental e short and stressfree with closely monitoring of
blood pressure
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',L 25
• Glomerular filtration rate (GFR) is a lab test used to determine how well the
kidneys are functioning. Specifically, it estimates how much blood passes through
the glomeruli per minute
Table 1 Stages of chronic kidney disease according to National Institute for Health and Clinical
Excellence
Stages GFR (ml mln.1.73 m~`) Description
1 >90 Normal or increased GFR, with other evidence of kidney damage
2 6089 Slight decrease in GFR, with other evidence of kidney damage

Moderate decrease in Gin, with or without other evidence of kidney
3A 4559 damage
38 3044
Severe decrease in Gin with or without other evidence of kidney
4 1529 damage
5 <15 Established renal fallure Including on dialysis
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Management of Medical conditions zt
Hepatitis
• Hepatitis is an inflammation of the liver that may result from both infectious
and noninfectious causes. Alcohol, prescription medications and drug abuse
are predominant noninfectious causes, while viruses are important infectious
etiolog
(HAV): Transmitted through close personal contact or contaminated
liepatitis 8 virus (HBV): Transmitted throughsL± contact or blood and blood

products.
Hepatitis C virus (HCV): Transmitted b blood and blood
Hepatitis D virus (HDV): Transmitted mainly through use, sexual contact or
blood an products.
irus (HEV): Transmitted through close personal contact or contaminated
food and water.
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26
Hepatitis
• Management:
• Consultation with the treating physician is recommended before dental
treatment.
• ln cases of severe liver destruction. coa
gulation factors will not be
resulting in increased blee
• Patients wit
treatment
• Short appointments, when patient is well rested.
• Minimize soft tissue trauma during dental procedures.
• Consider a hospital setting for advanced surgical procedures or severely
coagulopathic patients.
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Cirrhosis (Alcoholic Liver Disease)

• Management:
• Patients with ascites may not be able to fully recline. (accumulation of
fluid in the peritoneal cavity, causing abdominal swelling)
• Defer elective dental procedures and a medical consultation is required.
• Deferral of surgical procedures may be necessary until the coagulation
and drug metabolism status of the patient can be determined.
• Unpredictable drug metabolism. Patient may show increased tolerance to
sedatives, hypnotics, and general anesthetics in earlier stages of disease.
With more advanced hepatic destruction, drug metabolism may be
markedly diminished.
• Medical consultation is recommended for sedation for surgical
procedures, general anesthetics, or drug administration.
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Alcohol Abuse and Dependence

• Alcohol dependence is a chronic addiction to ethanol in which a person craves
and uncontrollably consumes ethanol.
• Management:
ng
_
Avoid complex and extensive care until the patient demonstrates an
interest in, and ability to care for, his or her dentition.
• Use supine positioning and discharge patient slowly to avoid orthostatic
hypotension.
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Iron Deficiency Anemia

• ls the most common form of anemia. May occur for many reasons: excessive
fb::?r%#pS;edgenf:CL:;,t,8:::Jtfoenc)r.easedabsorptlonoflronorincreaseddemand
• Management:
• The dentist should always be on the lookout for signs and symptoms of
undetected iron defi.ciency anemia in patients who present to the office.
•tFh°:rEapt:::[cScWo'#r:,ihaog:;#Spt°ofLr::ndde/f:Cr'ehnec#oagn,:T,'na>a|8owgh/°L):rteh:feder
are no contraindications to routine dental care.

• Avoid use of macrolide antibiotics: er
romycin, azithrom cjn and
clarithrom cin with t to cause abd ominal
cramping.
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Red blood cellcount

Male: 4.325.72 triHion cells/L* (4.325.72 million cells/mcL**)
Female: 3.905.03 trillion cells/L (3.905.03 million cells/mcL)
HemoglobinHGB Male: 1417 5grams/dL*** 135175 rai=TS L

Female: 12.015.5 grams/dL (120155 grams/L)
Patient diagnosed with Anemia when

HGB for females : <12 gin
HGB for Males: <14 gin
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Gastroesophageal Reflux Disease (GERD)
• GERD is one of the most prevalent digestive diseases among adults. It occurs
when the lower esophageal sphincter does not close properly and stomach
contents either leak back into the esophagus, causing heartburn, or go into
the back of the mouth.
• Management:
apt lt is safe to place most patients with GERD in a supine position, but some
patients with severe GERD need to be kept at a 45° for their visit.
• Routine dental care may be provided or GERD; however,
the decision should be based on patient comfort and convenience.
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Human lmmunodeficiency Virus/Acquired lmmunodeficiency

Syndrome(HIV/AIDS)
• ls a human retrovirus capable of producing profound immune deficiency and
dysfunction. HIV selectively infects specific sites such as Thelper (CD4)
lymphocytes and lymphoid tissues. Also it invades the central nervous system
during early stages of infection.
• AIDS is a condition caused by HIV and is diagnosed when a person's immune
system becomes compromised and one or more opportunistic infections have
occurred.
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CD4 count Clinical significance
S001,500 cells Healthy/ HIV negative
•`
<500 cells
200 cells \
Immune system is weakened
Risk of infection is small
HIV treatment should be considered
Very compromised immune system
asr'Skofllfethreateninginfect,ons
Tuberculosis (TB)
• TB is a disease caused by an infectious and communicable organism,
Mycobacteri_y!r twbercu/o5is. The disease is spread by in;±±ja±iQLnpfjnfe!!£g
Management
• Patients with recently diagnosed, clinically
.5± cultures should receive dental treatment n an appropriate

etting.
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Chemotherapy
• ls the treatment of cancer with an antineoplastic drug or combination of
drugs intended to kill rapidly growing cancer cells in the body.
•,Management:
I_ys± 'l • Generally, elective care is deferred during active chemotherapy,
• A consultation with the patient's medical providers in order to determine
medical stability/immunologic suppression is strongly recommended prior
to scheduling a dental appointment.
• lf oral surgery or other invasive procedures are required, allow at least
1014 days of healing before initiation of chemotherapy.
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Dementia and Alzheimer Disease

• Is a slow, progressive decline in
that incl udes ijnpainnelif
in memory, abstract thinking, ment. Alzh eimer disease arid stroke are
mon causes o ementia. Onset is usually after 60 years of age
• Management:
• Schedule short appointments, especially for patients with advanced
dementia.
• Discharge patient slowly to avoid orthostatjc hypotension.
• Place patients on an aggressive preventive dentistry program.
• Complex dental procedures should be performed as soon as possible
before the disease has reached the moderate to advanced stage. Patients
with advanced dementia are often anxious, hostile, and uncooperative in
the dental office and can be difficult to treat.
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• Cervicofacial and Mediastinal Emphysema

• The clinical presentation is characterized by a sudden onset of hemifacial
swelling with the sensation of fullness of the face and closure of the eyelids
on the involved side. Cre itation is noted on palpation and is almost
pathognomonic for s aneous emphysema.
Th c,1+corv\o LL q`trr
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Management of Medical conditions gffiRE
• Cervicofacial and Mediastinal Emphysema

• Clinical Features Of Cervicofacial Emphysema
Local swelling Diflinse §weuing
Crepins Local erythema
Local discomfort Pain
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Medical Emergencies
A. Acute asthmatic attack H. Hyperglycemia (diabetic coma).

(bronchospasm). I. Hypoglycemia (insulin shock).
8. Upper airway obstruction.
J. Hyperventilation.
C. Mild allergic reaction.
K. Local anesthetic toxicity.
D. Anaphylaxis.
L Epinephrine reaction.
E. Angina pectoris/myocardial
M. Vasodepressor (vasovagal)
infarction.
Syncope.
F. Cardiac arrest.
N. Seizure disorder.
I Gfrebrovascularaccident.
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alfut\ryl
Medical Emergencies
A. Acute asthmatic attack (bronchospasm).

Signs and symptoms: Management:
: ye:::Z:::Lffocation : ::y::nn'S::: S_:I,b:iLm,°tj 2 Puffs)£€;#fty

• Nonproductivecough. aA,\6L. Unresponsive:
itial does is 0.30.5

:[nh::ek:::r:nr:;pLr:::ruys:::trtu.mflj#..£±p;n[.;;:f:o:te:i,:
ults andrmg/kg
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a. Upper airway
Signs and Symptoms:
.#,u!#m£[ Management:
tyv2JJCL
• Snoring Conscious coughing: No

• Gurgling
diE= I iii|i`rvcnt:`cmlì.?C+S`.`l.V
• Exaggerated respiratory Efforts • Consciouswith no h#:to'#

(muscle use)
• Stridor Unconscious: Ventilate patient fc,, P a
• Wheezing andbegincarrfeEi6mpressi6Tns,
• Absence of breathing sounds head tilt/chin lift, oxygen, finger
• rapid pulse sweep, call 911
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Management Of The Airway
• Basic Airway Maneuvers:
• Position: Supine position with the feet elevated slightly.
! i:.`... head tiltchin li (ln 80% of instances in which the tongue is
e cause of the airway obstruction, this procedLr:
effectively opens the airway).
•..,..,:i:,;ij
JawThrust Maneuver.
• Fingers behind the posterior border of the ramus of the
victim's mandible and displaces the mandible anteriorly
#:i[:htHtjngthepatientsheadbackwardandopeningthe
• Dislocation of the mandible js a painful procedure.
Therefore, the jawthrust maneJver gives the rescuer a
as Sense of the depth of the victim's unconsciousness.


• Establishing An Emergency Airway:
• NonInvasive procedures:
• Back blows.
• Abdominal thrust (Heimlich maneuver).
• Chestthrust.
i
'Fi nger sweep
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i lur` lc)Qt 0\`\ vow.a)
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• Noninvasive procedures:
• Abdominal thrust (heimlich maneuver) and chest thrust.
• Chest thrust is recommended for:
• Patients in advanced stages of pregnancy
• Markedly obese patients
• Recommended for infants because abdominal thrusts are more likely to cause
organ damage
• Less likely to cause regurgitation than is abdominal tbrust
• Abdominal thrust (heimlich maneuver):

• Recommended for older patients, whose more brittle ribs are more likely to be
fractured in the chest thrust, and for ch.ildren.
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• Invasive Procedures For Opening The Airway
Tracheostomy Versus Cricothyrotomy

• Surgical opening of the airway may be performed in several ways, Two of the
in:St::a:hme°o:%:Syed=3g?rfe`#4#.*fut`2thqtrLxfro8dri:.jtaT¥k
2. Cricothyrotomy
• Limitation: Performed only by persons trained in the techniques and only when
proper equipment is available.
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•'1F
• Tracheostomy:
• Once was considered the primary technique for the reli.ef of acute airway
obstruction.
• For a variety of reasons, cricothyrotomy is now considered by many to be the surgical
procedure of choice for sudden airway obstruction.
• Currently used most often for longterm airway management
• With a few exceptions:
• Direct laryngeal fracture.
• Emergency airway management in infants.
• Tracheostomy site contains numerous important anatomic structures:
• The isthmus of the thyroid gland.
• Several large and important blood vessels and nerves.
• Accidental perforation of the esophagus.
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• Tracheostomy
.G ,.`'JL,
Cricold
ill;l cartilage
frond'
third, and
fourth
uncheat
n`nos
Vertical midline or transverse incis ns are used for

tracheostomy through 2nd and 3r tracheal rings
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39
'`!`
• Cricothyrotomy (cricothyroid membrane puncture):

• lt is the establishment of an opening in the airway at the level of the
cricothyroid membrane.
• lt is an acceptable procedure for emergen cy airway access.
• Easier and quicker than tracheostomy.
• lower Incidence of complications.
• No significant anatom tures are found near the cricothyroid
• Provides the most accessible point of entry into the respiratory tree inferior
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• Cricothyrotomy:
Incision is made inferior to the thyroid cartilage and superior to cricoid cartilage.
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40
• Cricothyrotomy:
:_. i t.:T::ii
Frontal and side view of anatomic relationships in cricothyrotomy.
Management Of The Airway JJ Jfroro

4ùthgivwl`
• Cricothyrotomy:
CrYl I CLJ9
• Contraindications:
• Should not be performed in children under 5 years.
•..``.` l'3 dr
• Preexisting pathologic processes in the larynx (e.g„ in the epiglottitis),
chronic inflammation, or cancer.
• Lack of familiarity with the technique and its complications.
• Trauma to the neck region.
\w4fty~=MfaLfthFTEL etryLLti i " chit
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Medical Emergencies
C. Mild allergic reaction

Symptoms:
• Dermatological
:#:r:::,saet,i:i;q.jLifsk3
• Additionally
• Pt may complain `'feel sick"
• Flushing (erythema)
• Nausea
• Rhinitis (runny nose)
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Medical Emergencies
D. Anaphylax ]s. _,gnvD"+i 2" motto Sds6_ fi A[41iÀ hQgiv.`j

Signs and Symptoms:
• DERM: itching, hives, eczema, swelling,
y,a_n|gêJT.e.:::
. Immediate:
J? ThnEL_
f::;:':ns8hortness of breath, cough, Wheeze #:cLe does of
• RESP: shortness of breath, cough, Wheeze k:cA
•Mouth:itching,sweHingoflipsandtongue_+tot. :bvde9^,Itùl,i,```titi
call emer medical services
• Throat: Itching, tightness, closure, hoarseness
fro tit, ìvy A
• CVS: hypotension, dizziness, syncope, ^
(50 mg i.in.)
tachycardia
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Medical Emergencies
amtw (mtrQi,I
E. Angina pectoris/myocardial infarction. cnd VIC~
Signs and Symptoms: Management:
• Angina Pectoris: • Immediate: vcii c7 el^` urh csh^
• Chest Pain and Levine's Sign • Nitroglyce
CtJitch,t\tl` ed u`,\
• Myocardial lnfarct
• Chest pain
ioTTT • O¥y8f n _
• call emergen
5
`y; Svystrfu!
no past history of angina) P <3oifi

• Levine's sign
• Pain in left arm
Xi,9h;``# • Appropriate: '{{ `
• Pain in jaw • + ASA3aEHr3><hd trè, Ash

• morphine
• Indigestion
cio t<xrM. pdi,`j
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Medical Emergencies
F. Cardiac arrest.
Signs and Symptoms:
Management:
• Immediate: ~> Cf r`
JLilo
utes if Ventilate atient and be in cardiac
minute
• QELen
• head tilt/chin lift
• call emer medical service
• + use automated external

defibrillation
• epinephrine
43
Medical Emergencies
G. Cerebrovascular accident.
Signs and Symptoms: anagement:
• Sudden headache • Oxygen
• dizziness • head tilt/chin lift
• nausea & vomiting • call emergency medical services
ae
Medical Emergencies
H. Hyperglycemia (diabetic coma).

Signs and Symptoms: Management :
• Thirst • Conscious:
• Excessive Urination • Hospitalize
• Weakness, fatigue
• Unconscious:
• Visual disturbances
• TA± crfe
• Extreme tiredness
• Oxygen
• Drowsiness
• call 911
ry Skin an
• BS >15 ormal Range 57
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44
Medical Emergencies
I. Hypoglycemia (insulin shock).

• Hunger, nausea
• Wefro he±he, ffroc`
• Unconscious:
ng`:L#ffiFtt4+
• Changes in mood or behavior
• ABCs
• Oxygen
•50% dextrose iv or lmg glucagon
• BG < 3.0 mmol/LNormal Range
57p>\®d er\u3L
Medical Emergencies
J. Hyperventilation.
Signs and symptoms: Management:
• S±±!j9±±!±apjd _breaL!±±Pg 4o +_ C o£ Breath into cupped hands or G
• Anxiety, emotional distress `,'\ rty`L 3"`te,
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Medical Emergencies
K. local anesthetic toxicity.

Signs and symptoms: L«` Management:
• Early Talkative • Mild:
apprehension, xcitabilit • Oxygen
speech Dizzin ess, meta taste'
visual or auditory disturbance,
• Deteriorating:
drowsiness `)t| e~ r,rtllt,LL • Oxygen
• Late Nystagmus • call emergency medical services
Tfuù k vomiting, disorien
4vutl • Unconscious:
Lirut+ \Q_ ( heart rate, blood pressure
r. LatestTonicclonic seizure,
• Oxygen
• head tilt/chin lift
decrease heart rate, BP
• call emergency medical services

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~_ \c2J2 Ta@ti
Medical Emergencies
L. Epinephrine I.eaction.
Signs and symptoms: . Management:

• lntravascular injection of epinephrine . Oxygen
may cause transient CVS symptoms
such as:
• tachycardia
• palpitations
• dizziness
• anxiety
46
Medical Emergencies
M. Vasodepressor (vasovagal) syncope.&£t`. Jtlole LiL\ hL4LLti Ou .r

Signs and Symptoms:
Management:
• Sudden, transient loss of conscious
• Position, ABCS, Oxygen
caused by:
• psychogenic factors
• . Decreased bloodflc
) C?nosxcyjg°e:SL± `hp`,/?.I,/.
.i , , i si.:^n::rhma,thTca.Ydpsr;:ae,::e :,ou:i., ,=a= • Unconscious:
• Oxygen, head tilt/chin lift
consciousness
• Irregularbreathing or apnea
.ri¢_uniir':u:i':`j
• convulsive moments, twitching
'£:ayohr,'cwhe::ifeos:seat,ng,nauseJfEL
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Medical Emergencies
N. Seizure disorder.
• Depends on seizure type
I Tonicclonic seizures are generalized
• Mild:
• No intervention necessa iEL
:._i l.,.,livavl`
full body muscular contractions/terms • Status Epilepticus? I+ \cldrs
Oxygen i_)_ywLL
call emergency medical services,
lorazepam
tr4 L`ìMi u`
5 vy\\v`s
47
Bisphosphonates and
Radiation Therapy
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Bisphosphonates
'v uul
Introduction: tj:rv;*Sty;L,twfj J
• Used to treat osteoporosis and ma!jgn±p±±±`P±+1let±±!jlsss
• Given to cancer patients to control bone loss resulting from

metastatic skeletal lesions
• They have antiangio enic properties and can be tumoricidal which
makes them an effective treatment agent in cancer therapy
fee:
48
Bisphosphonates
Introduction (Cont.):
• Can be provided intravenously or orally, depending on the type of medical
condition being treated and the potency of the drug required
• Orally administered bisphosphonates is mainly given to patients with
osteoporosis. Injectable bisphosphonates is given to cancer patients who
have primary lesions of bone or skeletal metastasis
• Can lead to BisphosphonateInduced Osteonecrosis of the jaws (BOJ)
C)£LCovujLCLOS`s ' S L>froi 'b y`c 4uJa+LJ

NlhuL~ 8 i~,(c.o
Bisphosphonates
Clinical signs and symptoms of BOJ:

• Osteonecrosis after treatment of the jaw (BOJ) affects the jaws exclusively
• Most common clinical presentation of BOJ is an ulcer with ex osed bone in a
patient who had a recent dental extraction

• Or an ulcer caused by an ill fitting prosthetic device
• Though most common cases is related to spontaneous bone exposures that
cannot be associated with any infection or injury
+I: Early stages of oral BOJ lacks radiographic presentation
Can be symptomless or very painful if the exposed necrotic bone gets infected
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49
Bisphosphonates
Clinical signs and symptoms of B0J (Cont.):

extensive areas of bony
.i
•C,` i±8eandmlghtleadt
Most reports of BOJ occur after the adminstartion of BisphosphonatesJgi£
month s or more
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I'REP DOCTORS
Bisphosphonates
Clinical signs and symptoms of BOJ (Cont.):

• When BOJ develops spontaneously, the initial complaint is usually a sudden
presence of intraoral discomfort and presence of roughness of the exposed

bone that might progress to traumatize the adjacent soft tissues
• The soft tissue will exhibit purulent discharge and local swelling with trismus
and re LQnallY hadenopiny
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I'Iu l' DOCTORS
50
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c+` \ h\c tl'i¢i(fuyul i.``,
E>pecjal' J5O+; r>wh, in,a_pcuL` I

EIL.
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tr3~ aprTha + flQrfu` tc3n\cLh` t EAHp&±+dt ct*encLLL~¢uo)

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Bisphosph
Management:
• Prevention of BOJ is very important for patients who will receive anti cancer
treatment because the inability to manage the lesions can worsen the
patient's medical status since an effective therapeutic measure for BOJ have
not yet been identified
• Patients to start receiving radiation treatment must be seen by the dentist
before the lv bisphosphonate therapy begins to minimize the occurrence of
BOJ. Teeth with poor prognosis should get extracted since majority of the
occurrence of BOJ occurs following routine dentoalveolar surgery
• Delay of startin the bis hosphonate therapy 4 to 6 wee
invasive procedure mportant to give time for the bon e to recover
of BOJ
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Bisphosphonates
Dental Care for Patients Receiving Bisphosphonates:

• Eliminate all potential sites of infection
liminate all carious lesions andd efective restorations

• Prostheticwork might beinot appropriate for some
patients
• Present prosthetic appl Ces must be evaluated for proper fit, occlusion and
stability and if necessary adjustments is needed
• Avoid if possible extraction of teeth
• Perform prophylaxis and proper oral hygiene instructions
• Information must be provided to the patient about the BOJ and the warning
early signs of BOJ
±FrequentperiodicfoHowupappointments
51
Bisphosphonates
Dental care for patients with BOJ:

I Aim:
~`. To eliminate or control pain

Prevent progression of exposed bone
Elimination of sharp bony edges irritating adjacent soft tissues
arp edges are removed with rotating diamond bur
iver attempt to cover the exposed bone with a flap as it might worsen the
symptoms and more bone exposure and increases the risk of path.ologic
fracture
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Bisphosphonates

I Treatment modalities of BOJ:
• Minor debridement under local anesthesia
• Major surgical sequestrectomies ( removal of necrotic bony islands
from the sound bone surrounding )
• Marginal and mandibular resections
• Partial and complete maxillectomies
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52
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Th *,\LQCLu_lew oi V\i`"#u:6\{o=?tL:+7`t|=th~
a 6C.u
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Bisphosphonates

I Treatment modalities of BOJ (Cont.):
•HBO therapy ( Hyperbaric oxygen therapy involves breathing pure
oxygen in a pressurized room or tube, the increase in oxygen in the
body helps fight bacteria and stimulate the release of substances
called growth factors and stem cells, which promote healing)
• Administraticm of antibiotics can help in reducing the incidence of
local infections postsurgical treatments such as extractions. ( Penicillin
V, Amoxicillin, Clindamycin
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rfu~\ ChoL``t Wtiv` bit\ihotQv¢€tc,
Radiation Therapy
Introduction:
• Used to treat malignancies of the head and neck
• Radiation therapy aims to destroy neoplastic cells without affecting normal
cells but jn practice even normal tissues receive radiation which can cause
undesirableeffect
• Any neoplasm can be destroyed by radiation if the radiation dose delivered is
sufficient
• The limiting factor is the amount of radiation the surrounding tissues can
tolerate
• Mechanism of action is interference with nuclear material necessary for cells
reproduction and maintenance. Therefore the faster the cellular turnover the
more susceptible the tissue is to the damaging effect of radiation.
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Radiation Therapy
Introduction (Cont.):
• Neoplastic cells usually have high turnover rates so they get affected mostly
` but other normal tissues with high turnover rates will be also affected, such
+. s hematopoietic cells, epithelial cells and endothelial cells
• Effect of radiation on the oral cavity is evident , such as destruction of the fine
vasculature and oral mucosa
• Salivary glands and bones are radioresistant but on the long run they might
get affected due to the vascular compromise resulting from the radiotherapy
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Radiation Therapy
Effects on Oral Mucosa

•:. Initial effect on the oral mucosa is evident from the first 1 or 2 weeks
•:. Erythema can progress to severe mucosms with/QutulceL±n
¢LEejEinaqgivhagquiffi culty swallowing )
•:.Loss of taste sense due to the taste buds being affected too
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Radiation Therapy
Effects on Oral Mucosa

• Management of mucositis:
• Not predictable but can be relieved to a certain extent with the use of
antibiotic lozenges containing hotericin, Tobramycin, Neomycin
iEE
• When the symptoms worsen, the use of viscous Lidocaine may
effective iiE
CJ17° i iLr \AL^pl*^| clrT\t+loglt€
Radiation Therapy
Effect on Mandibular Mobility

•:.Radiation can cause inflammation to the omasseteric slin
Pe riarticular connective tissues
•:.Irradiated muscles becomes fibrotic and tend to contract
•:.ThemandibulararticulatingsurfacesuLp4
•:.All the above chances will lead to trismus
•:.Limited mouth o is evident too and takes place usually over the first
year after the radiation therapy a_nd is painlesLs_
•:.Once interincisal opening decreases to 20mm > food in take becomes difficult
Eta
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Radiation Therapy
Effects on Salivary Glands

•:.Salivaryglands are considered radioresistant because the s.g epithelium has
slow turnover rate
•:.Damag e evident is due to the destruction of the fine vasculature by radiation.
Such changes include atrophy, ibrosis egeneration
presents as xerostomia
•:.Xerostomia: decrease of saliva roduction which can lea d to dry mouth,
d ifficu lty ta 9, chewing , swallowing, esophageal dysfunction, malnutrition,
increased incidence of glossitis, candidiasis, angular cheilitis, halitosis,
bacterial sialadentitis, loss of buffering capacity, inability to wear dental
prostheses and rampant caries
•:.Severity of xerostomia depends on which salivary glands are within the scope
of radiation
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Radiation Therapy
Effects on Bone
•:.Osteonecrosis: is devitalization of bone by cancericidal doses of radiation
•:.Bone getting radiated becomes nonvital due to loss of fine vasculature within
bone. Also the turnover rates is sl6wied doTwn and regeneration is not possible
lar dissolution o and can lead to pain and

re and may need surgical resection
fee:
56
Radiation Therapy
• Evaluation of Dentition
=``, • Main aim is to
revent osteoradionecrosis
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Radiation Therapy
Preparation of Dentition for Radiotherapy & Maintenance after

Irradiation:
• Prophylaxis and topical fluoride application to be scheduled before
radiotherapy
• Oral hygiene instructions must be demonstrated and reinforced
• Eliminate any mechanical irritation such as sharp cusps (need to be rounded)
• Tobacco and alcohol consumption should be terminated
• Chlorhexidine mouthrinse prescribed twice a day to minimize bacterial and
fungal levels
''L
aft
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Radiation Therapy
Extraction after radiotherapy:

• lf extraction is necessary after the initiation of radiotherapy , it can be still
performed but done through routine extraction without primary soft tissue
closure or surgical extraction with alveoloplasty and primary closure
• Use of systemic antibiotics is recommended
• Use of HBO ( Hyperbaric Oxygen) before and after extraction can be effective
fab
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Radiation Therapy
Management of Osteoradionecrosis:
• Patient must discontinue wearing any prosthesis
• Irrigation remove necrotic debris
'&` stemic antibiotics
osteT6F5dionec.rosisbeca
wound
::eut:Fsf:]o'tn#:i±tc
I intervention is needed for non healing wounds or resec
ts of sur interve ntion is evident with
#+ti_
#fuf##ife Oil
the use of HB0 therapy in conjunction
Sris
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D r hi T I s T a y
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Exodontia
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Exodontia
Dental Extractions: Mechanics

Lever: The firstclass lever transforms small force and large movement into
smallmovement and large force
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59
Exodontia

Wedging: Can be used to expand, split, and displace portions of the substance
that receives it.
Example: Elevator, beak of extraction forceps
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Exodontia

Wheel & Axle: Identified with triangular or pennantshaped elevators. The
handle serves as the axle and the tip of the triangular elevator acts as a wheel
which engages and elevates the tooth root.
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Exodontia
Dental Extractions: Open vs. Closed Extraction

• The closed technique (routine) is the most frequently used technique in any
given situation.
• The open technique (surgical techniqueFlap formation) is used when the
clinician believes that excessive forces would be necessary to remove the
tooth, the crown that is present is fragile and when a large amount of the
crown is missing or is covered by tissue.
• Three fundamental principles are required for both techniques:
1) Adequate access and visualization of the field of surgery

2) Unimpeded pathway for the removal of the tooth
3) The use of controlled force to luxate and remove the tooth
Exodontia
Dental Extractions: Closed Extraction

• For the tooth to be removed from the bony socket it is necessary to expand
the alveolar bone. It's necessary to tear the periodontal ligaments fibers that
hold the tooth in the bone.
• Using elevators and forceps as levers and wedges with steady increasing force
can help with extraction.
• 5 general steps will now be discussed for closed extraction procedure
Eta
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Exodontia

1. Loosening Soft Tissue Attachment:
• lt is necessary to loosen the soft tissue attachment from the cervical portion
of the tooth with a sharp instrument such as a blade or a periosteal elevator.
• The purpose of this is as follows:
• Allows the surgeon to ensure that there is profound anesthesia
• Allows the elevators and extraction forceps to be positioned more apically
without impinging on the soft tissue of the gingiva
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Exodontia

2. Luxation with Dental Elevators:
• Expansion and dilation of the alveolar bone and tearing of
periodontal ligaments using a straight elevator
• The elevator is inserted perpendicular to the tooth in the
interdental space and is turned with a slow strong force
• Luxation should be done with caution because excessive force
can damage adjacent teeth.
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Exodontia

3. Adaptation of Forceps:
• The beak of the forceps should be shaped to adapt to the
root surface anatomy beneath the soft tissue and parallel to
the long access of the tooth
•Bonscs:bi:,S++:sn:::i:j%rf:,Pnsg:.reposltionedasapicaHyas
• The beaks act like a wedge and dilate the crestal bone
(Buccal and Lingual)
. The cerite.r of roL±±±jQrmf the forces are displaced
towards the apex of the tooth which resu Its in better

ne expansion an likelihood of tooth fracture
Exodontia

4. Luxation with Forceps:
• The major portion of the force is directed towards the thinnest bone. For the
maxilla and all but the molar teeth jn the mandible the major movement is
labial and buccal.
• The surgeon uses slow and steady forces to displace the tooth buccally, and
then to the lingual (palatal).
• As the boney walls expand the forceps are reseated more apically.
• Small rotationa.I motions are used for conical (singleJ rooted teeth
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63
Exodontia

5. Removal of the Tooth From Socket (Traction Force):
• After luxation and the expansion of the alveolar bone a slight traction force
directed buccal can be used to extract the tooth.
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Exodontia
Dental Extractions: Open Extraction

Indications for Open Extraction:
• Initial attempts with forceps L> failed
• Dense bone (older pt)
• Very short clinical crowns (attrition)
• Roots close to max. Sinus
• Relationship to adjacent teeth
• Extensive caries/ resto.
• Proximityto vital structure
• Impacted tooth
. Multiple exo
• Difficulty:'hypercementosis, divergent, dilaceration, hooks.
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Exodontia
Dental Extractions: Open Extraction

Surgical Principles:
• Adequate flap elevation to allow for adequate exposure
• Bone removal to produce a trough to access tooth (Note:
Lingual bone is rarely removed from the mandible in fear of
damaging the lingual nerve)
• Tooth sectioning
• Irrigation and Debridement + Need to use sterile
saline/water. Distilled water is hypotonic and will cause cell
death
• Replacement of flap and suturing
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Exodontia
DentalExtractions:C|oset^°Ex¥r;:tion
Extra Information
• ln the maxilla: The buccal bone is thinner than the palatal bone
• ln the mandible: The buccal bone is thinner up to the molar area, in the
molar area the buccal bone is thick and dense
•::::eoqs:eerT::b°:f:rue't::i:r::trractj°&Ssh&uLd€b:mixtl#eforfroma
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Exodontia
Dental Extractions: Impacted Third Molars

• Tooth that fails to erupt into the oral cavity within its expected developmental
time period due to a physical barrier
• Impacted teeth have many causes:
• Lack Of Space Inadequate Arch Length
• Obstruction Of Eruption Pathway
• Adjacent Teeth
• Dense Overlying Bone
• Pathology (Eg. Supernumerary)
• Genetic Abnormality
• Ectopic Eruption
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Exodontia
Dental Extractions: Impacted Third Molars Extraction Indications:

• Periodontal disease (adjacent tooth)
• Dental caries
• Pericoronitis
• Root Resorption of Adjacent
• Prevention of odontogenic cysts and tumors
• Prevention of jaw fractures
• Prosthetic or orthodontic treatment
• Optimal periodontal healing
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Exodontia

• Impacted third molars can be classified in two ways by: 1) Angulation and 2)
Pell and Gregory
1) Angulation: ln order from the easiest to extract to the most difficult to
extract Hori2ontal Mesioangular
• Mandible:
• Mesioangular, horizontal, vertical, distoangular
• Maxilla:
• Distoangular, Vertical, Horizontal, Mesioangular
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Exodontia

2) Pell and Gregory Classification
Ramus:
Class I: Completely Anterior
Class 11: Half Covered
Class Ill: Completely Within

Relationship to occlusal plane:
Class A: Near or at the level of the 2nd Molar
Class 8: Between the occlusal plane & CEJ
Class C: Below the CEJ
67
Exodontia
Dental Extractions: PostOperative Instructions:

• Do not disturb the arealt is important to allows the body to form a good
blood clot to start healing. Avoid swishing, sucking through a straw, and
smoking to avoid dislodging the clotlwithin the first 24 hours.
• Bleeding: Bite on gauze for at least 30 minutes post extraction. If bleeding
continuesyou maybitetea bag, O,r.anothergauzF b_A^^ Qhn^ ho.aliL+,
• Smoking: Avoid smokin
• A soft diet is recommen
¥i§`?i:ce:o8::de\+dr\#,*Pfro¥t;7tyJ4`5
• Application of cold can be used in 15 minute intervals if the.re is swelling
• Analgesics are used for postoperative pain depending on the severity
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0rNyi3TR(
Surgical Flaps
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Surgical Flaps
Flaps Introduction:
• Flaps are a section of soft tissue that are:
Outlined by surgical incision
Carries its own blood supply
Allows surgical access
Placed back to its original position after surgery
Mai.ntained by suture & expected to heal
• Are used to obtain access to an area or move tissue from one locatjon to another.
To avoid complications such as necrosis, dehiscence and tearing several basic flap
design principals should be followed.
Surgical Flaps
Flaps Introduction:
• There are 5 important principles to consider when making incisions:
1A sharp blade of proper size must be used (to avoid repeated strokes)
2Firm, continuous stroke should be used when incising
3I(now your anatomy! Avoid cutting vital structures (Ex. Mandible:
Lingual and Mental Nerve, Maxilla: Greater Palatine, Nasopalatine Nerve
and Arteries)
4lf a cut is made through the epithelial surfaces the blade should be
held perpendicular to the surface. This allows for wouW edges that are
easier to reorient during suturing.
5Incisions in the oral cavity should be placed properly. Incisions over
attached gingiva and healthy bone and more desirable than incisions
over unattached gingiva and missing bone
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69
Surgical Flaps
Flap Design Principals: Prevention of Necrosis

1) The base of the flap should always be wider than the
apex (tip) unless a major artery is present at the base. The
sides of the flap should preferably converge moving from
the base to the apex.
2) The length of length of a flap should be no more than

twice the width of the base. (Length of the flap should
n#+e#
er exceed th 'dt#°fft/1;hf'£u cL` o7i 4 ;utcct.~\
.t,utv t(;[Dnalny'a6{th#j;
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Surgical Flaps
Flap Design Principals: Prevention of Necrosis

3) Axial blood supply should be included in the base of the flap whenever
possible.
..`.:.....,:...iìi,:,
Fèlcasing inclsfort
Blcod supply
4) Be very cautious when moving the flap around. Do not twist, grasp, stress the
base in order to preserve a good blood supply and the lymphatics.
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Surgical Flaps
d4,a:.` .Peg |£llb ==
Flap Design Prjncipals: Prevention of Flap Dehisc'ence (Separation)
1) Place the edges of the flap over healthy bone
2) Handletheedgesoftheflapwith care
3) When suturing the wound do not use excessive force to pull the tissue
together. Do not place the flap under tension.
Vote: Flaps for oral surgery are generally mucoperiosteal

•~aps containing both the mucosa and periosteum (full
:hickness)
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Surgical Flaps
Flap Design Principals: Prevention of Flap Tear

I Tearing the flap is a common complication when an inexperienced surgeon
.:::::aptpsrtoop::,ryf::Ta:r:::_:::uffig~haef::spj:::tasp:::[daessa,:;uofrf:c:enne::tc,csess
preferred to create a large flap initially to provide access
• Vertical releasing incisions should be placed a full tooth anterior to the area
where bone is anticipated to be removed and the incision generally starts at
the line angle and carried apically to unattached gingiva
71
Surgical Flaps
Types of flaps:
1) Envelop Flap:
• Incision made at the gingival sulcus in dentulous patients and on the crest
of the ridge on edentulous patients. •= €.':,.:
• Advantage:
> Easy to approximate
>Avoids vertical incisions
• Disadvantages:
>Limited access
> Difficult to reflect
>GreatTensionTearing
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PRf p DooroRs
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nrNT,3TDy
Surgical Flaps
Types of Flaps:
2) Two Sided Flap (ThreeCornered Flap):
• Envelope flap with a single vertical incision
• Allows for great access
3) ThreeSided Flap (FourCornered Flap):

• Horizontal and two vertical (releasing) incisions
• Excellent access
• Produces gingival recession
• Rarely indicated
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72
Surgical Flaps
Types of Flaps:
4) Semilunar Incision:
• A Semilunar incision in which the convex portion faces the crown to in cll"hal J lt,u
• Advantage: b GvlQJ
> Avoids trauma to papillae and the gingival margin (no recession) :.(,..:,.,.\,\..
> May be placed over the defect

• Disadvantage:
> Limited to periapical surgeries of limited extents
> Limited access
> Difficult to extend the I.ncision in cases where more access is required
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Surgical Flaps
Types of Flaps:
5) YIncision
• Indicated for palatal torus removal
• The thin tissue covering the torus should be carefully reflected
73
Sutures
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Sutures
Aim of Suturing:
1. To reapproximate the wound edges together until the healing process is
complete
2. Protect underlyingtissues from infection or other irritants
3. Prevents postoperative hemorrhage
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74
Sutures
• Criteria of an efficient suture materials:
1. Nontoxic
2. Nonallergic
3. Strong (tear resistant)
4. Flexible ( for easy manipulation like tying and creating knots)
5. Mustlackthewickeffect ( meansthesuturedoesn'tallowfluidsfrom
outside to penetrate the wound site which can lead to causing infections)
• Materials are classified According to
1. Diameter
2. Resorbability
3. Monoor polyfilament
` _
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Sutures
Ofameter
• Determines the size of the suture and is designed by a series of zero, such as
20, 30 and so on
• The more O's in number the smaller the suture
• Oral mucosa: 3/0 or 4/0 suture
• Size 3/0 (000) is the most common size in oral surgery because its:
1. Large enough to withstand tension

2. Strongenoughtoeasilymake knots
• Scalp: 3/0 suture
• Facial skin: 5/0 or 6/0 suture
• Microsurgery: 9/0 or 10/0 suture
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Sutures
Resorbability:
•3rb:I::¥a°bi;hc3isnuci8:es#he{La:t;obur:akh8:Wnngifmejrnaggivenperiodoftime
.;e:fi:,vF::,::ydt:astret#;:ttf:Fj=,ntt,Ss#;::i:Pter::udryh:5,{¢:e:,,T,:i:ar,:yuture
I, L,
Types:
1. ::E:nr63tqguuitck|dye( e serosal surface of the sheep intestine,
5 days )
2. Chromiccatgut: by chromic acid sts longer ( 71
3.
•,,'...`..,.i:'', .`
#cg,:aaTRap:rix;fa'r:,TejycT!h8:!Say:s:,::;y:E;rssmg.:j|;iy:ce#at:1
§aayrse,::i::asmpo°hy;,¥sce°£j:na:jrda]
vREg*actl:!V#[Thiy=°tcL:T£#yuserfe|°Lr|:uigeh`~rfe
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0,Nt,ST?,
Sutures
Nonresorbable sutures:
• made of materials that can't be metabolized or broken down by the body
• Materials used:
Silk( most common ), nylon, stainless steel, vinyl

• Silk is easy to use, economic and has good ability to hold knots
• The other materials are rarely used in the oral cavity
• Use of resorbable sutures is preferred for internal tissues and nonresorbable
for external tissues
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76
Sutures
Mono filament versus polyfilament sutures

• Mono filament sutures are made of only one thread.
o Plain catgut, chromic catgut, nylon, stainles5 steel
o Advantages: no wicking effect
o Disadvantages: difficult to tie, tend to untie, cut ends are stiff
which can irritate soft tissues
• Polyfilament sutures are made of several filaments braided
together
o Silk , polyglycolic acid
°fod;:#ij8:::easytotieandthecutendsaresoftandnoni.rritating
o Disadvantages: tend to wick oral fluid which increases chances of

wound infections
I_
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Sutures
Tie most commonly use sutures in the oral cavity is the 3/0 black silk
• Size 3/0 gives appropriate strength
• The polyfilament nature of the silk makes it easy to tie and is well tolerated by
the soft tissues
• The color of the silk makes it easy to see the suture when the patient return
for removal of suture
• The suture stays up to 57 days so the wicking effect is of little importance
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77
Sutures
Function of Sutures:
• Hold the flap in position
• Approximate wound edges
• Hemostasis
• Hold the soft tissue flap over intact bone
• Maintain blood clot in socket ( for figure of 8 suture)
Sutures
Principals of Suturing
1. Control bleedingpriortosuturing
2. The needleshould passfromthemobiletissuesidetothefixed
tissue side and be at least 5mm away from the edges to avoid
wound dehiscence, facilitate suturing and for better healing
•+..i.
3. The needle penetratesthe surface at right angle
4. Avoid overtighteningofthe suture to eliminatethe risk of tissue
necrosis
5. Thetwoendsofthesutureusuallytied in a knotandthesutureis
cut 5mm above the knot
6. The knot is to be placed on the side but not over the incision since
it acts as a stagnant area for debris
•t

PREp DocTors
78
Sutures: Techniques
1. Simple Interrupted suture:

o The simplest and most frequently used type in all surgical
procedures of the oral cavity
o The needle enters 5mm away from the margin of the flap
(mobile end) and exits at the same distance on the opposite
side. The two ends of the sutures then tied in a knot and cut
5mm above the knot
< oAdvantages of this technique is that when placed in a row,
loosening of one or more wont influence the rest of the
sutures
Eta © 2017 Prep Doctors, all rights reserved
Sutures: Techniques
111111111+
The needle enters 5mm away

Needle exits at the same
from the margjn of the flap
distance on the opposite side
T ____
The two end of the sutures are
then tied in a knot and are cut
5mm above the knot
79
Sutures: Techniques
2. Continuous suture
o Used for suturing long incision. Ex: incision for reshaping
the alveolar ridge of the jaws
o This technique doesn't require making knot for each stitch
which makes it a quicker technique and fewer knots which
means less debris collected
o Helps to distribute tension and create watertight closure
o The disadvantage of this technique is that if one stich is cut
or loose then the entire suture line becomes loose
fee:
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80
Sutures: Techniques
3. Horizontal Mattress suture:

o Useful when strong and secure reapproximatjon of wound margins is required
o So when wound compression is desired in one layer
Sutures: Techniques
I. Vertical mattress Suture:

= Similar to horizontal mattress except for the depth of penetration which
varies
= Used to create tight closure
= Suturing of the wound is done in to layers ( deep and superficial )
I
aF:
_ ,|IORS © 2017 Prep Doctors, all rights reserved
81
Sutures:.Techniques
5. Figure of eight suturing :

o Mainly used to maintain the blood clot in the alveolar
socket after tooth extraction
o Aids in hemostasis by providing a barrier to clot
displacement
o Can be used to maintain the hemostatic materials over
tooth socket after extraction.
fee:
PREl' DOCTORS
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DFNT)Stay
82
Fractures and Managements
Facial Fracture: Introduction

• The major cause of facial fracture includes motor vehicle accidents and
physical altercations. Other causes include sportrelated incidents, falls and
workrelated incidence.
• Fractures depend on the direction, force and type of injury
[ Mandibularfractures
• Are classified under the type of fracture, location of fracture, and whether the
fracture is favorable or unfavorable.
• Midface fractures
• are classified zygomatico maxillar
fractures, an
1
ae=
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83
Faciial Fi.acture.. Mandibular Fractures

• Classificatiom |vpe of Fracture
• Greenstick Fracture Incom lete fracture with flexible bone. Exhibit
m'n'm al mobility. usually found in the young
• Simple Fracture lete transection of the bone wi

fragmentation
fae:
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© 2017 Prep Doctors. all rlBhts reserved
Fac.ial Fi.acture.. Mandibular Fractures

•Classification:T+LpeofFractu±e
• Comminuted Fracture Fractured bone is left in multiple fragments. Due
to highimpact injuries su ch as gunshot woun
•::JE#=:t.u(rEex,Acu:gg;:gg::::#::::::if:::::#:::::#ae,
sulcus or periodontal ligament etc)

pROEee9rs
84
Fac.ial Fi.acture.. Mandibular Fractures

• Classification: Location of Fracture
• Fractures are designated by occurrence in the condylar, ramus, angle,
body, symphyseal, alveolar and rarely coronoid process areas.
• Below is an image that shows distribution of mandibular fractures:
lcadr c+`ry\tr\o` UfT cldrry)li``
ty\os+ ` C}`twJut _ C^nJuti ~

C_L)ty`mov\ Fhamus
~, d CaMu.be 2_Pin ~ R;
3)T>+2pnELunowhal3
Symprtysis
'1i#uLs: cjaHc{£ c+ LIJ2` clu,`\1, ,dct,`fftl, >4najAt`\

\ }^ \ ^
bodt> a\ytrfu ` > ^9``..a ` LO`(trho+i3I
ac.ial Fractui.e.. Mandibular Fractures

• Classification: Favorable Vs. Unfavorable De
pending on the
angulation of the fracture and the force of the muscle pull
proximal and distal to the fracture
esists the
•fur:jE:tE#5CangJSS±,SLPJegnthe
oùUW|
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Fac.ial Fracture.. Mandibular Fractures

• Classification: Favorable Vs. Unfavorable Muscles involved in displacing
mandibularfracture
• Displacing the fractured segment anteriorly and medially:
+b
ujLJ L
.D,.SPL,:tc:nrag'tTee#r¥du:::ements:tfeTor`±krfuit~CJfro:HtQha
.. ' i 1
:spii:::;;?::#s:oci:,re:!es#i#i#i¥T:¥lrfu!L=j
Displacing the fracture segment
• Digastric, Geniohyoid, Muscles
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PREl' DOCTORS
I) C N T , ., ? a Y
Fac.ial #racture.. Mandibular Fractures

• Signs and Sy mptoms
Lower lip numbness

illEI
/ . Pain
• Bleeding
• Crepitation on manual palpation
• Alteration in mandibular range of motion
• Deviation jn mandible o
larities in the plane of occlusion

RF+
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PRE I. DoaroRs
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86
G±=`
I
Factial Fracture.. Mandibular Fractures

• Signs and Symptoms continued:
• B"ateral fracture of the neck of#4CLonp.q# hrh ,`.q cLiprttul C|`6
ciutQ_~
ATE;:
/in f Anterior open bite
ability to protrude wh_fr*cutrl
teral fracture of the neck of the condyle: wlul{cJ
Forward displacement of the hL£±±j2±ihe condyle bv the latf'ri]l rttprthdusde rpte^1mtl
Shift to the affected side
• Symp sis fracture
Usually associated with subcondylar fracture (opposite side)

tL
Fac.ial Fracture.. M idfacial Fractures

Le Fort I (Transmaxillary Fracture)/4.unit |14`Lfu^+
• Due to horizontal forces to the maxilla, whi.ch fractures the maxilla through
the maxillary sinus and a long the floor of the nose.
• The fracture separates the maxilla from the pterygoid plates and nasal and
zygomatic structures
i? Hdec.cLAittra^
+ PhLefu
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+ ,itlofofu ~
87
Facjial Fracture.. Midfacial Fractures

Le Fort 11 (Pyramidal Fracture):
• Due to forces that are applied in a more superior direction
• lt is the separation of the maxilla and the attached nasal complex from the
orbital and zygomatic structures
• Note: The attachment 9f the zygomatic bone to the skull is preserved
Pchcwhrftyeel
;fuapco`rfuT#ifaL~
ap,.sfato J`
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', t N I , , I 9 Y
Fatiiat Fracture.. Mid~facial Fractures

Le Fort 111:
• Horizontal force is superior enough to separate the NOE (nasoorbitoethmoid)

complex, the zygomas and the maxilla e crania
• There is cranial separation at the rontozygoma ntal
junction, orbital floor and zygomatic arch laterally.
Note: The NOE complex consists of the nasal, frontal,

maxillary, ethmoid, lacrimal and sphenoid bones
pREfseous
':3
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`tyD f3ie"fro,ttl aft

dylcA>f CA~ c=
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cr7`4|futh _doth
Fracturesansd„£MaT,i§e#Le`.n,:,sbo+i
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Facjial Fracture.. Midfacial Fractures
Zygomaticomax"lary`€oinp|efF;;;t'ur= at `T \hTtoTt`l lLj ff v+¥L^c, bo_i
•UsuaHyduetoadi.rectinjurytothemalareminenceofthecheek(assault)i
• Fractureof_thezygom
bone at the:
:1u,
2) Zygomaticomaxillary buttre
/):;::t=::,rc°oC;:Sx„[
3) lnfraorbital rim
4) Zygomatic arch
) Lateral orbital wall
ae
I = DOCTORS © 2017 Prep Doctors, all rights reserved
Factial Fracture.. M idfacial Fractures

Zygomaticomaxillary Complex Fracture continued:
Signs and symptoms include
• Periorbital edema and ecchymosis
• Epistasix
• Subconjunctival
::;:.tntenlngofthemalarprominence'] J}+c`
Hemmorrhage
• Deformity of the zygomatic buttress ' Crep itatjon
• Deformity of^the orbital margin
nequal pupillary levels
• Djplopja
fjFF\
:::I:e|tuhsesia?f cheektry • Enopthalmos
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ir`7 =OcTORs © 2017 Prep Doctors, all rights reserved
89
Ou 6 trycul
Fatiial Fracture.. Midfacial Fractures

Orbital Floor Fractures:
• Caused by direct trauma to the lobe. Can occur as an isolated injury or
can be in combination with other fractures (Ex. Le Fort 11 and Ill,
zygomatic arch fracture)
• Fragments of bone can get displaced downward into tral cavity.
• Ocular muscles such as the rior rectu s muscle and inferior
muscle can becomaefr]trap
fae:
PREP DOCTORS
Factàl Fracture.. Midfacial Fractures

Orbital Floor Fractures continued:
Other symptoms may include:
;::o::t;;s::(miit=.|36ulT
• Epistaxis Gel
_pr£4thJ±J
• Periorbital edema and cchymosis
• Subconjunctival ecchymosis
• Pupillary dysfunction
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PREl' DOCTORS
D,N,)St3,
i.
90
twos+ /+of whyi
Fitthcrfewi hard, b44j2+ prtrfut_
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ExtraOI.al Radiographic Techniques

LATERAL CEPH
Film paralli.I
to midsogEhal
pfang
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c
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tut
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Fractures and anagements

ErtraOral Radiographic Techniques:
Submentovertex
I AIIows for investigation of the palate, pterygoid region, base of the skull and
the henoid sinuses.
Visualize fractures of the zygomatic
aF:
_ . __ , I 0 RS
91
ExtraOral Radiographic Techniques:

Waters Projection:
• Allows for visualization of the facial skeleton and the maxillary sinus without
aE
I'REp DoeroRs © 2017 Prep Doctors, all rights reserved
Fractures and Managements ffi
hniques:
PosteriorAnterior Pr Ojectio
• Xray beam passes in a posteriorto anterior direction through the skull
• Used to identify disease, trauma, developmental abnormalities
•VisualizationofasymmetryduringorthedLendro`Jaln2±ion
\h ''1vT t5L (ZLactbeut dr.i ha,,+` \£ at`re+fu

Posit/LìaL AyLtituc,v oci
lot ah
slr\~ioc,ha`,
fee
PREl' DOCTORS © 2017 Prep Doctors, all nghts reser\/ecl
92
ExtraOral Radiographic Techniques:

Reverse Towne Pro n:
• Used when there is a suspected fractu
e condylar neck
dreL. ~ {4L` L|L^ uJL6i` CTC+^``
CÙcofl ¢Ls rmELLEL A±' PD€SlbEL,
I
ET=
i.=CTORS © 2017 Prep Doctors, all rights reserved
thraOral Radiographic Techniques:

Lateral Oblique View:
• Largely replaced by panoramic view
• Indicated to view positio
Û ur^
E=
93
Fracture Management:
Reduction
• Reduction is the process of restoring bony segments to their proper anatomic
locations after an injury
• This process should be done as soon as possible to avoid infection and mal
union
•fYx°att:;:.[QE£[i{:!±±Sairetat+enshlpshouldbeestablishedbeforereductionand
war+\ThEL^~TH+I,i+±=+cQ+dcLLuAfoLL~
fee:
I'REP DOCTORS © 2017 Prep Doctors, all ri8hts reserved
Fractures and Managements ffi
Open Reduction Vs. Closed Reduction:
• open Reduction: A surgical procedure to allow for dJ[S£L
air access to the fracture site. Used in severe b actures

in i dface fra ctu
The incision can be made intraorally, extra rally or a
combination of both.
cur
• Closed Reduction: When the fracture has aLjayQLur_able
PJ9BPQsjsfnd there is no displacement of the fractu
ln this process there is irect o Penlng an
manipulation of the fracture
fae:
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94
Open Reduction Vs. Closed Reduction:
• Open Reduction: A surgical procedure to allow for direct
access to the fracture site. Used in severe bone fractures
with displacement. It is also used for mid face fractures.
The incision can be made jntraorally, extraorally or a
combination of both.
• Closed Reduction: When the fracture has a
progm_¢i< and there is no dis ent of t

ln this process there is no direct opening and
a manipulationofthefracture area.
: : /DOCTORS © 2017 Prep Doctors, all rights reserved

uhJat # orul#\*qu¢|o
:icture Management:
Fixatlòn Rigid Fixation, onRigid (Closed) Fixation
• Rigid Fixation: Prevents micromotion across the fracture line allowing for
e er ealn .
without callous formation

• Some techniques used includ
ag screw techn pression
~
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95
Rigid Fixation, SemiRigid Fixation, NonRigid (Closed) Fixation
• SemiRigid Fixation: Allows for areas of primary and secondary bone
formation
• Both wire fixation and miniplates are considered to be types of semirigid
fJ&chT_
• Note: Miniplates are commonly used for open reduction and internal fixation
in both the maxilla and mandible
r::`/J//
I(
ae
I>REi> Doeroirs
Rigid Fixation, SemiRigid Fixation, NonRigid (Closed) Fixation
• NonRigid (Closed) Fixation: Maxillomandibularfixation (MMF) with arch
I
ba rs, ivy loops, transalveolar screws and ints are considered nonrigid
fixation.
MMF maintain er occlusal relatio ip by wiring teeth together for Ee.
more than 2
. Allowsforsecondary bone formation
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96
r).4j/ cAmw~ c®rf;^J±iJ.;A a/r3O ctAf an b))h irnfuJ
faJJfro
6
c
Edentulous Patient:
denture can be wired to the mandibl
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Osteomyelitis
97
Osteomyelitis
• Acute or chronic inflammator rocess in the medullary spaces or
• Begins in the medullary cavity, involving cancellous bone; then it

extends and spreads to cortical bone and eventually to the
periosteum,
faeE
I'R£P DOCTORS
Osteomyelitis
• Occurrence: (relatively rare)

• Much more common in the mandible than in the maxilla:
• The blood supplyto the maxilla is much richer and is derived from
• The denserQ!±er!ying cortical bonej2±±he mandible limits_penetration

of periosteal blood vessels.
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I>Rf p DoeroRs
u,Joe
erved
98
Wqual Py.tr iE C,N|)
Ver~L®i.t4thL^LJ PTt ]==grr Pt`t®i4
H4h+p+ pyi\aort PTT
rm4Sylst. i Pit £iti{ihul EIEE]EE= P|
Osteomyelitis
• Types:
1. Acutesu urative Osteom
• Exists
throu
• Patients havesigns and symptoms of an acute

inflammatory process. •,,(#Sg d soflJissge
• Xra
ned radiolucen
arkable or
.
demonstrate
Q' J|1 e L` Y\ {hoJ
rfu.go
Osteomyelitis
. Types:
2. Chronicsu urative Osteom
'::t:beii:,s:,::
• This pattern b=ETns to evolve about 1 month after the
spread of th
initial acute infection rocess that
manage unless the problem is approached aggressively.
aF=
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99
Osteomyelitis
• Treatment and Prognosis:

1. Acutesu urative Osteom
• lf obvious abscess formation
antibiotic medications and
èn:,ffi
the treatment
• The antibiotic medications most frequ
pLenicillin.clindamvcin..cephalexin,£eLot±±LmeJQbnmycin,
8e±cin.
•:nb:r:::£:ii:E:Sf::::fii:i:3:rat::haep::::I:::::::1::#|e:g::t::n
faE
pREp DOcToirs © 2017 Prep Doctors, all rights reserved
Osteomyelitis
• Treatment and Prognosis:

2. Chronicsu urative Osteom
•¥
• Very difficult t_o manage with antipi_gtics, b2££ausej2Qcketapf.dead
bone and or c drugs by the
I;.:
ul..\
Ontlbl
ae
I>REp irocTORs © 2017 Prep Doctors, all rights reserved
cELct tr€j*giv#
nE=
100
Osteomyelitis
• Osteomyelitis With
ftri=
Proliferative Periostitis
(Periostitis Ossificans,
Steomye
erative peri ostitis represents a periosteal reaction to the
presence of inflammation
•£,r+:C:e±^P.a±i::Es_tfep9tobeprimarilychildrenandyoungadults,
with a mean age of 13 years. Fro sex predi5fiTinance 'is noied
uent cause is caries with assp±pical
•rRoaud:#yrappat:,fei::cnhstor#:;at#:E:#,un%':fmtLnea:i:rnt:c:[B:#:(tih::12
in number). ±===='
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Osteomyelitis
• Osteomyelitis With Proliferative Periostitis (Periostitis Ossjficans,
Garr6's Osteomyelitis) :
• Treatment is directed towards elimination of the
source of
infection. extractio n of the offendin
8 tooth or appropriate
endodontic thera
• After the focus of infection has been eliminated and inflammation
has resolved, the layers of bone will consolidate in 6 to 12 months
as the overlying muscle action helps to remodel the bone to its
original state._
. `. i :..i`
_`\
i)(ThL
101
o9ieitL.I ?1
EEens,ngoste,t,stFo:,Sstc:e:a:n:::::,osmye,,t.s,
• Localized areas of bone sclerosis associated with the apices of_teeth with pulpitis Or
`__it]
sociation with an area of inflammatic>n is these lesions can
ble several other intrabony processes that produce a somewhat sim ilar
pattern.
• Seen most frequently in children and young adults but also can occur in older adults.
• Localized, usuaHy uniform zone of increased radiodensity adjacent to the apex of a
tooth that exhibits a thickened periodontal ligament space or an apical inflammatory
lesion.
fae:
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n I N,13? a y
Osteomyelitis
• Condensing Osteitis (Focal Sclerosing Osteomyelitis):

• Treatment and prognosis:
• Treatment consists of elimination of the odontogenic focus of i nfection
• After extraction or appropriate endodontic therapy o tooth'
approxi n8 Osteitis will regress, either partially or
•A
!9rty.
I area of condensing ostei
inflamlfiEtoryfocusistermed
t remains after resolution of the
pREf±ors
I, r H , I , , a Y
OcdrL
102
Fascial Spaces and lnfections
What are fascial spaces?

• Fascialined tissue
compartments.
• Filled with loose, avascul
ar'Ze connective tissue.
• In a heal th
y person, the deep fascial spaces are Qn±l
„ t.|f ro`
.§Pnaccee=::::::=::::::mtmt:n#a:emwr=h::ac::t;:rrt;eT:fFo: ha4£ L"tqu`
can spread rather quickly. Even all the way to the mediastinum.
103
NanOdontogenic lnfections: Independent of the teeth examples
• Lyis.
ections o Woun ds due to injuries.
• PosL±onifection.
• Infection of the skin and mucosa (ex. labial herpes, herpes zoster).
Odontogenic lnfections: Arises the teeth (majority of cases)

• Periapical.
• Periodontal disease.
• Postextraction infection.
• Pericoronitis.
faeE
l>REi. Doeroirs © 2017 Prep Doctors, 311 rights reserved
Progression of Odontogenic Infection:

• Pulpitis? Necrotic Pulp.
• Periapical Periodontitis.
• Osteomyelitis, Periostitis.
• Abscess, Cellulitis.
pREf±ous © 2017 Prep Doctors, all rights reserved
104

• The infection is ir!itiallv localized to the Dulp and the root canal
(PELS and necrbtic pulp)

• The infection then spreads via the apical foramen to the periapical
area

• From the periapical area, the infection s
reads into the bone
(Osteomvelitis)
• lf the infection erodes throu
h the cortical plate ( Periostitis
105

• The infection breaks through the periosteum and is localized under
the mucosa Abscess
• The infection can spread to deeper locations including the fascial
Spaces
Characteristics Cellulitis Abscess
Duration Acute phase Chronic phase
Palm Severe and generallzed Localized
Size Large Small
Localization Diffuse borders Wellcircumscnbed

Palpat,On Doughy to indurated Fluctuant
Presence of pus No Yes
fee
Less
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Progression of Odontogenic Infection: The location of the abscess and

the spread of the infection depends on a 4 main factors:
1) Infection erodes through the thinnest bone and causes

infections in the adjacent tissue.
faeE
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106

• For example the labial bone overlying the apex of anterior teeth is thin
compared with the palatal
• Therefore, as the infection spreads its more likely to go through to the
labial creating a Vestibular Abscess.
ae © 2017 Prep Doctors, all rights reserved

• lf the tooth is severely inclined (for example in th
fae:
ii = rocloRs © 2017 Prep Doctors, all rights reserved
107

2) The relationship of the oint of bone perforation to the muscle
attachmenLrty vement for example:
• When the tooth a ex is lower
abscess
• lf the infection erodes through the bone superior to the attachment of the
muscle (buccinator) the adjacent fascial space is involved >Buccal Space
fee:
I'Rf l' DOCTORS © 2017 Prep Doctors, all rights reserved

3) Virulence of an organism.
4) Patients immune system.
Note:
'M ost odontogenic infections will penetrate the bone and become a vestibular
• On occasion, the infections erode into deep fascial spaces directly.
fee:
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108
Fascjal Spaces and lnfecti.ons
Symptomsoffasci.all.nfection/Inflammation:
• Pain
. Dysphag,.a
• Dysphonia
• Trismus + Difficu'tym openingthe mouth duetoatonicspasm of the
muscles of mastjcati.on
rtrykyH1.equudrs`=`Dtttry
ul
e'.p n G7 ònTh
© 2017 Prep Doctors, a« rlghts reserved
Fascjal Spaces and lnfectjons
.>rjmary Facial Spaces:

DlrectlyAdjacentToTheOrlginOfTheOdontogemlnfectlons
1)Vestjbu'ar4EEEBiinuL.
Bucral Space
2) Buccal cnar
3) Palatal Space
4) Subli.ngual Space
5)Submandjbularspace
`9st:%*i:%**
€).Ma,xjllarysi.nus
© 20" Prep Doctors, a« r/8hts reserved
109
Symptoms of fascial infection/Inflammation:

• Pain
• Dysphagia
• Dysphonia
• Trismus + Difficultyin openingthe mouth dueto atonicspasm of the
muscles of mastication
rty in rqu in.s`= bDft hi

fse5ous © 2o]7 Prep Dfr¥r:s=:ved61 [OnTh
Primary Facial Spaces:

• Directly Adjacent To The Origin Of The Odontogenic lnfections
1) Vestibular 4E± irno

2) Buccal Space
3) Palatal Space
4) Sublingual Space
5) Submandibular Space
`;T`{;%'#Ay:¥*frat`9frfty~
109
Secondary Facial Spaces:

• Facial spaces that become involved following`spread of infection from the
primary spaces
• lnclu
Tndrut,
ry8Oma
I & deep temporal i: .,. __..` .. :
faei.
PRE iJ DocToirs ©zO,7prepDO:a:aifeiedi£|rfuiut
lnfections arising from the maxillary teeth:

. infraorbita| space ~> {T CA` ûl ha \® tEL~ }j}`Ctryha"dot:a ul=:+
• Buccal Space
• Palatalspace hLJ`(W\ quu
• lnfratemporal Space L4`,

• Maxillarysinus
fae:
110
Infections arising from the maxillary teeth:

lnfraorbital space:
• Potential space between the
levator anguli oris and levator labii superioris
``1,11`.` I ..
•lnfectionofthemL±ZS!!!!P!±±±jL=a±jJ±e
or extension of an infection from the
buccal space
Fascial spaces and lnfections ff

Buccal Space:
Tnfection oTi;rnating from the posterior maxillary teeth
• Perforation of the buccal
cortical bone and eriosteum superior to the
attac ment 0 the buccinator muscle
• Swelli ng below the zygomatic arch
t:i`':tlo`ctl+ ? bLng\
``1\.
ilf

Palatal Space:
• Infection from maxillary teeth erode through palatal bone and get entrapped
beneath thick palatal periosteum
Origin:
>Any max teeth (rarely canines)

>Laterals (severely inclined lateral incisors)
>Palatal root of A maxillary lst molar
> ist premolar
FIE:
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Infections arising from the maxillary teeth:

lnfratemporal Space:
• Rarely infected
• Lies posteriorto the maxilla
• The cause is usually an infection in the third maxillary molar
NOTE! Conlalns branches of the ate

the ad of the infection to the cavernous sinus #:.I.Yi#:
fee
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112
fuoJL,VY
bucì\JL_tot
unit
L).1 CJ=+ a Lo c fu 1" kwyou#wyu
i)c\LeJ=c u+ 7 , Vt` i €0"J i,dy'Lal,J
i"clv,`,\\`vl S\ yl w ,
bJc hf ve
iiiiiiiiiiii= thvJ+"JL
c,,QJ
o , aJtt
toriwl,
Fascial Spaces and I uvtirotw)
:`. `:.
QAv`W,
VAhQ~
Maxillary Sinus:
/ ht,,
• Infection of the maxillary posterior teeth eroding superiorly through the floor
of the maxillary sinus
• Can cause swemng and redness around the eyelids
• The infection can sDread directlvJlmh= ==r,.=rT,L|,i]
gr cavernous sinus thrombosis) anteriorly via the inferior and superior

PPEaJmJ
• This can be a life threatening, serious infection
jaE
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lnfections arising from the mandibular teeth:

Can erode into the vestibular space or deeper fascial spaces such as:
• Buccal space
• Perjmandibularspaces (Submandjbular, Submental, Sublingual)
• Masticatory spaces (Submasseteric, Pterygomandibular, Superficial And Deep
Temporal)
NOTE! lnfections can spread into the deep fascial of the neck compromising
breathing. Can even extend into the mediastinum to threaten the heart, lungs
and great vessels.
aB=
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113
Infections arising from the mandibular teeth:

Buccal space:
• The posterior mandibular teeth perforate the buccal cortical bone and
periosteuminferiora=±totheattachmentofthebuccinatormuscle.
faeE
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Submandibular (perimandibular spaces):
• Lies beneath the attachment of the mylohyoid muscle
nI
• Communicates with the deep fascial spaces of the neck
• Etiology: Lingual_per_for_at_Lon of infections from the lowe
molars (usuaily the sEE5hdand third)
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114

Submandi bular (perimandibular spaces)
• Large submandibularswelling!

Sublingual Space Infection (Perjmandibular Space):
• Lies between the oral
mucosa of the floor of the mouth and the mylohyoid
muscle
I
: :t::I::T;i::::iayt:h:i;|rstth:::abr:aa::i:rue':ros,::sce(aLivrty fr
• lntraoral swelling, causing the tongue to be elevated
aF=
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\bwh i\.\^pr hwhv MtrA+trQ\ ,chthil` t5mlJull,i \
ky tap ut~ `hthThus whdiT cs\ùrfuLiarJ nya Lh


Submental Space Infection (Perimandibular Space):
• Between the mylohyoid muscle superiorly and the plat sma muscle inferiorl
• Etiology: I infections are rare enerall read from
submandi ar infection ), caused by infections of the lower incisors
faeE
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Masticatory Space Infection:
• Submasseteric
• Pterygomandibular
• Superficial Temporal
• DeepTemporal
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116
lnfections arising from the mandi r teeth

Masticatory Space lnfectio bmasseteric
• Space between the mass
surface of the ascending ramus of the mandible
• From
(perJprnitial=
• Causes swellin
trismus masseter muscle
aE=
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I,3TgY

Masticatory Space Infection: Pterygomandjbular
Space
• Between the medial pte
rygoid muscle em ial
surface of the ascending ramus
::'at::°erinufee:I:a:an`=::,I:rtrnaecrkvjenfbe':t:§n
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117

Masticatory Space Infection: Pterygomandibular Space
• Infection primarily from the third molar area (ie pericornitits)
Little to no facial swelling

SIGNIFICANT trismus (medial pterygoid muscle involvement)
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Masticatory Space lnfectiom Temporal Spaces
Superficial Between the temporal fascia and the temporalis muscle
DeepBetween the Temporalis muscle and the skull
. Rare severe cases
fee:
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118
Fascjal Spaces and lnfectjons
Cel.Vical Fascial S aces:

• Lateral pharyngeal
• Retropharyngeal
• Prevertebral
+~<+wJ
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1¥rp`pqeET9RS
Deep Cervical Fascial Spaces:

Lateral pharyngeal:
•ExtendsfromthebaseoftheskuHatthesphenoidbonetothehyoidbone
inferiorly.Medialtothemedialpterygoidmuscles,Iateraltothesuperior
pharygneal constrictor muscles.
• Contains the carotid sheath and cranial nerves (lx,X,XIl). May cause
thrombosisofinternalj.ugular,erosionofthecarotidartery,interferencewith
nerves
• Extends to
the retropharyngeal
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119
Deep Cervical Fascial Spaces:

``
Retropharyngeal Space:
• Lies behind the soft tissue of the posterior aspect of the
T3 Infection can proceed via t 'S Space e mediasti
3~'*:#(lhvît&i
`:= .`' .:. .
`s;;`;v?:j\&#¢ ±^@e,y+Mpit
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C ILrwl\ rv`
utfu ,i
*iirghts?et*Tur"ult
\ a \\\\
`3ulbtylo`
121
ig,s Angina :
LifeThreatening cellulitis of the floor of the mouth
When the r spaces (submandibu !aLsublingual and submental)
• This infection is a rapidly spreading cellulitis that can obstruct the airway and
commonly spreads posteriorly to the spaces of the neck
• Diagnosis is based on history and nature with CT
fee:
122
123
Odontogenjc Infection: Incision and Draina
• Management of Odontogenic lnfections:

• Incision and Drainage.
• Incision of the abscess or cellulitis allous removal of the accumulated pus
and bacteria from the underlying tissue, decreases the lriarl nf hartcin.a
_I _____J.:_ _I_I_ .
and necrotic debris and reduces the h drostatjc ressure jn the re
8ion by
decompressi ng tissues, which improves the local blood
increa ses the enses and
•u_after
area
• Fluctuance: body forms a

localization of infection (fluctuant
barrier around the abscess, separ
infection from the surroundings (circulation).
fee:
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Odontogenic Infection: Incision and Draina

• Technique:
• Anesthesia:
'1
:::i:#.t,:#:uO#e,:r:i: presence of inflammation
preferred
Short incision about lcm

• Healthy skin/M
Cosmetically & Functionally Acceptable place
• "Incision should be made
firm th rough periosteum to b One" endodontics
• " Incision is made ... throu
e mucosa and submucosa into the
contemporary Oral & maxinofacial surgery 5`h ed, By Hupp.
fee:
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125

• Technique:
• BIunt dissection:
• Break up small location or cavities of pus that have not been
e ln'tla
• Drain
• Small drain inserted to maintain the opening
• Sterilized rubber drain may be used
• The drain is sutured in place with a nonresorbable suture
fact
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• Technique:
• Remove the drain:
• Gradually form deep sites
• Drain should remain 25 days
fee:
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126

• Technique:
>=apicalinfectionthrough Abscess is Beaks of hemostat are inserted small draln ls

:.+cal plate created a Incised with through incision and opened so that inserted to depths
lei;:.b u la r a bscess No.11 blade beaks spread to break up any of abscess cavity
loclllations of pus that may exlst ln
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abscessed tissue

• Technique:
The drain js sutured into place
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127
Foltovmup
provantho and
Tostorotbe care
H,Story ul
physlcal omminaton
pa,n
swenhg
11 mo
perkrdontits
peiberonm9
Assess Severty
enrmy crmpromlse
i anaou unkm
O##"c rate ol pTogreesfori
E\raluato Herd DOTer\ses
merdcat corrrorbldmoa
inmune onprtrfeo
Bysromc reervo
1
X.ray emmhatlco
pehapca I peoi03ts
perirfutat bone lose
inpacndfroih
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Healing
Soft tissue Healin

Secondary intention:
• Agap is leftbetween edgesofthewound
• Reepithelialization migration from the wound edges, collagen deposition in the
connective tissue, contraction and remodeling during healing.
• Healingisslowerand results in scarringandwound depression
• Example: Extractionsocket
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130
131
'`'` <|". _ |° INe^ho,.``f icaLL]
q;i > \vy\Th r iT\apr`trir~: pÂA¢L'.dr
ftfro ut+v\ L,defty CJftyu ff AOL# LchLLe( futhA

LoxpLLe! \dvi.
®.hu\ ,BLff cJal

•` ..`, ba~ l'J"
3+ ){Lha4 4.prfty. €m©rd,La
Frenulum
LT#mAmngrw:Fc`Cve#a:LFT#onJ"froc,4L.at
6n'o4`LLL\ S\^ nun ei„ùlc €&~t

J,
pREfsesoRs © 22=r:òo?o#S}t„eserved
132
Frenulum
• Frenectomy:
• Labial frenal attachments consist of thin bands of fibrous tissue covered with
mucosa.
• Extends from the lip and cheek to the alveolar periosteum.
• The level of frenal attachments may vary.
• from the height of the vestibule to the crest of the alveolar ridge and even to the incisal
papilla area in the anterior maxilla.
• With the exception of the midline labial frenum in association with a
diastema, frenal attachments generally do not present problems when the
dentition is intact.
• Construction of a denture may be complicated when it is necessary to
accommodate a frenal attachment.
fee:
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133
!S'3. ( ,`*g:L`•,`r,:<,;?;*`,Frenulum
• Frenectomy:
• Surgical Techniques:
• Anesthesia:
• Local anesthetic infiltration is often sufficient for surgical treatment of
frenal attachments. Care must be taken to avoid racci`/a anoctheticinfiltrationdirectlyinthefrenumareabecauseitmayobscureth
artatomv that must be visualized at the time of excision
fae:PR[l'DOCTORS
134
Frenulum
• Frenectomy:
• Surgical Techniques:
2. ZplastyTechnique:
• An excision of the fibrous connective tissue is done similar to that in the
simple excision procedure.
• Two oblique incisions are made in a z fashion, one at each end of the
previous area of excision.
• The two pointed flaps are then gently undermined and rotated to close
the initial vertical incision horizontally.
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135
Diseases of the Maxillary Sinus
• Inflammatory diseases of the sinus such as infection or allergic reactions cause

hyperplasia and hypertrophy of the mucosa and rna cause obstruction of the
ostThhi. _
• lf ti=:ium becomes obstructed, the mucus produced by the secretory cells
lining the sinus is collected over a long period. Bacterial overgrowth may then
produce an infection, which results in the signs and symptoms of sinusitis as well
as the radiographic changes seen with these conditions.
fae:
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DiseasesoftheMaxillarysinus grRE
developing sense of
vicinity of the affecteL±sinus (premolar
:LfiLffnua#essese,nthj
Often this p mistaken for dental ain, however in this case the teeth
remain vital. There is generally 0 Perc of multiple teeth that border the
sinus
• lt may be accompanied by f_afi±i swelling and erythema, malaise. fever. andrlraipLage
rynx.
::I::#sTnu=t::isug:a;;::!!!i;a;E::g:::::fi;::::::::::::5::::?:::rtaq uires
jmT±nand aggressl.ve medica Sur8lca
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140
141
Dental Patient Management
.a
• Young patient usuallytolerate surgeryverywell

• Older individuals have the most postoperative difficulties
• Try to minimize complications, perform atrumatic surgery
.a
142
Instructions followi"! oral surgery/extraction:

•No spitting, no rinsing for 24 hours >> to prevent plug dislodgment
•Bite down firmly on the gauze for 3060 minutes
•Warm salt water rinses starting 24 hrs post extraction.

•Nothing too hot for the first 24 hrs.
•Do not drink through a straw (negative pressure)
•Avoid smoking & alcohol
•Don't bend over>> keep head elevated
fee:
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discomfort:
• Expectacertain amount of
Paln
• Analgesics>> NSAIDS/opioids
Swelling:
• Its not uncommon for swelling/ bruisingto occur following oral surgery
• lcepacksappliedl5 m'n On 5min off
• Mightgetworseòverthe nextcòupleof days
(2448hours)
• Maximumswellingwithin72hr
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Hemorrha Bleedin
• Normal for fresh extraction site to ooze slightly for up to 24 hours
• Prevention ofpostoperative bleeding:
• Reviewhistory
• Atraumaticsurgical technique
• Obtain good hemostasis at surgery
• Provide patient instructions
f9eE
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Means of obtaining wound hemostasis:

Assisting natural hemostatic mechanism
Use of heat (thermal coagulation)
Suture ligation of the vessel
Placement of a pressure dressing over the wound

Use a vasoconstrictive substance
fact
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', r \ 7 ) , , a ,
145
Primary Hemorrhage:
• Occurs duringthe surgery
• Occurs normally due to laceration injury or transection of vessels (arteries, veins,
capillaries) in the area
Management:
• Pressure
• Electrocautery
• Vessel ligation
• Bone wax or other topical hemostatic agents
faE:
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Postop. Hemorrhage:
• lt is NOT normal for hemorrhage to persist after the surgery in normal patients.
• Instruct the patient to bite on gauze
• Instruct the patient to bite on a tea bag >> Tannic acid promote hemostasis
• Hemorrhage persist usually due to:
Bleeding From Vessel Not Having Been Taken Care Of
Mechanical Dislodgement Of The Platelet Plug
High Pressure Within The Vessel Preventing The Formation Of The Plug
#[:
PREP DOCTORS
Granulation Tissue Remnants
146
147
148
Local Hemostatic Agents:
• Used locally to stop bleeding caused by injury of small blood vessels.
• Fully absorbed by the body withl.n weeks
• lndicati.on; post extraction bleedi.ng socket
• Types,
A. Natural collagen sponge
A white nonantigenic sponge materi3l
a. Gelati.n sponge(gelfoam) :
A nonantigenic sponge material
C. oxidized cellulose (surgical):
Avajlable ingauze form or pellet form
D. Bonewax
ls a sterilized, nonabsorbable solid plate of wax.
Used to control bleeding orlginatlng from bone or chlpped edges of bone
Thehemostaticactlonlsdonethroughthemechanicalobstructionoftheosseollscavity
fae:
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Materialsforcoveringwoundorfillingsurgicalcavjty
1. Vaseline gauze:
o Preparation : gauze in sterilized packages
o Indications: to cover exposed wounds, bony cavities
•}`. ` .... `
2. Iodoform paste and gauze:

oPreparation:availableinaribbongauzeorpastethathasantiseptic,analgesi.c
and hemostatic properties
olndications:tocoverexposedwounds,bonecavitiesandtreatdrysocket
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149
Hematoma:
• The effusion of blood into extravascular spaces.
• The blood effuses from vessels until extravascular exceeds intravascular pressure,
or until clotting occurs.
• Caused by nicking of a blood vessel during administration of LA
• Swelling and discoloration of the region usually subside gradually over 714 days
• Hematomas that occur after the inferior alveolar nerve block are usually only
visible intraorally, whereas posterior suEierior alveolar hematomas are visible
extraorally
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Hematoma:
Prevention:
• Knowledge of the normal anatomy
• Use of short needle for the PSA nerve block
• Minimize the number of needle penetration into tissue
• Never use a needle as a probe in tissues
• Hematoma is not always preventable ky/rjJan^
pREfse5asdrofiope:ubps3Mtoa]Q:#it{o:ckt'|rd{:;tetLc,`rd`L{\"'n®`
0 I H J \ r, Y a T
151
Hematoma:
Management:
• Direct pressure should be applied to the site of bleeding for no less than 2
minutes
• Advise the patient about possible soreness and limitation of movement (trismus)
• Discoloration is likely to occur as a result of extravascular blood elements,

resorbed over 714 days
EL#ng fto#w: :d:ulal;L1+edfro„.Salma4i ?i

a OEL;rth
I, r\r\,T,\t, a
PRDEfpkpp3q39RS\ ..
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152
Trismus:
•Limitation in mouth opening, often associated with pain
•Symptoms usually arise 614 days after surgery.
Causes:
• Muscles of Mastication >> inflammation ortonl'c spasm
+ Anesthetic Needle >> if i

LnieLS±!9P±±!!£J2±±Le±ratedmuscleMeflja!|2±s!:¥g8Ld
• Surgery >> excessive trauma or post surgical infecti.on
• Heamatoma
• TMJ Disc Displacement>> deferential diagnosis
ffa'nfect'°n'>faclallnfections,pericoron,t,s
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154
155
157
J:' Ai) ):s( 'i(a ;zg! +>`
Dental patient Management A/;~un`quk£:Li£,Fracturesltuberositv):
• The maxillary tuberosity is important forthe construction ofa stabl ntive

maxillarv denture.
Management of fractured maxillary tuberosity:

• lf the bone remains attached to the periosteum >> tuberosity should be stabilized with
mucosal sutures
ap . lfsplint
the the
tuberosity
tooth andis eter
excessively mobile
the exl:raction and
Tor b8 cannot be dissected from the tooth >>
weeks
• lf the tuberosity is completely separated from the soft tissue >> smooth the sh rp
edges of the remaining one. rcipusiiiuri driu su[Llre [ne remainings ft tissue
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158
A, y(`,T`,DentalpatientManagementf~: ._L•OroantralCom unications:
• Communication between the oral cavitv and the maxillarv si

nus
• Removal of maxillarv molars ocracinnallv results in communication betweentheoralcavityandthemaxillarvsinus.
• Factors Increasing The Risk Oroantral Communications:

1. Singlemaxillarymolar
2. Pneuma iza[ionoTt emaxillarysjnus.
3. Little or noboneexistin between the rootsoftheteeth andth 11
. ooso t etoot arewidelydivergent.•Sequelae: *r( EN\aex,§g\ r:
x ,ife\.xa..„ `g\.`\
1. Postoperative maxillary sinusitis.
2. Formation ofa chronlcoroantralfistiila. st> .`"ngTas' is
~
fee:
159
162
163
• Root Displacement:
• Management:
• lf the tooth fragment is a small (2 or 3 mm) root tip, and the tooth and
ave no reexIS
• First attempt: Irrigate through the socket and then suction the
irrigating solution from the sinus via the socket. This occasionally
flushes the root apex from the sinus through the socket
• lf not successful, no additional surgical procedure should be
performed and the root tip should be left in the sinus.
• Patient must be informed, Regular monitoring of the root and the
sinus.
• The oroantral communication should be managed as discussed.
pREf±oms © 2017 Prep Doctors, all rights reserved
164
• Management:
• lf the tooth root is infected or the patient has chronic
sinusitis:
• Removal of the root tip via a CaldwellLuc procedure.
• lf a large root fragment or the entire tooth is displaced into
the maxillary sinus, it should be removed by CaldwellLuc
approach.
fact
• Management:
• CaldwellLuc approach:
• Surgical opening into the maxillary sinus by way of an incision into the
canine fossa above the level of the premolar roots.
• The patient should be referred to an oral surgeon to perform this
procedure
fae:
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165
Temporomandibular Disorders
Classification of Temporomandibular Disorders:

• My_i_ofa scial Pain • Systemic Arthritic Conditions
• Internal Derangements • Chronic Recurrent Dislocation
• Anterior Disk Displacement with
• Ankylosis
Reduction
• lntracapsular Ankylosis
• Anterior Disk Displacement
Without Reduction • Extracapsular Ankylosis
• Wilkes Staging Classification for • Neoplasia
Internal Derangement of the • lnfections
TemporomandibularJoint
• Degenerative Joint Disease
(Arthrosis, Osteoarthritis)
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166
• Internal Derangements:
• Normally the condyle functions in a hinge and a sliding fashion. During full
opening, the condyle not only rotates on a hinge axis but also translates
forward to a position near the most inferior portion of the articular eminence.
0/.,`...,.¥! •f.`,..`.giv§:i
The biconcave disk is interpositioned When it translates forward, the thin Maximum open position.
between the fossa and the condyle intermediate zone stays in consistent
in the clo'sed position.
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a 8 ri T i .. , R Y
167
• Internal Derangements
• Anterior Disk Displacement with Reduction:
• The disk is positioned anterior and medial to the condyle in the closed
position.
• During opening, the condyle moves over the posterior band of the disk
and eventually returns to the normal condyleanddisk relationship,
resting on the thin intermediate zon
• During closing, t e condyle then slips posteriorly and rests on the
faE
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£ \hJm4ct? JAiL p4L4eLea~

1,.\_.:.+ gL#T ur:"L``~vulT
&rc„hcLg|~ SftyqL 4 ctft<
• Anterior Disk Displacement with Reduction:
toutds
•,`::.,.,,,`=\::.:. : = : ==i
Biconcave disk is situated anterior to Afterthe click occurs, the disk remains in Maximum opening position.
articulating surface of condyle. When the appropriate relationship with the condyle When the mandible closes, the
condyle translates forward, it eventually through the remainder of the opening relationship between the
passes over the thickened posterior band of cycle. condyle and the disk return to
the disk, creating a clicking noise the first position
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rs,h
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168
• Anterior Disk Displacement without Reduction:
!'''`F`¥i.
When the condyle begins to In the maxjmum open position, the disk
translate forward, the disk tissue continues to remain anterior to the
remalns anterior to the condyle, with the posterior attachment
rtry condyle. tissue interposed between the condyle

and the fossa.
fab
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169
171
Temporomandibular Disorders tfin L~ex_L~_I.D:E=c:uedr::jj¥ree::,jfnr:DDejrsf::ast:jsr:hr3esrj:,ydamaRE:sj,jassoc,at,onw,th
articuiar surtace abhormalitioTa ci irh±cular surface flattening anderosions
• Three possible mechanisms of injury:
1. Direct mechanicaltrauma.
2. Hypoxia reperfusion iniury.
3. Neurogenic inflammation.
G cfudci pcapiL`
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172
• Chronic Recurrent Dislocation

• Treatment:
•:;s:t,:cr::oLnte:n:ttt#[:h::::6;n::ribTerp::sshuer:::#:,cyhTg,da::onmw;::,gae:,upr:s::rior
• Muscular spasms may prevent simple reduction.

• Anesthesia of the auricular temporal nerve and the muscles of mastication
may be necessary.
• Sedation to reduce patient anxiety
instruction after reduction;
Restrict mandibular Open'`ngf r 2 to 4 wee
ML9jsiber.
Nonste roidal antiinflammato
RI
fee:
173
Temporomandibular Disorders Treatment#
• Nonsurgical Therapy
• occlusalspllnts: ,) dot ,i,u_ ûtw 'h wo t?"r. L,`~/I,i L|`vLL#``
A. AL±±±g±epg±i!igpjpg: For muscle orjoint pain when no specific
anatomically based pathologic entity can be identified.
Br! nterior repositioning splint: Protrudes the mandible into a forward
osition, recapturing the normal disccondyle relation.
C| 1 L i
ELLi|.i,foJ:``cLfol
pR[f±ous
i, , v T , , t g y
175
stst`.((,
Temporomandibular Disorders Treatment##;`:=~ae "•SurgicalTherapy:
• Indications:
n
• Patients with pain and dysfunction with signs and symptomsj]£L
C5 . part|cnuiariy ifd|agn:::td ::tahpadvaTTced Internal d:r:nges+ent caused
by ankylosis, rheumatoid arthritis, or severe degenerative

osteoarthritis.
• Patients with no improvement in range of motion and mouth opening
o candidates for surgical therapy.tsreserved
despite conservative treatment are alspREeeors©2Oi7prepI,actors,a,,I,gh
176
177
178
179
Orthognathic Surgery
ls the art and science of diagnosis, treatment planning and execution of

treatment by combining orthodontic treatment, oral and maxillofacial
surgery to reform the musculoskeletal, dentoosseous and soft tissue
deformities of the jaws and associated structures.
• To achieve a successful orthognathic surgery, it requires comprehensive
understanding and cooperation of the oral and maxillofacial surgeon,
orthodontist and general dentist.
• Proper diagnosis and treatment plan requires executing the treatment at the
appropriate time and referral to the needed specialists when needed. Such as
periodontists, endodontists, neurosurgeons, ophthalmologists,
prosthodontists, plastic surgeons and speech pathologists.
fEE
180
Types of imaging techniques used for diagnosis of dentofacial

deformities:
1. Lateral cephalometric radiograph
• Useful to analyze the skeletal, dentoalveolar and soft tissue relationships in the anterciposterior and
vertical dimensions
1. Panoramicradiograph
2. Periapical radiograph
• Both panoramlc and perlapical radlographs are helpful to determine the teeth alignment, root angulation
and any present pathoses.
• Some patients need other imaging modalities such as posteroanterior

cephalograms, TMJ tomograms, MRl and CT scans.
fact
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181
Dental Model Analysis

Important to establish proper diagnosis, treatment goals especially for the
presurgical orthodontic aspect of the treatment plan
1. Arch length measurements
2. Toothsizeanalysis
3. Toothposition
4. Archwidthanalysis
5. Curveofspeeandwilson
6. Cuspidmolarposition
7. Tooth arch symmetry
8. Missi.ng, broken orcrownedteeth
aE
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Definitive Treatment Plan:

1. Dental and Deriodontaltreatment
2. Extractions +]rfun /ei|4ì the+J 4whso\Lhertyl
3. Presurf!ical orthodontics
4. Orthognathicsureerv
5. PostoDerative orthodontics
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182
3. Presur orthodontics 6 Goals

1) Position the teeth over the basal bone and eliminate dental
compensation.
•::rd:'sct;:::,P::8:i::a:eenxeps::€'a°nn'b:r:I:8:8'i:,XpP,annts:::fi°pr:I,:,do:T::Cecxapr:n:':snt'
be taken to avoid transverse orthodontic relapse.

• Long term retention js required to maintain a stable occlusion
2) Align and level the teeth within the arches according to the
determined ceph, models and clinical analyses.
• Ex: for the excessive curve of Spee can be corrected either orthodontically or
surgically (mandibular body osteotomies).
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183
3) Adjusting toothsize discrepancy:

According to Bolton analysis if the discre it may be impossible to
achieve a class I canine relat ical orthodontic adjustments.
Osteotomies can be also used to correct certain
4) Correcting rotated teeth
5) Plan for divergence of roots adjacent to surgical sites
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• lf roots are too close to each other postsurgically it can lead to periodontal problems
that can lead to loss of interdental bone and teeth.
61 Coordinating upper and lower arch widths: such discrepancies can be
corrected orthodontically or by dentofacial orthopedics or surgical rapid
maxillary arch expansion.
aF:
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184
185
Orthognathicsurgery: Mandibular fir r:cL@3.Verticalramusosteotomy:
• Aim of surgery: irearing Mandibular Prognathism

• 2 approaches : Extra And lntra Oral Techniques
• Extraoral technique :
• Lateral ramus exposure performed using a submandibular incision
• Then the ramus is sectioned in a vertical fashion
• Th\entheentirebodyand anteriorramusare moved oster. ly•Proximalsegmentotramuswilloverlatment.•Healingphaseincludesmandiblestabilizationwithwiringoftherfn`^r`+.IoaTI^nllclna|MF
fr ThTsr:sJTt;in pro eroc eteae
Orthognathic Surgery: Mandibular
3. Vertical ramus osteotomy continued:

• lntraoral technique :
• lntraoral technique is the same as an extra oral technique,
however it's done with an intraoral incision.
• Eliminates the need for skin incision and decreases the risk of
damage of the mandibular branch of the facial nerve
• Healing phase includes stabilization using IMF with/out direct
wiring of the segments or by using rigid fixation with bone
plates or screws which eliminate the need for IMF
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186
Extraoral approach of vertical ramus osteotomy
A Submandibularapproach to lateral aspect ofuamusshowing lntraoral approach of vertical
vertical osteotomy from sigmold notch area to angle of ramus osteotomy
mandible
a Overlapping segments after posterior repositioning of anterior
portlon of mandible
Proximal segment containing the condyle's is overlapped on the
fa±atera'aspectoftheanteriorportionoftheramus

fa.ii.vO..uL.,...u,DL.y.
4Sag,tta,sp,,tosteotomvi,#aptc.a,ngivTh
• Aim: Cgrrecting mandibulaT defifjenc}4are)¢de€
• Horizontal osteotomy on the medial aspect and vertical
osteotomy on the lateral aspect of the mandible is
performed to divide the ramus
• Then these sections are connected by anterior ramus
Osteotomy
• The lateral cortex of the mandible is then separated \€
from the medial aspect Bilateral sagittal spl ff*+c,
• Mandible is either placed forward ( in deficiency) or osteotomy with
advancement of mandible
backward ( in excess ) for treatment of class 11
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187
6. Inferior border osteotomy (Geniopl
A. Achievefavorable position ofthechin

8. Vertical reduction, augmentation or correction of
asymmetries
• lnfe_rior por±!Qnof tbe mandlble ls Qsleatamlzed, then
moyLedforwardandfiabilized.
•3l'o°j::ae±ugmentch,n A. Advancementof inferior
border of mandible to
increase chin projection
a. Alloplastic implantcan be
used to augment the chln
ae
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anterior portion which
eliminates the need for
osteotomy
188
189
190
Orthognathic Surgery: Distraction Osteogenesi
• Aim: correction of deficiencies jn mandible and maxilla
• This technique involves cutting an osteotomy to separate

segments of bone and application of an appliance that facilitates
the gradual incremental separation of bone segments.
• This gradual change helps in continuous bone deposition with
maintaining the integrity of the surrounding soft tissue such as the
muscles, tendons, nerves, cartilage, blood vessels and skin.
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192
193
194
Bone Grafts
Classification of grafts:
(also called al!ografts):. are composed of tissues taken from

ual of the same s es who is n ot genetically relaTedtanebarfent
(usually cadaver
Pes
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grafts.
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Fresh frozen bone : However is rarely used due to the concern related to transmission of disease.
195
196
Bone Grafts
The ideal graft properties:

• Should be replaced by the host bone
• Withstand mechanical forces
• Produce no immunologic response (or rejection )
•A::it¥elyassistosteogenic(boneforming)processesofthe
NOTE! The greatest osteo lc otential occurs with an

enous cancellou ;teg?gfetn: dp hemopoietic marrow.
aYltoopi astic 8 rafts cannotbe us ed in phase 1 osteogenesis
slnce no via enlc Ce s are presen
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Bone Grafts
Fixation of Bone Gi.afts:

• Boneplates
• Biphasicpins
• TjtaniumMesh
• lntraosseouswires
• SuturesAre NotGenerally used
fab
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197
199
Dental Implants
Contraindications:
5. I.V Bisphosphonate Therapy
1.Acute/terminal illness
previous i
2.Poor oral hygiene Suspicion that therapy is an absolute contraindical|Qn
inadequate ygiene is likelyto continue tg_+1,af:unrtgeeTryp:fJ?mes
is a relative contraindication
3.Uncontrolled systemic disease ie Hupp

Uncontrolled diabetes, bone metabolic 6. Other factors; unrealistic

disease expectations, improper motivation, lack
4. Tumorcidal radiation of operator experience, nonrestorable
implant site (prosthodontically)
Pyma Ow imp
200
thB3bnyDetalImpntsImplantPcemnt:PhysiolgcaRequirments
Requirements for the Maxilla:

•AnteriorMaxillaMinimumoflmmof neshoulbetweentheapicalendoftheimplantandthenasal
dbe'eft _cavit
P
•Posterior Maxilla A minimum of lmm of bone should remain
etween t e apical end ot the implant and the maxi ary sinus
•Avoid midline Due to otential of injuring the incisive canal
`ng€ng^.ii
.:,i.i:/
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201
202
Dental Implants
Implant placement: Biological Considerations
e Quality: 4 Types of Bone

• Type I: Consists of homogenous compact bone (anterior mandible)
• Type 11: Consists of a large layer of compact bone surrounded a core of dense
trabecular bone
• Type Ill: Consists of a thin layer of cortical bone surrounding a core of
trabecular bone
• Type IV: Composed of a thin layer of cortical bone with a core of low density
trabecular bone (posterior maxilla
TE: Implant anchorage and success is better with Type I and 11 bone, and is
the worst with Type lv.
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Dental Implants
Implant Placement: Biological Considerations

Bone Quantity:
•Bone quantity refers to the degree of bone loss present. The more bone
available at the implant site the greater the implant success rate will be.
•A and 8 are considered to have a higher success rate than D, E
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203
Dental Implants
Implant Placement: Biological Considerations

Osseointegration:
• To achieve intimate contact between living bone and a
loadbearing endosseous implant at the light microscopic
level.
• For osseointegration to occur several factors are required:
1. A biocomoatible material (the implantl
2. Atraumatic surgerv to minimize tissue darneEe
3. ImDlant Dlacement ln intimate contact with bone
4. Immobilitv of the imDlant. relative to bone. during the healing
Qbese
fael
204
205
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Dental Implants
Soft TissueImplant Interface:
•ln natural dentition the I.unctional epithelium provides a seal at the
base of the gingival sulcus.
•ln implants epithelial cells attach to the surface of titanium through
basal lamina and by the formation of hemidesmosomes
• There is no insertion of connective tissue
around the implant (no sharpey's fibers).
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207
J*
211
Dental ImplantsPlatformSwitching
• Placing an abutment of narrower diameter on an implant of widerdiameter.
• Why? The marginal bone loc< arrillnd Dlatformswitched implants was>significantlylessthanaroundDlatformmatchedimpants.

3 .
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213

Oral Surgery

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Oral Surgery

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Management of Medical Conditions

Management of Medical conditions ffigrng

TID supine posl

Look for the signs associated wlth

i`­­." : © 2017 Prep Doctors, all rights reserved

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Management of Medical Conditi.ons

© 2017 Prep Doctors, all rl8hts reserved

Management of Medical Conditions

Chronic Renal Failure

pREeeoI`s © 2Oi7 prep DOctor5, all r,ghts reserved

2 60­89 Slight decrease in GFR, with other evidence of kidney damage

Management of Medical conditions zt­

liepatitis 8 virus (HBV): Transmitted throughsL± contact or blood and blood

pREfse5oRs © 2oi7 prep Doctors, all rights reserved

Cirrhosis (Alcoholic Liver Disease)

Management of Medical Conditions

Alcohol Abuse and Dependence

Iron Deficiency Anemia

are no contraindications to routine dental care.

Management of Medical Conditions

Red blood cellcount

Female: 3.90­5.03 trillion cells/L (3.90­5.03 million cells/mcL)

Hemoglobin­HGB Male: 14­17 5grams/dL*** 135­175 rai=TS L

Patient diagnosed with Anemia when

Management of Medical Conditions

Human lmmunodeficiency Virus/Acquired lmmunodeficiency

S00­1,500 cells Healthy/ HIV negative

.5± cultures should receive dental treatment n an appropriate

Management of Medical Conditions

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Dementia and Alzheimer Disease

• Cervicofacial and Mediastinal Emphysema

Management of Medical conditions gffiRE

• Cervicofacial and Mediastinal Emphysema

Local swelling Diflinse §weuing

Crepins Local erythema

Local discomfort Pain

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A. Acute asthmatic attack H. Hyperglycemia (diabetic coma).

A. Acute asthmatic attack (bronchospasm).

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itial does is 0.3­0.5

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• Snoring Conscious coughing: No

• Exaggerated respiratory Efforts • Consciouswith no h#:to'#

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as Sense of the depth of the victim's unconsciousness.

Management Of The Airway

• Establishing An Emergency Airway:

• Abdominal thrust (heimlich maneuver):

Management Of The Airway

• Establishing An Emergency Airway:

Tracheostomy Versus Cricothyrotomy

• \\¥ly#giv\tiirrill..? NaVALfravj @whu#~ir prtulu

Management Of The Airway

Vertical midline or transverse incis ns are used for

• Cricothyrotomy (cricothyroid membrane puncture):

Management Of The Airway

`t~.hcj*t i~v c`ch>­

© 2017 Prep Doctors, all rights reserved

Management Of The Airway JJ Jfroro

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2 6089 Slight decrease in GFR, with other evidence of kidney damage

Management of Medical conditions zt

Female: 3.905.03 trillion cells/L (3.905.03 million cells/mcL)

HemoglobinHGB Male: 1417 5grams/dL*** 135175 rai=TS L

S001,500 cells Healthy/ HIV negative

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itial does is 0.30.5

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M. Vasodepressor (vasovagal) syncope.&£t`. Jtlole LiL\ hL4LLti Ou .r

E>pecjal' J5O+; r>wh, in,a_pcuL` I

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1) Adequate access and visualization of the field of surgery

Li\ti L` that,vu_ onci%,~~

Dental Extractions: Impacted Third Molars Extraction Indications: