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Today we will complete the last lecture topic complication of

exodontia.

We said how to deliver a tooth out from its socket after we finishthe extraction ? we need suction , for laxation we can use anelevator , for the delivery of the tooth we always use a forceps -and for that you should have a proper grip either with a forceps orwith other instrument which can grip the tooth well likefricklings instrument not sure a!out the spelling" ".

( the most important thing that we cant use elevators foreliver! "

#ow , if you extracted a tooth and there are a remnant from the!one or the tooth , you should do a proper irrigation not $ust inthis case , we alwa!sdo irrigation after tooth extraction !c% itdecreases the rate of retention of fragment , increases the rate ofhealing , reduces the pain after extraction, and irrigation &withlike normal saline- can flush any fragments out " .

so to remove fragments you can use irrigation, you can use thecrier elevator triangular tip elevator used to remove remainingroot " , ape#o elevator, eno files we can insert it in the socket ifthe remaining root is minimal to engage either the root itself ortry to $ust dig it !etween the root fragments and try to move it out.

now the other option is leaving the fragment. sometimes if

leaving the fragment is !etter then take it out we will favour it.now there are an re$uirementsfor that '

- when the risk & !enefit ratio favours leaving the fragment- when ( will cause more destruction !y getting the fragment

out

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- when ( will traumati%e vital structure , for example the toothis near mental nerve so when ( remove !one to remove thefragments ( can traumati%e the mental nerve ,or while ()msearching on the root ( can displace it somewhere that ismore difficult to take it out from , or it can lead to someserious pro!lems like push the root !etween the maxillarysinus -for example- and that cause chronic sinusitis.

- the remaining root should !e less than one third of theoriginal root . so if it is more than the half of the root &forexample- we cant leave it in the situ .

- the remaining root shouldn)t !e infected .

* epriement %

we knew that when can we remove the fragment and whenleave it , now epriement is one of the !enefits of flushingduring irrigation , you will take any loose !one out . theyinserted this flushing - depridement techni+ue in the handpieceinstrument !y normal saline to take any sort of depree out .

we can -as will- depride the sharp specules not !y flushing ,!ut !y a fileor !y a largeroun &urto remove any sort of!one that you think it will hold you from doing a properprosthetic management , for example you need to make acomplete denture for a patient and to do you should extract atooth and after that you saw a deep undercut in the socket sowe should depride this undercut to make sure that theprosthetic treatment will !e fine .

' suturing %

fter we made a flap and extract the tooth , the flap shoulreturn to its normal placeand this is the aim of suturing . so

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the suturing isn)t covering every thing !y the flap , its $ustcovering the area that was covered !efore , $ust put the softtissue over !one . you shouldn)t make any sort of retention onthe edges of the soft tissue !c% this can cause necrosis in thatarea , so $ust position the soft tissue in its place .

ometimes we use suturing to hold the clot , when ?? mainlywhen we extract an upper six and we suspect that there is anoroantral communication !etween the sinus and the oral cavity- we can do suturing over the socket and the aim of thissuturing mainly is to make sure there is a clot can !e sta!ili%edunder the suture and this clot can close that sort of

communication .

uture t!pes,

There are a lot of classifications and the !etter is ' resor&a&lean nonresor&a&le )

*esor&a&le+ the !ody can take that suture out eat it " !y

en%ymes or whatever , the main idea that it should !e eaten !ythe !ody itself !y any reaction like inflammatory reactionthat happened !ecause of the suture itself " .

#ow the types of resor!a!le sutures are '- gut (,-./ (sutures ' it)s a natural and resor!a!le sutures .

we can take it from sheep and cat . the cat gut is de!ata!leand some people said its mainly from a sheep or goat"

- 0ol!galactic an pol!galactin 'its resor!a!le !ut notnatural synthetic ", its stronger and last for a longer time .

The pro!lem of the naturall! resor&a&legut" that it can !eeasily get resor!ed . now they treat this naturally resor!a!le !y

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some sort of materials to make these sutures more dura!le stay for longer time " like instead of staying for / days , itwill stay for a week .

The synthetic resor!a!le 0olygalactic and polygalactinitsmore common name is vicr!l"" is stronger and stay longer ,and now it)s the main source of suture used for oral surgery,why ? !c% '

- strong and stay 1 or 2 weeks- you don)t need give a patient appointment for review . now

if it nonresor!a!le the patient will come !ack to remove it

after some time, !ut in our case its resor!a!le so we can $ustdismissed the patient.

ome old people said that the rate of infection is higher inresor!a!le !c% we will leave the suture in its place and this canaccumulate !acteria and other infectant , !ut now new studiessaid there is slight difference !etween resor!a!le andnonresor!a!le in hygienic . so the nonresor!a!le is morehygienic !ut the patient will need a review appointment .

#ow when we look to this pic !elow we should !e a!le toknow '- the name of the suture arrow"- the length of the thread 34 , 54 " arrow"- the curvature of the needle ,it will detect the ark of the

needle and its part of a circle /67 circle , 162 circle "arrow"

- the tip of the needle , it might !e round or cutting or reversecutting . the&est for oral surger! is reverse cutting,!c%the cutting edge of it is straight and will not tear the flaparrow"

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ome company will write if the suture is monofilament ormultifilament .

1onresor&a&le +- sil2 + its used in the oral cavity andwe said its more

hygienic than resor!a!le .

- n!lon +its multifilament it has 2 types multi and monofilament" like threads that are tightened together .multifilament is always less estheticthan monofilament , soon the skin we use monofilament not to cause !ig scar at thearea of suturing .

- pol!ester an pol!prop!lene + monofilament sowe canuse them extraorally .

*techni$ue of suturing %we need to use '

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- neele holer' should !e held !y putting the thump in oneeye of the holder and the ring the finger next to the middle" on the other eye pic !elow "

#ow we catch the last 26/ or 16/" of the needle !y the tip of

the needle holder , and if you catch the middle of the needle itsnot wrong !ut we prefer the last thirds .the needle should !e 89 degree with the needle holder then youleave one edge of the flap and go to the other we should startfrom the mo!ile part of the flap not the nonmo!ile " and theneedle should go in the flap vertically and go out vertically !ythe twee%er and then you will do the knot :;< . !ut howmuch knots should ( do ??

=very suture material have a special num!er of knots and weshould make sure that each knot is sta!le . for e#ample then!lon nee 3 2nots % vicr!l nee 4 2nots )

*suturing t!pes +

1- interrupte suture(universal the most common t!pe in

oral surger! " + you should know how to do it once yougraduated , every suture knot is alone .

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2- continuous suture (running " + we continue suturing allthe way without stopping .

now the good thing in continuous suture that its stronger than

interrupted suture !ut if one part is torn all the flap will open ,not like in interrupted $ust that torn area of the flap will open ./- continuous loc2ing' the aim of this suture is to make sure

its water dried , that)s mean it close the flap in away thatinhi!it water to go in it . this description is not real !c% itcant inhi!it water from going in !ut this description tell ushow much this suture is tight ".

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3- hori5ontal mattress + there are 2 lines on each side of theflap and tightened in one side . they are hori%ontal on theflap .This suture will give good closure of small flaps .http'66www.youtu!e.com6watch?v>vcau43vyg"

4- vertical mattress + here there are 2 lines one of them nearthe edge of the flap and the other is away and they arevertical on the flap . http'66www.youtu!e.com6watch?v>+#c@A8BC9s"

''' the octor sai + these part of the lecture is neverlearne theoreticall! % !ou shoul google it )

#ow after all of this steps we reached post operative care,and this steps is vital as extraction . after you dismissed thepatient home you should know what is going on ,for examplewe tell the patient today there will !e some sort of pain ,swelling and all of this not to surprise the patient then youwill loose his6her trust in you .

now if there will !e pain you need to give analgesics or painkiller , if there will !e infection give anti!iotics . swelling thepatient should tolerate it . and this is a list of somecomplications that might !e happened '

ecchimoses : its mean !lood accumulation large hematoma ", it could !e in the site of extraction or could !e outside .

petechiae : small hematoma like points .

swelling : its something normal and you cant inhi!it swellingafter extraction ,!ut you can reduce it !y '

http://www.youtube.com/watch?v=Svcau54Svyghttp://www.youtube.com/watch?v=qNcM6D9OK0shttp://www.youtube.com/watch?v=qNcM6D9OK0shttp://www.youtube.com/watch?v=Svcau54Svyghttp://www.youtube.com/watch?v=qNcM6D9OK0shttp://www.youtube.com/watch?v=qNcM6D9OK0s

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- in the extraction day first day" tell the patient to put somecolcompressors DEFG HFI JKDFLM , !c% this will decrease the!lood that come to the area of extraction so decrease edema

- in the second day tell the patient to put hotcompressors !c%its already now theres edema and we want to remove it !yvasodilatation

- we can give anti-inflammatory !efore the procedure toreduce the patients reaction toward this swelling . this anti-inflammatory is cortisol steroids like dexamethasone "

trismus :it)s a reduction of mouth opening . the reason of it

mainly is the muscle get spasmatic. after extraction theremight !e some !lood that reached the muscle around the faceand that cause an inflammation in them so they wont workproperly and that cause trismus . not $ust the !lood cause that ,any manipulation of the muscles cause trismus .

' patients foo'

(n the first day we till the patient to drink soaps should !e nottoo hot" and don)t eat solid food .(n the days after the patient can eat any thing that he6she wantand focus on high calories food to recover very soon .

' oral h!giene'We need to make sure that the extraction area is kept clean aspossi!le . also we need to make sure that pain is controlledand the patient pain free as possi!le . we need to preventinfection !y giving anti!iotics &ut not to allpatients $ust tothose who are immune compromised even it was simpleextraction .

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lways we give a patient a recall after any dental procedure tomake sure that every thing is fine .

1ow how can we use an elevator 66The elevator)s !lade should !e wedged !etween the tooth andthe !one that support the same tooth , never ever think to relyon the ad$acent tooth !c% you could laxate it .

7he elevators t!pes +89 coplan elevator:9 ;r!er elevatorarwic2 elevator

?ultiple e#traction +

=s we 2now we shoul start &! ma#illar! teeth %wh! 6 &c5 thee#traction of most of the upper is &! &ucco9paltal movement % thelower &! some sort of vertical movement so !ou can hit the upper ifthe! were not e#tracte ) the secon reason to prevent an! &loo orwhatever from going own into the lower soc2et )7he octor prefer to start &! the mani&le % wh!6 @c5 when we e#tractthe lower teeth first% the &loo will go own an the area will &e clear )

Aor sure we start e#traction from posterior to anterior teeth e#ceptfirst molar an canine % so the e#traction se$uence is li2e this + (fromleft to right" B C D 34 : h! is that 66 &c5 3 has &ig roots so when we e#tract the surrouningteeth we will have more space an &etter manipulation % an < has thelongest root so we can manipulate it easil! )

EF G'

orr! for an! mista2e % H trie m! &est to ma2e the lecturesimple as possi&le )

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Ione &! +Jah!a al Kmar!