Anatomical and physiological features of the Anatomical and physiological features of the development and structure of tissues and development and structure of tissues and organs maxillofacial area (SCHLD) in organs maxillofacial area (SCHLD) in children. Local and general anesthesia in children. Local and general anesthesia in children (types and methods of local children (types and methods of local anesthesia in children, indications, anesthesia in children, indications, contraindications). Indications, contraindications). Indications, contraindications for tooth extraction in contraindications for tooth extraction in children, technique, tools for removing children, technique, tools for removing teeth.Features deleting temporary and teeth.Features deleting temporary and permanent teeth in children, prevention of permanent teeth in children, prevention of early and late complications.early and late complications.

Anaesthesia is the loss of consciousness and all form Anaesthesia is the loss of consciousness and all form of sensation. of sensation.

Local Anaesthesia is the local loss of pain, Local Anaesthesia is the local loss of pain, temperature, touch, pressure and all other sensation.temperature, touch, pressure and all other sensation.

In dentistry, Only loss of pain sensation is desirable. In dentistry, Only loss of pain sensation is desirable. Local Analgesia.Local Analgesia.

Are drugs that block nerve Are drugs that block nerve conduction when applied locally conduction when applied locally to nerve tissues in appropriate to nerve tissues in appropriate concentrations, acts on any part concentrations, acts on any part of the nervous system, of the nervous system, peripheral or central and any peripheral or central and any type of nerve fibres, sensory or type of nerve fibres, sensory or motor.motor.

Methods:Methods: Reducing temperatureReducing temperature..

Is used only to produce surface anaesthesia e.g. ethyl Is used only to produce surface anaesthesia e.g. ethyl chloride spray.chloride spray.

PhysicalPhysical damage to nerve trunk e.g. nerve damage to nerve trunk e.g. nerve sectioning.sectioning.

Unsafe for therapeutic uses, only in Trigeminal Unsafe for therapeutic uses, only in Trigeminal Neuralgia.Neuralgia.

ChemicalChemical damage to nerve trunk e.g. damage to nerve trunk e.g. neurolytic agents.neurolytic agents.

Silver nitrate, Phenol - Unsafe for therapeutic use.Silver nitrate, Phenol - Unsafe for therapeutic use.

Methods:Methods: ContCont

Anoxia or hypoxiaAnoxia or hypoxia resulting in lack of resulting in lack of oxygen to nerve.oxygen to nerve.

Unsafe as well.Unsafe as well.

Stimulation of large nerve fibresStimulation of large nerve fibres, , blocking the perception of smaller blocking the perception of smaller diameter fibres.diameter fibres.

includes Acupuncture and TENS (Transcutaneous includes Acupuncture and TENS (Transcutaneous Electronic Nerve Stimulation) Electronic Nerve Stimulation)

DrugsDrugs that block transmission at sensory that block transmission at sensory nerve endings or along nerve fibres.nerve endings or along nerve fibres.

There action is fully reversible and without There action is fully reversible and without permanent damage to the tissues.permanent damage to the tissues.

Properties of Ideal local Anaesthetic:Properties of Ideal local Anaesthetic: Possess a specific and reversible action.Possess a specific and reversible action.

They stabilize all excitable membrane including motor They stabilize all excitable membrane including motor neurones neurones

CNS is extremely sensitive to its action.CNS is extremely sensitive to its action.

Non-irritant with no permanent damage Non-irritant with no permanent damage to tissues.to tissues.

No Systemic toxicityNo Systemic toxicity High therapeutic ratio.High therapeutic ratio.

Rapid onset and long durationRapid onset and long duration Active Topically or by injectionActive Topically or by injection

Chemistry:Chemistry: They are weak bases, insoluble in waterThey are weak bases, insoluble in water

converted into soluble salts by adding Hcl for clinical use.converted into soluble salts by adding Hcl for clinical use.

They are composed of three partsThey are composed of three parts:: AromaticAromatic (lipophilic) residue with acidic group R (lipophilic) residue with acidic group R11..

IntermediateIntermediate aliphatic chain, which is either ester or amide aliphatic chain, which is either ester or amide link Rlink R22..

Terminal Terminal aminoamino (hydrophilic) group R (hydrophilic) group R33 and R and R44..

RR33

RR11CO RCO R22 N N

RR44

Classified according to their chemical structures Classified according to their chemical structures and the determining factor is the intermediate and the determining factor is the intermediate chain, into two groups:chain, into two groups:

Ester Ester AmideAmide

They differ in two important respect:They differ in two important respect: Their ability to induce hypersensitivity reaction.Their ability to induce hypersensitivity reaction. Their pharmacokinetics - fate and metabolism.Their pharmacokinetics - fate and metabolism.

These are very important for local These are very important for local anaesthetic activity.anaesthetic activity.

Ionization:Ionization: They are weak base and exist partly in an They are weak base and exist partly in an

unionized and partly in an ionized form.unionized and partly in an ionized form. The proportion depend on:The proportion depend on:

the pKthe pKa a or dissociation constantor dissociation constant The pH of the surrounding medium.The pH of the surrounding medium.

Both ionizing and unionizing are important Both ionizing and unionizing are important in producing local anaesthesia. in producing local anaesthesia.

pKpKa a is the pH at which the ionized and is the pH at which the ionized and

unionized form of an agent are present in unionized form of an agent are present in equal amounts.equal amounts. The lower the pKThe lower the pKa a , the more the unionized , the more the unionized

form, the greater the lipid solubility.form, the greater the lipid solubility. The higher the pKThe higher the pKa a , the more the ionized , the more the ionized

form and the slower the lipid solubility form and the slower the lipid solubility

Cont:Cont: Unionized form is able to cross the bi-Unionized form is able to cross the bi-

lipid nerve membrane.lipid nerve membrane.

The ionized form then blocks The ionized form then blocks conduction.conduction.

Some of the unionized inside the cell Some of the unionized inside the cell will become ionized depending upon the will become ionized depending upon the pKpKa a and the intracellular pH (lower than and the intracellular pH (lower than extracellular)extracellular)

Cont:Cont: In general the amide type have lower In general the amide type have lower

pKpKaa, and greater proportion of the drug , and greater proportion of the drug is present in the lipid-soluble is present in the lipid-soluble (unionized) form at the physiological pH (unionized) form at the physiological pH

This produces faster onset of action. This produces faster onset of action. Lignocaine 1 – 2 minutes Lignocaine 1 – 2 minutes Procaine 2 – 5 minutes.Procaine 2 – 5 minutes.

The lower the The lower the pKpKaa the faster the onset. the faster the onset.

Partition coefficient:Partition coefficient: This measures the relative solubility of an This measures the relative solubility of an

agent in fat and water.agent in fat and water. High numerical value means:High numerical value means:

High lipid-solubleHigh lipid-soluble less water-soluble.less water-soluble.

More fat solubility, means rapid crossing More fat solubility, means rapid crossing of the lipid barrier of the nerve sheath.of the lipid barrier of the nerve sheath.

The greater partition coefficient, The The greater partition coefficient, The faster the onsetfaster the onset

Protein binding:Protein binding: Local anaesthetic agents bind with:Local anaesthetic agents bind with:

αα11-acid glycoprotein, which possess high affinity -acid glycoprotein, which possess high affinity but low capacity.but low capacity.

Albumin, with low affinity but high capacityAlbumin, with low affinity but high capacity The binding is simple, reversible and tend to The binding is simple, reversible and tend to

increase in proportion to the side chain.increase in proportion to the side chain. Lignocaine is 64% bound, Bupivacaine is Lignocaine is 64% bound, Bupivacaine is

96%96% The duration of action is related to the The duration of action is related to the

degree of binding. degree of binding. Lignocaine 15 – 45 minutes, Lignocaine 15 – 45 minutes,

Bupivacaine 6 hoursBupivacaine 6 hours

Vasodilatory ability:Vasodilatory ability: Most Local anaesthetics possess a Most Local anaesthetics possess a

vasodilatory action on blood vessels vasodilatory action on blood vessels except Cocaine.except Cocaine.

It influence the duration of action of the It influence the duration of action of the agent.agent.

Prilocaine is 50% bound to proteins but Prilocaine is 50% bound to proteins but has a longer duration than Lignocaine has a longer duration than Lignocaine (64%) since it possess no strong (64%) since it possess no strong vasodilatory effect.vasodilatory effect.

Affect the duration of action of the agentAffect the duration of action of the agent

SummarySummary Rapid Onset:Rapid Onset:

Low Low pKpKaa value– more unionized – Amides value– more unionized – Amides Higher Partition coefficient – more lipid Higher Partition coefficient – more lipid

solublesoluble Long duration of action:Long duration of action:

High protein High protein binding.binding. Low vasodilating property.Low vasodilating property.

AgentAgentpKpKaa

%base %base pH 7.4pH 7.4

P-CP-C P-BP-B tt0.50.5 (m)(m)

Max Max dose dose

mg/kgmg/kg

LignocaineLignocaine 7.97.9 2525 33 6464 9090 4.44.4

PrilocainePrilocaine 7.97.9 2525 11 5050 9090 6.06.0

MepivacaiMepivacainene

7.67.6 3333 11 7777 120120 4.44.4

BupivacaiBupivacainene

8.18.1 1717 2828 9696 160160 1.31.3

EtidocaineEtidocaine 7.97.9 2525 141411

9494 160160 8.08.0

ProcaineProcaine 9.09.0 22 0.60.6 66 66 6.06.0

Reversible block of conduction in nerve. Reversible block of conduction in nerve. Direct relaxation of smooth muscle & Direct relaxation of smooth muscle &

inhibition of neuro-muscular inhibition of neuro-muscular transmission in skeletal muscle producing transmission in skeletal muscle producing vasodilatation.vasodilatation.

Intra-arterial procaine reverse Intra-arterial procaine reverse arteriospasm during I.V. Sedationarteriospasm during I.V. Sedation

Class I antidysrhythmic-like action on the Class I antidysrhythmic-like action on the heart.heart.

Stimulation and/or depression of the CNS.Stimulation and/or depression of the CNS.

The site of action is the nerve cell The site of action is the nerve cell membranemembrane

TheoriesTheories:: The membrane expansion theory.The membrane expansion theory. The specific binding theory.The specific binding theory.

Membrane expansion theory:Membrane expansion theory: A non-specific mechanism similar to the A non-specific mechanism similar to the

action of general anaesthetic agents.action of general anaesthetic agents. Relies upon the lipophilic moiety of local Relies upon the lipophilic moiety of local

anaesthetic agent.anaesthetic agent. The molecules of the agent are incorporated The molecules of the agent are incorporated

into the lipid cell membrane.into the lipid cell membrane.

The resultant swelling produces physical The resultant swelling produces physical obstruction of the sodium channels, obstruction of the sodium channels, preventing nerve depolarization.preventing nerve depolarization.

Specific receptor theory:Specific receptor theory: Local anaesthetic drug binds to specific receptor Local anaesthetic drug binds to specific receptor

within the sodium channel producing physical within the sodium channel producing physical obstruction to entry of sodium ions.obstruction to entry of sodium ions.

The act of binding produces a conformational The act of binding produces a conformational changes within the channel.changes within the channel.

It bind to a closed gate and maintain it in the closed It bind to a closed gate and maintain it in the closed position.position.

It is, then, essential that the nerve fires, and It is, then, essential that the nerve fires, and the gate assumes the closed position. (Use-the gate assumes the closed position. (Use-dependant phenomenon dependant phenomenon

Absorption:Absorption: Many factors influence entry of local Many factors influence entry of local

anaesthetic into the circulation:anaesthetic into the circulation: Vasodilating ability of the drug.Vasodilating ability of the drug. Volume and concentration.Volume and concentration. Vascularity of the tissues.Vascularity of the tissues. The route of administration.The route of administration. The presence of vasoconstrictorThe presence of vasoconstrictor..

CocaineCocaine:: The first and most potent local The first and most potent local

anaesthetic agent, rarely used because anaesthetic agent, rarely used because of the problems of misuse.of the problems of misuse.

It is unique in it is ability to produce It is unique in it is ability to produce intense vasoconstriction. Half life 30 intense vasoconstriction. Half life 30 minutes.minutes.

Dosage:Dosage: Used as topical 4 – 10% solutionUsed as topical 4 – 10% solution Maximum dose is 1.5 mg/kg – 100mg max.Maximum dose is 1.5 mg/kg – 100mg max. Used intranasally during apical surgery. Used intranasally during apical surgery.

Procaine:Procaine: The only indication for its use in dentistry is The only indication for its use in dentistry is

in patients with proven allergy to the amide in patients with proven allergy to the amide group.group.

Used intra-arterially, as part of the Used intra-arterially, as part of the recognized regimen, to treat the recognized regimen, to treat the arteriospasm which might occur during arteriospasm which might occur during intravenous sedation. intravenous sedation.

It has an excellent vasodilatory properties.It has an excellent vasodilatory properties.

Onset & duration of Action:Onset & duration of Action: Has a very shot duration (5 minutes) and a Has a very shot duration (5 minutes) and a

long onset time of 10 minuteslong onset time of 10 minutes

Dosages:Dosages: The maximum dose is 6 mg/kg, 400 mg The maximum dose is 6 mg/kg, 400 mg

max.max. Used as 2% with 1:80 000 epinephrine to Used as 2% with 1:80 000 epinephrine to

increase efficacy.increase efficacy.

Metabolism:Metabolism: Rapidly by plasma esterase.Rapidly by plasma esterase.

BenzocaineBenzocaine:: Used mainly as topical, due to its poor Used mainly as topical, due to its poor

water solubility, and because of its low water solubility, and because of its low toxicity, it is used in concentration up to toxicity, it is used in concentration up to 20%.20%.

Hydrolyzed rapidly by plasma esterase Hydrolyzed rapidly by plasma esterase to p-aminobenzoic acid accounting for to p-aminobenzoic acid accounting for its low toxicity. its low toxicity.

Metabolism of Ester drugs:Metabolism of Ester drugs: Metabolized in plasma by Metabolized in plasma by

peudocholinesterase enzyme, and some peudocholinesterase enzyme, and some in the liver.in the liver.

People, who lack the enzyme, are at risk People, who lack the enzyme, are at risk of an overdose by the ester type local of an overdose by the ester type local anaestheticanaesthetic

Para-aminobenzoic acid (PABA) is the Para-aminobenzoic acid (PABA) is the major metabolite of ester with no major metabolite of ester with no anaesthetic effect.anaesthetic effect.

It is the agent responsible for ester allergies. It is the agent responsible for ester allergies. Rapid metabolism procaine half-life is 2 Rapid metabolism procaine half-life is 2

minutes minutes

Lignocaine (Lidocaine):Lignocaine (Lidocaine): Synthesized in 1943 and used in Synthesized in 1943 and used in

dentistry since 1948 and is also known dentistry since 1948 and is also known as Xylocaineas Xylocaine

It highly lipophilic (partition coefficient It highly lipophilic (partition coefficient 3) , rapidly absorbed.3) , rapidly absorbed.

Metabolized only in the liver and its Metabolized only in the liver and its metabolites are less toxic with no action. metabolites are less toxic with no action.

Has half-life (Has half-life (tt0.50.5) of 90 minutes ) of 90 minutes

Dosage:Dosage: 4.4 mg/kg – 300 mg max4.4 mg/kg – 300 mg max

Used as 2% plain or with 1:80 000 epinephrineUsed as 2% plain or with 1:80 000 epinephrine 4 and 10% spray, 2% gel and 5% ointments.4 and 10% spray, 2% gel and 5% ointments.

Onset & duration of action:Onset & duration of action: Rapid onset 2 – 3 minutesRapid onset 2 – 3 minutes Plain- short duration (10 minutes)Plain- short duration (10 minutes) With epinephrine- intermediate duration (45 – 60 With epinephrine- intermediate duration (45 – 60

minutes)minutes)

Prilocaine:Prilocaine: A very potent local anaesthetic and is less A very potent local anaesthetic and is less

toxic than Lignocaine.toxic than Lignocaine. It produces less vasodilatation than lignocaine It produces less vasodilatation than lignocaine Rate of clearance is higher than other amide-Rate of clearance is higher than other amide-

types, suggesting extra-hepatic metabolism types, suggesting extra-hepatic metabolism with relatively low blood concentration.with relatively low blood concentration.

It’s metabolite o-toluidine lead to methaemo-It’s metabolite o-toluidine lead to methaemo-globinaemia globinaemia (more than 600 mg in adults) (more than 600 mg in adults)

Used either plain 4% or 3% combined with Used either plain 4% or 3% combined with 0.03IU/mL of Felypressin as vasoconstrictor.0.03IU/mL of Felypressin as vasoconstrictor.

Onset & Duration:Onset & Duration: Slower onset – 4 minutes.Slower onset – 4 minutes. It’s duration of action is similar to Lignocaine.It’s duration of action is similar to Lignocaine.

Dosage;Dosage; 6.0 mg/kg – max. 400 mg.6.0 mg/kg – max. 400 mg.

Combined with Lignocaine as a topical Combined with Lignocaine as a topical anaesthetic agent to be used prior to vene-anaesthetic agent to be used prior to vene-section and during dental sedation in section and during dental sedation in children.children.

Mepivacaine:Mepivacaine: Possess the least vasodilating effect.Possess the least vasodilating effect. Metabolized in the liver and has Metabolized in the liver and has tt0.50.5 of 120 of 120

minutes.minutes. It’s main indication is when local It’s main indication is when local

anaesthetic without vasoconstrictor is anaesthetic without vasoconstrictor is needed. 3% plain is more effective than needed. 3% plain is more effective than lignocaine.lignocaine.

Onset & duration:Onset & duration: Rapid onset but slightly shorter duration.Rapid onset but slightly shorter duration.

BupivacaineBupivacaine:: A long-acting local anaesthetic agent, with a A long-acting local anaesthetic agent, with a

tt0.50.5 of 160 minutes due grater binding capacity of 160 minutes due grater binding capacity to plasma protein and tissue proteinsto plasma protein and tissue proteins

Metabolized in the liver.Metabolized in the liver. Used mainly in Oral surgical procedures for its Used mainly in Oral surgical procedures for its

long-lasting pain control.long-lasting pain control. Longer onset and longer duration Longer onset and longer duration (Regional 6 – 8 (Regional 6 – 8

hors)hors) Dosage:Dosage:

1.3 mg/kg – Max 90 mg1.3 mg/kg – Max 90 mg 0.25 – 0.75% with or without adrenaline 1:200 0000.25 – 0.75% with or without adrenaline 1:200 000

EtidocaineEtidocaine:: A long-acting agent similar to A long-acting agent similar to

Bupivacaine but with faster onset.Bupivacaine but with faster onset. Metabolized in the liver. Metabolized in the liver. Dosage:Dosage:

8 mg/kg – Max 400 mg8 mg/kg – Max 400 mg 1.5% with 1:200 000 epinephrine.1.5% with 1:200 000 epinephrine.

Lignocaine is the most common used agent both Lignocaine is the most common used agent both topically and by injection as 2% with or without topically and by injection as 2% with or without adrenaline, with a maximum dose of 4.4 mg/kg.adrenaline, with a maximum dose of 4.4 mg/kg.

Amide Drugs:Amide Drugs: metabolized in the liver, except metabolized in the liver, except

Prilocaine which undergo some Prilocaine which undergo some biotransformation in the kidney and biotransformation in the kidney and lungs.lungs.

Some of the metabolites possess local Some of the metabolites possess local anaesthetic and sedative properties. anaesthetic and sedative properties.

Normal local anaesthetic dose in patient Normal local anaesthetic dose in patient with impaired liver function will result in with impaired liver function will result in relative overdosage. relative overdosage.

Old age patient shows reduction in liver Old age patient shows reduction in liver function function

Reduce doseReduce dose

Originally added to reduce systemic Originally added to reduce systemic uptake in an attempt to limit toxicity.uptake in an attempt to limit toxicity.

Prolong the duration Prolong the duration Produces profound anaesthesia.Produces profound anaesthesia. Reduce operative bleeding.Reduce operative bleeding.

Two types:Two types: Sympathomimetic naturally occurring.Sympathomimetic naturally occurring. Synthetic polypeptides, FelypressinSynthetic polypeptides, Felypressin

EpinephrineEpinephrine: (Adrenaline): (Adrenaline) Uses in dentistry:Uses in dentistry:

Local anaesthetic solution.Local anaesthetic solution. Gingival retraction cords.Gingival retraction cords. In the ER as life-saving drug in anaphylaxis.In the ER as life-saving drug in anaphylaxis.

Mechanism of action:Mechanism of action: Interact with adrenergic receptors in the vesselsInteract with adrenergic receptors in the vessels

αα1 & 1 & αα2 2 producing vasoconstriction in skin & MMproducing vasoconstriction in skin & MM ββ2 2 stimulation causing vasodilatation in skeletal stimulation causing vasodilatation in skeletal

muscles.muscles.

Metabolism:Metabolism: Appears very rapidly in the systemic Appears very rapidly in the systemic

circulation !!! circulation !!! Exogenously administered Exogenously administered

epinephrine is metabolized epinephrine is metabolized extraneuronal and 1% is excreted in extraneuronal and 1% is excreted in the urine unchanged.the urine unchanged.

Dosage:Dosage: 1:80,000 is the commonest dose 1:80,000 is the commonest dose

used, 12.5 used, 12.5 µg/mlµg/ml

Systemic effect:Systemic effect: Being a naturally occurring hormone, it Being a naturally occurring hormone, it

exert a number of physiological exert a number of physiological responses on the different systems.responses on the different systems.

The heart:The heart: Has direct and indirect action.Has direct and indirect action.

Direct action on Direct action on ββ11 receptors increases the rate receptors increases the rate and force of contraction raising cardiac output.and force of contraction raising cardiac output.

Indirect action, increase pulse and cardiac Indirect action, increase pulse and cardiac output, lead to rise in systolic blood pressure, output, lead to rise in systolic blood pressure, (not with dental dose)(not with dental dose)

Blood vessels:Blood vessels: Contain Contain αα11,, αα22 andand ββ2 2 adrenoreceptors adrenoreceptors

in the vessels of the skin, mucous in the vessels of the skin, mucous membrane and skeletal muscles.membrane and skeletal muscles.

αα11 receptors causes vasoconstriction receptors causes vasoconstriction

since they are susceptible to endogenous since they are susceptible to endogenous nor-epinephrine and exogenous nor-epinephrine and exogenous epinephrine. Reduce operative bleedingepinephrine. Reduce operative bleeding

αα22 receptors are only susceptible to receptors are only susceptible to circulating epinephrine.circulating epinephrine.

ββ2 2 found in the skeletal muscles, and found in the skeletal muscles, and very uncommon in the skin and very uncommon in the skin and mucous membrane. mucous membrane. ββ22 stimulation stimulation result in vasodilatation, lowering result in vasodilatation, lowering peripheral resistance and a fall in the peripheral resistance and a fall in the diastolic blood pressure. (with dental diastolic blood pressure. (with dental dose)dose)

Haemostasis:Haemostasis: The vasoconstricting effect.The vasoconstricting effect. Adrenaline promote platelets aggregation in the Adrenaline promote platelets aggregation in the

early stages.early stages. Fibrinolytic activity compromise clot stability. Fibrinolytic activity compromise clot stability.

Lungs:Lungs: Stimulation of Stimulation of ββ22 receptors in the lung lead to receptors in the lung lead to

bronchial muscle relaxation, life-saving in bronchial bronchial muscle relaxation, life-saving in bronchial (spasm) constriction during anaphylactic reaction.(spasm) constriction during anaphylactic reaction.

Wound healing:Wound healing: Reduced local tissue oxygen tension.Reduced local tissue oxygen tension. Epinephrine-induced fibrinolysis. Epinephrine-induced fibrinolysis.

Felypressin:Felypressin: It is an analogue of the naturally occurring It is an analogue of the naturally occurring

Vasopressin.Vasopressin. Bind to vasopressin VBind to vasopressin V11 receptor in the vascular receptor in the vascular

smooth muscle producing vaso-constriction and smooth muscle producing vaso-constriction and reduce local blood flow.reduce local blood flow.

Less potent than the catecholamines &poorer Less potent than the catecholamines &poorer control of bleeding during operative procedures.control of bleeding during operative procedures.

Acts on the venous side rather than the arterial Acts on the venous side rather than the arterial side.side.

Dose:Dose: 0.03 IU/ml (0.54 0.03 IU/ml (0.54 µg/ml)µg/ml)

1.1. Local infiltrationLocal infiltration- type of injection that anesthetizes a type of injection that anesthetizes a

small area (one or two teeth and small area (one or two teeth and asscociated areas)asscociated areas)

- anesthesia deposited at nerve anesthesia deposited at nerve terminalsterminals

2.2. Nerve blockNerve block- type of injection that anesthetizes a type of injection that anesthetizes a

larger arealarger area- anesthesia deposited near larger nerve anesthesia deposited near larger nerve

trunkstrunks

MaxillaryMaxillaryA.A. posterior superior posterior superior

alveolar blockalveolar blockB.B. middle superior middle superior

alveolar blockalveolar blockC.C. anterior superior anterior superior

alveolar blockalveolar blockD.D. greater palatine blockgreater palatine blockE.E. infraorbital blockinfraorbital blockF.F. nasopalatine blocknasopalatine block

MandibularMandibularA.A. inferior alveolar blockinferior alveolar blockB.B. buccal blockbuccal blockC.C. mental blockmental blockD.D. incisive blockincisive blockE.E. Gow-Gates Gow-Gates

mandibular nerve mandibular nerve blockblock

dental procedures can usually commence dental procedures can usually commence after 3 – 5 minutesafter 3 – 5 minutes

failure requires re-administration using failure requires re-administration using another methodanother method

never re-administer using the same never re-administer using the same methodmethod

keep in mind the total # of injections and keep in mind the total # of injections and the dosagesthe dosages

never inject into an area with an abcess, or never inject into an area with an abcess, or other type of abnormalityother type of abnormality

Chart 9-1Chart 9-1 pulpal anesthesia:pulpal anesthesia: through anesthesia of each nerve’s through anesthesia of each nerve’s

dental branches as they extend into the pulp tissue (via dental branches as they extend into the pulp tissue (via the apical foramen)the apical foramen)

periodontal:periodontal: through the interdental and interradicular through the interdental and interradicular branchesbranches

palatal:palatal: soft and hard tissues of the palatal periodontium soft and hard tissues of the palatal periodontium (e.g. gingiva, periodontal ligaments, alveolar bone)(e.g. gingiva, periodontal ligaments, alveolar bone)

PSA block:PSA block: recommended for maxillary molar teeth and recommended for maxillary molar teeth and associated buccal tissues in ONE quadrantassociated buccal tissues in ONE quadrant

MSA block:MSA block: recommended for maxillary premolars and recommended for maxillary premolars and associated buccal tissuesassociated buccal tissues

ASA block:ASA block: recommended for maxillary canine and the recommended for maxillary canine and the incisors in ONE quadrantincisors in ONE quadrant

greater palatine block:greater palatine block: recommended for palatal tissues recommended for palatal tissues distal to the maxillary canine in ONE quadrantdistal to the maxillary canine in ONE quadrant

nasopalatine block:nasopalatine block: recommended for palatal tissues recommended for palatal tissues between the right and left maxillary caninesbetween the right and left maxillary canines

figures 9-2 through 9-7figures 9-2 through 9-7 pulpal anesthesia of the pulpal anesthesia of the

maxillary 3maxillary 3rdrd, 2, 2ndnd and 1 and 1stst molarsmolars required for procedures required for procedures

involving two or more involving two or more molarsmolars

sometimes anesthesia of sometimes anesthesia of the 1the 1stst molar also required molar also required block of the MSA nerveblock of the MSA nerve

associated buccal associated buccal periodonteum overlying periodonteum overlying these molarsthese molars including the associated including the associated

buccal gingiva, periodontal buccal gingiva, periodontal ligament and alveolar boneligament and alveolar bone

useful for periodontal work useful for periodontal work on this areaon this area

target: PSA nervetarget: PSA nerve as it enters the maxillar as it enters the maxillar

through the PSA foramen on through the PSA foramen on the maxilla’s infratemporal the maxilla’s infratemporal service – service – Figure 9-2 & 9-3Figure 9-2 & 9-3

into the tissues of the into the tissues of the mucobuccal fold at the apex of mucobuccal fold at the apex of the 2the 2ndnd maxillary molar maxillary molar ((figures 9-4 and 9-5figures 9-4 and 9-5))

mandible is extended toward mandible is extended toward the side of the injection, pull the side of the injection, pull the tissues at the injection site the tissues at the injection site until tautuntil taut

needle is inserted distal and needle is inserted distal and medial to the tooth and medial to the tooth and maxillamaxilla

depth varies from 10 to 16 mm depth varies from 10 to 16 mm depending on age of patientdepending on age of patient

no overt symptoms (e.g. no no overt symptoms (e.g. no lip or tongue involvement)lip or tongue involvement)

can damage the pterygoid can damage the pterygoid plexus and maxillary arteryplexus and maxillary artery

limited clinical usefulnesslimited clinical usefulness can be used to extend the can be used to extend the

infraorbital block distal to the infraorbital block distal to the maxillary caninemaxillary canine

can be indicated for work on can be indicated for work on maxillary pre-molars and maxillary pre-molars and mesiobuccal root of 1mesiobuccal root of 1stst molar molar ((Figure 9-8Figure 9-8))

if the MSA is absent – area is if the MSA is absent – area is innervated by the ASAinnervated by the ASA

blocks the pulp tissue of the 1blocks the pulp tissue of the 1stst and and 22ndnd maxillary premolars and maxillary premolars and possibly the 1possibly the 1stst molar + associated molar + associated buccal tissues and alveolar bonebuccal tissues and alveolar bone

useful for periodontal work in this useful for periodontal work in this areaarea

to block the palatine tissues in this to block the palatine tissues in this area – may require a greater area – may require a greater palatine blockpalatine block

target area: MSA nerve at the apex of the target area: MSA nerve at the apex of the maxillary 2maxillary 2ndnd premolar ( premolar (figures 9-8 and 9-9figures 9-8 and 9-9)) mandible extended towards injection sitemandible extended towards injection site stretch the upper lip to tighten the injection sitestretch the upper lip to tighten the injection site needle is inserted into the mucobuccal foldneedle is inserted into the mucobuccal fold tip is located well above the apex of the 2tip is located well above the apex of the 2ndnd

premolarpremolar figure 9-11figure 9-11

harmless tingling or numbness of the upper lipharmless tingling or numbness of the upper lip overinsertion is rareoverinsertion is rare

figures 9-12 through 9-14figures 9-12 through 9-14 can be considered a local can be considered a local

infiltrationinfiltration used in conjunction with an used in conjunction with an

MSA blockMSA block the ASA nerve can cross the the ASA nerve can cross the

midline of the maxilla onto the midline of the maxilla onto the opposite side!opposite side!

used in procedures involving used in procedures involving the maxillary canines and the maxillary canines and incisors and their associated incisors and their associated facial tissuesfacial tissues pulpal and facial tissues involved pulpal and facial tissues involved

– restorative and periodontal – restorative and periodontal workwork

blocks the pulp tissue + the blocks the pulp tissue + the gingiva, periodontal ligaments gingiva, periodontal ligaments and alveolar bone in that areaand alveolar bone in that area

target: ASA nerve at the apex of the target: ASA nerve at the apex of the maxillary canine – maxillary canine – figures 9-12 & 9-figures 9-12 & 9-1313

at the mucobuccal fold at the apex of at the mucobuccal fold at the apex of the maxillary canine – the maxillary canine – figure 9-13figure 9-13

harmless tingling or numbness of the harmless tingling or numbness of the upper lipupper lip

overinsertion is rareoverinsertion is rare

figures 9-15 through 9-17figures 9-15 through 9-17 anesthetizes both the MSA and anesthetizes both the MSA and

ASAASA used for anesthesia of the used for anesthesia of the

maxillary premolars, canine and maxillary premolars, canine and incisorsincisors

indicated when more than one indicated when more than one premolar or anterior teethpremolar or anterior teeth pulpal tissues – for restorative workpulpal tissues – for restorative work facial tissues – for periodontal workfacial tissues – for periodontal work

also numbs the gingiva, also numbs the gingiva, periodontal ligaments and periodontal ligaments and alveolar bone in that areaalveolar bone in that area

the maxillary central incisor the maxillary central incisor may also be innervated by the may also be innervated by the nasopalatine nerve branchesnasopalatine nerve branches

target: union of the ASA and MSA with the IO target: union of the ASA and MSA with the IO nerve after the IO enters the IO foramen – nerve after the IO enters the IO foramen – figure 9-15figure 9-15

also anesthesizes the lower eyelid, side of nose also anesthesizes the lower eyelid, side of nose and upper lipand upper lip

IO foramen is gently palpated along the IO rimIO foramen is gently palpated along the IO rim move slightly down about 10mm until you feel the move slightly down about 10mm until you feel the

depression of the IO foramen – depression of the IO foramen – figure 9-16figure 9-16 locate the tissues at the mucobuccal fold at the apex locate the tissues at the mucobuccal fold at the apex

of the 1of the 1stst premolar premolar place one finger at the IO foramen and the other on the injection place one finger at the IO foramen and the other on the injection

site – figure 9-17site – figure 9-17 locate the IO foramen, retract the upper lip and pull the tissues tautlocate the IO foramen, retract the upper lip and pull the tissues taut the needle is inserted parallel to the long axis of the tooth to avoid the needle is inserted parallel to the long axis of the tooth to avoid

hitting the bonehitting the bone harmless tingling or numbness of the upper lip, harmless tingling or numbness of the upper lip,

side of nose and eyelidside of nose and eyelid

figures 9-19 through 9-21figures 9-19 through 9-21 used in restorative procedures that involve more used in restorative procedures that involve more

than two maxillary posterior teeth or palatal than two maxillary posterior teeth or palatal tissues distal to the caninetissues distal to the canine

also used in periodontal work – since it blocks the also used in periodontal work – since it blocks the associated lingual tissues associated lingual tissues

anesthetizes the posterior portion of the hard anesthetizes the posterior portion of the hard palate – from the 1palate – from the 1stst premolar to the molars and premolar to the molars and medially to the palate midlinemedially to the palate midline

does NOT provide pulpal anesthesia – may also does NOT provide pulpal anesthesia – may also need to use ASA, PSA, MSA or IO blocksneed to use ASA, PSA, MSA or IO blocks

may also need to be combined with nasopalatine may also need to be combined with nasopalatine blockblock

target: GP nerve as it enters the target: GP nerve as it enters the GP foramenGP foramen located at the junction of the located at the junction of the

maxillary alveolar process and the maxillary alveolar process and the hard palate – at the maxillary 2nd or hard palate – at the maxillary 2nd or 33rdrd molar – molar – figure 9-19figure 9-19

palpate the GP foramen – midway palpate the GP foramen – midway between the median palatine between the median palatine raphe and lingual gingival margin raphe and lingual gingival margin of the molar tooth – of the molar tooth – figure 9-21figure 9-21

can reduce discomfort by applying can reduce discomfort by applying pressure to the site before and pressure to the site before and during the injectionduring the injection produces a dull ache to block pain produces a dull ache to block pain

impulsesimpulses also slow deposition of anesthesia will also slow deposition of anesthesia will

also helpalso help needle is inserted at a 90 degree needle is inserted at a 90 degree

angle to the palate – angle to the palate – figure 9-22figure 9-22

figure 9-23 through 9-26figure 9-23 through 9-26 usefuluseful for anesthesia of the bilateral portion of for anesthesia of the bilateral portion of

the hard palate the hard palate from the mesial of the right maxillary 1from the mesial of the right maxillary 1stst premolar to premolar to

the mesial of the left 1the mesial of the left 1stst premolar premolar for palatal soft tissue anesthesia for palatal soft tissue anesthesia

periodontal treatmentperiodontal treatment required for two or more anterior maxillary teethrequired for two or more anterior maxillary teeth for restorative procedures or extraction of the for restorative procedures or extraction of the

anterior maxillary teeth – may need an ASA or anterior maxillary teeth – may need an ASA or MSA block also MSA block also

blocks both right and left nervesblocks both right and left nerves

target: both right and left nerves as they enter the target: both right and left nerves as they enter the incisive foramen from the mucosa of the anterior hard incisive foramen from the mucosa of the anterior hard palate – palate – figure 9-23 & 9-25figure 9-23 & 9-25 posterior to the incisive papillaposterior to the incisive papilla

injection site is lateral to the incisive papilla – injection site is lateral to the incisive papilla – figure figure 9-269-26

head turned to the left or righthead turned to the left or right inserted at a 45 degree angle about 6-10 mm – gently inserted at a 45 degree angle about 6-10 mm – gently

contact the maxillary bone and withdraw about 1mm contact the maxillary bone and withdraw about 1mm before administeringbefore administering

can reduce discomfort by applying pressure to the site can reduce discomfort by applying pressure to the site before and during the injectionbefore and during the injection produces a dull ache to block pain impulsesproduces a dull ache to block pain impulses also slow deposition of anesthesia will also helpalso slow deposition of anesthesia will also help

can anesthetize the labial tissues between the central can anesthetize the labial tissues between the central incisors prior to palatal blockincisors prior to palatal block can block some branches of the nasopalatine prior to injectioncan block some branches of the nasopalatine prior to injection

Chart 9-2Chart 9-2 infiltration is not as successful as maxillary anesthesiainfiltration is not as successful as maxillary anesthesia substantial variability in the anatomy of landmarks when substantial variability in the anatomy of landmarks when

compared to the maxillacompared to the maxilla pulpal anesthesia:pulpal anesthesia: block of each nerve’s dental branches block of each nerve’s dental branches periodontal:periodontal: through the interdental and interradicular through the interdental and interradicular

branchesbranches Inferior Alveolar block:Inferior Alveolar block: for mandibular teeth + associated for mandibular teeth + associated

lingual tissues and for the facial tissues anterior to the lingual tissues and for the facial tissues anterior to the mandibular 1mandibular 1stst molar molar

Buccal block:Buccal block: tissues buccal to the mandibular molars tissues buccal to the mandibular molars Mental block:Mental block: facial tissues anterior to the mental foramen facial tissues anterior to the mental foramen

(mandibular premolars and anterior teeth)(mandibular premolars and anterior teeth) Incisive block:Incisive block: for teeth and facial tissue anterior to the for teeth and facial tissue anterior to the

mental foramenmental foramen Gow-Gates:Gow-Gates: most of the mandibular nerve most of the mandibular nerve

for quadrant dentistryfor quadrant dentistry

also called the mandibular blockalso called the mandibular block most commonly used in dentistrymost commonly used in dentistry for restorative, extraction and for restorative, extraction and

periodontal workperiodontal work pulpal anesthesia for extractions and pulpal anesthesia for extractions and

restorativerestorative lingual periodonteal anesthesialingual periodonteal anesthesia facial periodonteal anesthesia of facial periodonteal anesthesia of

anterior mandibular teeth and anterior mandibular teeth and premolarspremolars

may be combined with the buccal may be combined with the buccal blockblock

can overlap with the incisive blockcan overlap with the incisive block local infiltrations in the anterior area local infiltrations in the anterior area

are more successful than posterior are more successful than posterior injectionsinjections

variability in the location of the variability in the location of the mandibular foramen on the ramus can mandibular foramen on the ramus can lessen the success of this injectionlessen the success of this injection

usually avoid bi-lateral injections since usually avoid bi-lateral injections since they will completely anesthetize the they will completely anesthetize the entire tongue and can affect entire tongue and can affect swallowing and speechswallowing and speech

target: slightly superior to the target: slightly superior to the mandibular foramen – mandibular foramen – figure 9-27 figure 9-27

the medial border of the ramusthe medial border of the ramus will also anesthetize the adjacent will also anesthetize the adjacent

anterior lingual nerve anterior lingual nerve – figure 9-30– figure 9-30 injection site is found using hard injection site is found using hard

landmarkslandmarks palpate the coronoid notch – above the palpate the coronoid notch – above the

33rdrd molar molar imagine a horizontal line from the imagine a horizontal line from the

coronoid notch to the coronoid notch to the pterygomandibular fold which covers pterygomandibular fold which covers the pterygomandibular raphe – the pterygomandibular raphe – figure figure 9-329-32

this fold becomes more prominent as this fold becomes more prominent as the patient opens their mouth widerthe patient opens their mouth wider

refer to video notesrefer to video notes figure 9-33figure 9-33

needle is inserted into the needle is inserted into the pterygomandibular space until the pterygomandibular space until the mandible is felt – retract about 1 mmmandible is felt – retract about 1 mm

average depth: 20-25mmaverage depth: 20-25mm diffusion of anesthesia will affect the diffusion of anesthesia will affect the

lingual nervelingual nerve

symptoms: harmless tingling and numbness of symptoms: harmless tingling and numbness of the lower lip due to block of the mental nervethe lower lip due to block of the mental nerve

tingling and numbness of the body of the tongue tingling and numbness of the body of the tongue and floor of mouth – lingual nerve involvementand floor of mouth – lingual nerve involvement

complications:complications: failure to penetrate enough can numb the tongue but failure to penetrate enough can numb the tongue but

not block sufficientlynot block sufficiently lingual shock – involuntary movement as the needle lingual shock – involuntary movement as the needle

passes the lingual nervepasses the lingual nerve transient facial paralysis – facial nerve involvement if transient facial paralysis – facial nerve involvement if

inserted into the deeper parotid gland – inserted into the deeper parotid gland – figure 9-34figure 9-34 inability to close the eye and drooping of the lips on the affected sideinability to close the eye and drooping of the lips on the affected side hematoma can occurhematoma can occur

some muscle sorenesssome muscle soreness patient-inflicted trauma – lip biting etc...patient-inflicted trauma – lip biting etc...

figures 9-36 and 9-37figures 9-36 and 9-37 for buccal periodonteum of for buccal periodonteum of

mandibular molars, gingiva, mandibular molars, gingiva, periodontal ligament and alveolar periodontal ligament and alveolar bonebone

for restorative and periodontal workfor restorative and periodontal work buccal nerve is readily located on the buccal nerve is readily located on the

surface of the tissue and not within surface of the tissue and not within bonebone

target: buccal nerve as it target: buccal nerve as it passes over the anterior passes over the anterior border of the ramus through border of the ramus through the buccinator – the buccinator – figure 9-figure 9-3636

injection site is the buccal injection site is the buccal tissues distal and buccal to tissues distal and buccal to the most distal molar – on the most distal molar – on the anterior border of the the anterior border of the ramus as it meets the body ramus as it meets the body – – figure 9-37figure 9-37

pull the buccal tissue tight pull the buccal tissue tight and advance the needle and advance the needle until you feel bone – only until you feel bone – only about 1 to 2mmabout 1 to 2mmfigure 9-38figure 9-38 patient-inflicted trauma – lip patient-inflicted trauma – lip

biting etc...biting etc...

figures 9-39 figures 9-39 through 9-41through 9-41

for facial for facial periodonteum of periodonteum of mandibular premolars mandibular premolars and anterior teeth on and anterior teeth on one sideone side

for restorative work – for restorative work – incisive block should incisive block should be considered insteadbe considered instead

target site: mental nerve before it target site: mental nerve before it enters the mental foramen where it enters the mental foramen where it joins with the incisive nerve to form joins with the incisive nerve to form the IA nerve – the IA nerve – figure 9-39figure 9-39

palpate the foramen between the palpate the foramen between the apices of the 1apices of the 1stst and 2 and 2ndnd premolars premolars

palpate it intraorally – find the palpate it intraorally – find the mucobuccal fold between the apices mucobuccal fold between the apices of the 1of the 1stst and 2 and 2ndnd premolars – premolars – figure figure 9-429-42

in adults, the foramen faces in adults, the foramen faces posterosuperiorlyposterosuperiorly

may be anterior or posteriormay be anterior or posterior can be found using radiographscan be found using radiographs

insertion site is the mucobuccal fold insertion site is the mucobuccal fold tissue directly over or slight anterior tissue directly over or slight anterior to the foramen siteto the foramen site

avoid contact with the mandible with avoid contact with the mandible with the needlethe needle

depth is 5 to 6mmdepth is 5 to 6mm no need to enter the foramenno need to enter the foramen

for pulp and facial tissues of the teeth for pulp and facial tissues of the teeth anterior to the mental foramenanterior to the mental foramen same as the mental block except pulpal same as the mental block except pulpal

anesthesia is provided alsoanesthesia is provided also restorative and periodontal workrestorative and periodontal work IA block indicated for extractions – no IA block indicated for extractions – no

lingual anesthesia with an incisive lingual anesthesia with an incisive blockblock

target: mental foramen – target: mental foramen – figure 9-43figure 9-43

injection site: injection site: figure 9-44figure 9-44 same as for the mental blocksame as for the mental block directly over or anterior to the directly over or anterior to the

mental foramenmental foramen in the mucobuccal fold at the in the mucobuccal fold at the

apices of the 1apices of the 1stst and 2 and 2ndnd premolars premolars

pull the buccal tissues laterallypull the buccal tissues laterally more anesthesia is used for this more anesthesia is used for this

block when compared to the block when compared to the mental blockmental block

pressure is applied during the pressure is applied during the injection – forces for anesthetic injection – forces for anesthetic solution into the foramen and solution into the foramen and block the deeper incisive nerveblock the deeper incisive nerve

the increased injection solution the increased injection solution may balloon the facial tissuesmay balloon the facial tissues

figures 9-45 figures 9-45 through 9-50through 9-50

blocks the IA, mental, blocks the IA, mental, incisive, lingual, incisive, lingual, mylohyoid, mylohyoid, auriculotemporal and auriculotemporal and buccal nerves – buccal nerves – figure figure 9-28 and 9-459-28 and 9-45

used for quadrant used for quadrant dentistrydentistry

buccal and lingual soft buccal and lingual soft tissue from most distal tissue from most distal molar to the midlinemolar to the midline

greater success than greater success than an IA blockan IA block

target site: anteromedial border target site: anteromedial border of the mandibular condylar neck of the mandibular condylar neck – – figure 9-46figure 9-46

just inferior to the insertion of just inferior to the insertion of the lateral pterygoid musclethe lateral pterygoid muscle

injection site is intraoralinjection site is intraoral locate the intertragic notch and locate the intertragic notch and

labial commisure extraorallylabial commisure extraorally draw a line from the draw a line from the

tragus/intertragic notch to the tragus/intertragic notch to the labial commisure – labial commisure – figure 9-47figure 9-47

place your thumb on the condyle place your thumb on the condyle (just in front of the tragus when the (just in front of the tragus when the mouth is open)mouth is open)

pull buccal tissue awaypull buccal tissue away place the needle inferior to the place the needle inferior to the

mesiolingual cusp of the MAXILLARY mesiolingual cusp of the MAXILLARY 22ndnd molar molar

the needle penetrates distal to the the needle penetrates distal to the maxillary 2maxillary 2ndnd molar molar

see the videosee the video

Teeth removalTeeth removal Tooth removal is one of the most Tooth removal is one of the most

widespread operations in polyclinic widespread operations in polyclinic stomatologic practice. For carrying out stomatologic practice. For carrying out its necessary to know the sequence of its necessary to know the sequence of techniques of performance and skills techniques of performance and skills of possession special instruments.of possession special instruments.

Indications and contra-indications to Indications and contra-indications to removal of permanent teeth.removal of permanent teeth.

Indications to planned tooth removal:Indications to planned tooth removal: 1.)Unsuccessfulness of endodonthyc 1.)Unsuccessfulness of endodonthyc

treatment with presence of the chronic treatment with presence of the chronic inflammation of periodontium and inflammation of periodontium and adjoining tissues of a bone. This adjoining tissues of a bone. This intervention is especially indicated in case intervention is especially indicated in case of chronic intoxications of the patient with of chronic intoxications of the patient with odontogenic intoxication centres odontogenic intoxication centres (chroniosepsis)(chroniosepsis)

2.) Impossibility of conservative treatment 2.) Impossibility of conservative treatment through considerable crown destruction or through considerable crown destruction or the technical obstacles connected with the technical obstacles connected with anatomic features, treatment errors, anatomic features, treatment errors, caused by root perforation. caused by root perforation.

3.) Total destruction of crown part of the 3.) Total destruction of crown part of the tooth, impossibility of using the root for tooth, impossibility of using the root for tooth prosthetics.tooth prosthetics.

4.) Mobility of 4.) Mobility of ІІІ degree and tooth promotions ІІІ degree and tooth promotions as a result of resorption of bone round a cell with as a result of resorption of bone round a cell with presence of heavy forms of a periodontosis and presence of heavy forms of a periodontosis and parodontitis.parodontitis.

5.) Atypically placed teeth which injure a 5.) Atypically placed teeth which injure a mouth mucous membrane, tongue, and mouth mucous membrane, tongue, and which can't be treated by ortodonthic which can't be treated by ortodonthic treatment. treatment.

6.) Unteethed in time or partially teethed 6.) Unteethed in time or partially teethed teeth which predetermine inflammatory teeth which predetermine inflammatory processes in adjoining tissues, which processes in adjoining tissues, which cannot be liquidated some other way.cannot be liquidated some other way.

7.) Placed in crisis cracks, teeth do 7.) Placed in crisis cracks, teeth do impossible reposition of fragments andimpossible reposition of fragments and can't be treated by conservative can't be treated by conservative treatment.treatment.

8.) Outstanding as a result of loss of the 8.) Outstanding as a result of loss of the antagonist teeth, teeth which antagonist teeth, teeth which convergence and divergence, disturb convergence and divergence, disturb embarrass the process of manufacturing embarrass the process of manufacturing tooth prosthetics. treatment. For tooth prosthetics. treatment. For elimination of anomalies of a bite elimination of anomalies of a bite (occlusion) during the orthodontic (occlusion) during the orthodontic treatment, intact teeth removal is also treatment, intact teeth removal is also indicated. indicated.

Contra-indications.Contra-indications. A number of A number of inflammatory and local diseases, and inflammatory and local diseases, and also some physiologic conditions are also some physiologic conditions are contra-indications to this contra-indications to this intervention. Removal of tooth at intervention. Removal of tooth at such patients can be done after such patients can be done after preparation and treatment.preparation and treatment.

Relative contra-indications to operations Relative contra-indications to operations of tooth removal are:of tooth removal are:

1.) Cardiovascular diseases (preinfarction 1.) Cardiovascular diseases (preinfarction conditions and 3-6 month after the infarction of conditions and 3-6 month after the infarction of a myocardium, hypertonic illness in crisis. a myocardium, hypertonic illness in crisis. IHD(ischemic heart disease), paroxysm, IHD(ischemic heart disease), paroxysm, blinking arhythmia, paroxysmal tachycardia, blinking arhythmia, paroxysmal tachycardia, acute septic endocarditis);acute septic endocarditis);

2.) Acute diseases of parenchymatosic organs - 2.) Acute diseases of parenchymatosic organs - liver, kidneys, pancreas (an infectious hepatitis, liver, kidneys, pancreas (an infectious hepatitis, (glomerunonephritis);(glomerunonephritis);

3.) Haemorragical diseases (a hemophilia, 3.) Haemorragical diseases (a hemophilia, illness of Verlgof, agranulocytosis, acute illness of Verlgof, agranulocytosis, acute leukemia);leukemia);

4.) acute infectious diseases (a flu, ARVD(acute 4.) acute infectious diseases (a flu, ARVD(acute respiratoric virus disease), a pneumonia);respiratoric virus disease), a pneumonia);

5.) disease of CNS (central neuronic 5.) disease of CNS (central neuronic system), (acute disorder of encephal system), (acute disorder of encephal blood circulation, a meningitis);blood circulation, a meningitis);

6.) Mental (psychological) diseases in 6.) Mental (psychological) diseases in an aggravation period (a schizophrenia, an aggravation period (a schizophrenia, a psychosis, an epilepsy);a psychosis, an epilepsy);

7.) acute radiation sickness 7.) acute radiation sickness І - ІІІ degrees;І - ІІІ degrees; 8.) disease of a mucous membrane of a 8.) disease of a mucous membrane of a

mouth (a stomatitis, gingivitis, mouth (a stomatitis, gingivitis, cheilitis).cheilitis).

Preparation of tooth removal:Preparation of tooth removal:

-Inspection.-Inspection. -Preparation of the patient.-Preparation of the patient. -Preparation of doctor’s hands.-Preparation of doctor’s hands. -Preparation of the operation field.-Preparation of the operation field.

Technique of tooth removal:Technique of tooth removal:

Tooth removal consists in violent rupture Tooth removal consists in violent rupture of tissues which connect root with walls of tissues which connect root with walls of a cell and gums, and its deducing from of a cell and gums, and its deducing from a cell. During removal of the distorted a cell. During removal of the distorted roots from a cell, its walls are being roots from a cell, its walls are being replaced and the entrance to it extends. replaced and the entrance to it extends. Tooth removal is being made by special Tooth removal is being made by special tools, forceps and elevators. In certain tools, forceps and elevators. In certain cases tooth extraction by using this tool cases tooth extraction by using this tool is impossible. Then a drill for bone is impossible. Then a drill for bone removal is used. (operation of root removal is used. (operation of root cutting)cutting)

Forceps and elevetaors for teeth Forceps and elevetaors for teeth removal:removal:

Forceps. Under the process teeth removal a Forceps. Under the process teeth removal a lever principle is used. Forceps consists of: lever principle is used. Forceps consists of: cheeks, handles and the lock. In some kind’s cheeks, handles and the lock. In some kind’s of forceps between cheeks and the lock there of forceps between cheeks and the lock there is a transitive part. Cheeks are used to cover is a transitive part. Cheeks are used to cover the root or a crown. The handle – a part which the root or a crown. The handle – a part which is used to hold the forceps. The lock is placed is used to hold the forceps. The lock is placed between the handle and a cheek.between the handle and a cheek.

For the best fixing of tooth or a root, cheeks For the best fixing of tooth or a root, cheeks have fillets with longitudinal cutting from the have fillets with longitudinal cutting from the inside. The external surface of handles on inside. The external surface of handles on significant length is relief, internal - smooth. significant length is relief, internal - smooth. The form of forceps is not the same. The form of forceps is not the same. Construction depends on anatomical structure Construction depends on anatomical structure of the tooth and it’s place in row of teeth.of the tooth and it’s place in row of teeth.

Kinds of forceps:Kinds of forceps:

1.) Forceps for removal of teeth and 1.) Forceps for removal of teeth and roots of the top and bottom jaws. roots of the top and bottom jaws. Forceps for the top jaw have Forceps for the top jaw have prolongated axis of the cheeks and prolongated axis of the cheeks and handles, are coincide or parallel, or handles, are coincide or parallel, or form a corner. With forceps for form a corner. With forceps for removal of teeth on the bottom jaw, removal of teeth on the bottom jaw, cheeks and handles are placed at cheeks and handles are placed at right angle or at an angle which is right angle or at an angle which is approached to it;approached to it;

2.) Forceps for removal of teeth with the 2.) Forceps for removal of teeth with the kept crown (crown forceps) and for root kept crown (crown forceps) and for root removal (root forceps). Cheeks for removal (root forceps). Cheeks for removal of a crowned teeth do not removal of a crowned teeth do not converge, for removal of roots - converge, for removal of roots - converge;converge;

3.) Forceps for removal of separate 3.) Forceps for removal of separate groups of teeth of the top and bottom groups of teeth of the top and bottom jaw. They differ by width and features of jaw. They differ by width and features of a structure of cheeks, their placing in a structure of cheeks, their placing in relation to handles, the form of handles;relation to handles, the form of handles;

4.) Forceps for removal of the first 4.) Forceps for removal of the first and the second molars of the top and the second molars of the top jaw on the right and at the left. The jaw on the right and at the left. The left and right cheeks of these left and right cheeks of these nippers are constructed unequally;nippers are constructed unequally;

5.) Forceps for removal of teeth of 5.) Forceps for removal of teeth of the bottom jaw in case of the the bottom jaw in case of the limited opening of a mouth. They limited opening of a mouth. They have a bend of cheeks in a have a bend of cheeks in a horizontal direction.horizontal direction.

Forceps for maxillaForceps for maxilla

Forceps for the root’s of maxillar Forceps for the root’s of maxillar teethteeth

Forceps for mandibulaForceps for mandibula

Structure of the forceps, about the Structure of the forceps, about the surfacesurface

Types of correct forceps handlingTypes of correct forceps handling

Luxation and rotation during teeth Luxation and rotation during teeth removalremoval

Correct and incorrect forceps Correct and incorrect forceps positions positions

To execute operation successfully, it is To execute operation successfully, it is necessary to apply the forceps, which design necessary to apply the forceps, which design to anatomic features of removable tooth.to anatomic features of removable tooth.

Removal of the central incisor, lateral Removal of the central incisor, lateral incisor and canine of top jaw, is being done by incisor and canine of top jaw, is being done by forceps which have the direct form, - direct forceps which have the direct form, - direct forceps. Longitudinal axes of cheeks and forceps. Longitudinal axes of cheeks and handles are in one plane and coincide. Both handles are in one plane and coincide. Both cheeks are identical by the form, from the cheeks are identical by the form, from the inside fillets, round off the ends. Forceps can inside fillets, round off the ends. Forceps can have big and small width cheeks. have big and small width cheeks.

Removal of small root teeth of the top jaw is Removal of small root teeth of the top jaw is being made by nippers which have S-like being made by nippers which have S-like bend. Cheeks are placed with them at an bend. Cheeks are placed with them at an obtuse angle to handles. Such form of forceps obtuse angle to handles. Such form of forceps allows to impose them correctly on tooth and allows to impose them correctly on tooth and during its removal to prevent obstacles from during its removal to prevent obstacles from the bottom jaw.the bottom jaw.

Removal of the big molars of the top Removal of the big molars of the top jaw is being made by forceps which jaw is being made by forceps which have S-like bend and are similar by the have S-like bend and are similar by the form to forceps for removal of small form to forceps for removal of small molars. However their cheeks are molars. However their cheeks are arranged differently. They are shorter arranged differently. They are shorter and are wider, the distance between and are wider, the distance between them in the closed condition is greater. them in the closed condition is greater. Both cheeks from inside have Both cheeks from inside have Deepening. End of one cheek is round, Deepening. End of one cheek is round, other one ends by a thorn, from which, other one ends by a thorn, from which, in the middle, from indside surface lasts in the middle, from indside surface lasts small crest.small crest.

During removal of tooth the thorn enters During removal of tooth the thorn enters between cheeks roots, the cheek with the between cheeks roots, the cheek with the plane end, captures a neck of tooth from the plane end, captures a neck of tooth from the palatal surface. One forceps the cheek with a palatal surface. One forceps the cheek with a thorn is on the right side, in the second - at the thorn is on the right side, in the second - at the left. Such structure of a cheek provides dense left. Such structure of a cheek provides dense coverage of the tooth and makes its removal coverage of the tooth and makes its removal easier. Removal of the third big molar of the easier. Removal of the third big molar of the upper jaw is being done by special forceps. The upper jaw is being done by special forceps. The oblong axis of cheeks and an axis of handles at oblong axis of cheeks and an axis of handles at them are parallel. Two cheeks are equally wide, them are parallel. Two cheeks are equally wide, with thin, and rounding in edges ends. On with thin, and rounding in edges ends. On inside they have a dimple; during interlocking, inside they have a dimple; during interlocking, forceps do not converge. The construction of forceps do not converge. The construction of forceps gives the ability to enter them deeply forceps gives the ability to enter them deeply into the oral cavity, thus the lower jaw does into the oral cavity, thus the lower jaw does not Hinders the operation carrying out.not Hinders the operation carrying out.

Roots of incisors, canines and premolars of Roots of incisors, canines and premolars of the upper jaw, are being deleted by the the upper jaw, are being deleted by the same forceps, as other teeth, only with same forceps, as other teeth, only with more thin and narrow cheeks. For removal more thin and narrow cheeks. For removal of roots of the big molars use bayonetlike of roots of the big molars use bayonetlike forceps. They have the transitive part from forceps. They have the transitive part from which long cheeks are going out which which long cheeks are going out which coincide with the thin rounding off end and coincide with the thin rounding off end and a fillet throughout an axis of all internal a fillet throughout an axis of all internal surface. The oblong axis of handles at them surface. The oblong axis of handles at them is parallel. Depending on width of cheeks is parallel. Depending on width of cheeks distinguish bayonetlike; with narrow, distinguish bayonetlike; with narrow, average and wide cheeks. They are used average and wide cheeks. They are used for removal of roots of incosors, canines, for removal of roots of incosors, canines, small molars and teeth with the destroyed small molars and teeth with the destroyed surface.surface.

Removal of teeth and roots of the lower Removal of teeth and roots of the lower jaw is being made by forceps, which are jaw is being made by forceps, which are bent on an edge and have beaklike bent on an edge and have beaklike form. The axis of brushes and an axis of form. The axis of brushes and an axis of handles form a corner, which is direct or handles form a corner, which is direct or close to direct. All components of close to direct. All components of forceps are allocated in a vertical plane, forceps are allocated in a vertical plane, handles - one over the second.handles - one over the second.

Cheeks of forceps for removal of Cheeks of forceps for removal of incsors of the lower jaw, are narrow with incsors of the lower jaw, are narrow with fillets on inside, they are rounded on the fillets on inside, they are rounded on the end, during interlocking they do not end, during interlocking they do not converge. Canines and small molars are converge. Canines and small molars are deleted buy such forceps, but with deleted buy such forceps, but with wider cheeks.wider cheeks.

Forceps for removal of the big molars have wide Forceps for removal of the big molars have wide cheeks which do not converge. Each of them cheeks which do not converge. Each of them ends by triangular bend(thorn). From the inside ends by triangular bend(thorn). From the inside both cheeks have a dimple. During both cheeks have a dimple. During superimposing on tooth bends enter the furrow superimposing on tooth bends enter the furrow between front and back roots that provides good between front and back roots that provides good fixing of forceps on tooth.fixing of forceps on tooth.

In case of restricted opening of a mouth,big In case of restricted opening of a mouth,big molars are deleted by the horizontal forceps, molars are deleted by the horizontal forceps, bent on a plane. They are constructed bent on a plane. They are constructed differently, than beaklike. Handles and the lock differently, than beaklike. Handles and the lock are allocated at an angle which comes nearer to are allocated at an angle which comes nearer to direct and is in a vertical plane. A working part direct and is in a vertical plane. A working part of brushes is the same, as the beaklike forceps of brushes is the same, as the beaklike forceps for removal of the big molars, bent on an edge. for removal of the big molars, bent on an edge. Roots of all teeth of the lower jaw are deleted by Roots of all teeth of the lower jaw are deleted by forceps of the same form, as incisors, canines forceps of the same form, as incisors, canines and small molars, only by cheecks that and small molars, only by cheecks that converge. converge.

The position of the doctor during The position of the doctor during

Elevators.Elevators. Extracting teeth by elevetaors, as well as by Extracting teeth by elevetaors, as well as by

forceps, use the lever principe. Elevator forceps, use the lever principe. Elevator consists of three parts: consists of three parts:

The working part, the connective rod and The working part, the connective rod and the handle. There are many different the handle. There are many different constructions of elevetaors, however the constructions of elevetaors, however the most widespread are three types: straight, most widespread are three types: straight, angular and beaklike elevator.angular and beaklike elevator.

Straight elevator. Its working part is a Straight elevator. Its working part is a continuation of the connective rod and continuation of the connective rod and together with the handle are allocated on together with the handle are allocated on one direct line. The cheek on the one hand one direct line. The cheek on the one hand convex, semicircular, from the other – bent, convex, semicircular, from the other – bent, also looks like a fillet, the end is refined and also looks like a fillet, the end is refined and rounded.rounded.

Straight elevators are intended for Straight elevators are intended for removal of roots of teeth,of the upper removal of roots of teeth,of the upper jaw which have one root. They are jaw which have one root. They are intented for removal of teeth of the intented for removal of teeth of the upper jaw allocated out of a tooth arc, upper jaw allocated out of a tooth arc, rarely - the lower third molar.rarely - the lower third molar.

Angular elevator. The working part Angular elevator. The working part

(cheek) is bent on an edge and (cheek) is bent on an edge and allocated to longitudinall axis by the allocated to longitudinall axis by the elevator at an angle, approximately 120 elevator at an angle, approximately 120 ⁰. ⁰.

Cheek small.One of its surface is convex, the Cheek small.One of its surface is convex, the second - slightly bent with longitudinal second - slightly bent with longitudinal edges. The concave surface of a cheek at edges. The concave surface of a cheek at one elevatorone elevator is turned to left (to itself), in others - to is turned to left (to itself), in others - to the right - from itself.the right - from itself.

In an elevator operation time, the concave In an elevator operation time, the concave surface of a cheek is directed to a root, surface of a cheek is directed to a root, which is being deleted, convex - to a cell which is being deleted, convex - to a cell wall.wall.

Angular elevator is used for removal of Angular elevator is used for removal of the lower teeth. the lower teeth.

Bayonetlike elevator (Lekljuz Bayonetlike elevator (Lekljuz Elevator).Connective rod of elevator is Elevator).Connective rod of elevator is bayonetlike, curve . The working part has bayonetlike, curve . The working part has spearlike form. It is narrowed and thiner in spearlike form. It is narrowed and thiner in finite department. The handle is round, finite department. The handle is round, thicker in the middle part, allocated thicker in the middle part, allocated perpendicular to connective rod and to perpendicular to connective rod and to working part. Elevator is intended for working part. Elevator is intended for removal of the third lower molar.removal of the third lower molar.

Types of elevators:Types of elevators:

Lekljuz elevatorLekljuz elevator

Types of elevators:Types of elevators:

Stages of operation of removal of Stages of operation of removal of tooth:tooth:

Operations of removal of tooth,are Operations of removal of tooth,are being led by forceps, also consists being led by forceps, also consists of several serial stages:of several serial stages:

1.) Superimposing of forceps1.) Superimposing of forceps 2.) Advancement of forceps2.) Advancement of forceps 3.) Interlocking of forceps (fixing)3.) Interlocking of forceps (fixing) 4.) A tooth Dislocation (luxation or 4.) A tooth Dislocation (luxation or

tooth rotation)tooth rotation) 5.) Deduction of tooth from a cell 5.) Deduction of tooth from a cell

(traction)(traction)

Extraction of teeth, and it’s roots using drill, Extraction of teeth, and it’s roots using drill, hammer and chisel.hammer and chisel.

In such cases, when tooth or the root can’t be In such cases, when tooth or the root can’t be removed by using forceps or elevator, it is removed by using forceps or elevator, it is necessary to use drill, hammer or chisel. as an necessary to use drill, hammer or chisel. as an indication to such operation could be presence of indication to such operation could be presence of a root or tooth which was not erupt, or a root with a root or tooth which was not erupt, or a root with the curved top, and also expressed the curved top, and also expressed hypercementosis. This method is used more often, hypercementosis. This method is used more often, when extracting of the bottom wisdom tooth is when extracting of the bottom wisdom tooth is needed.needed.

Processing of a wound after tooth removal. After Processing of a wound after tooth removal. After the termination of operation of removal of tooth it the termination of operation of removal of tooth it is necessary to examine it carefully. Presence of is necessary to examine it carefully. Presence of keen edges in the root channel testify a root crisis. keen edges in the root channel testify a root crisis. It’s unallowed to leave the broken root in a cell, It’s unallowed to leave the broken root in a cell, especially if removal was spent concerning a sharp especially if removal was spent concerning a sharp purulent periodontitis. Root removal needs to be purulent periodontitis. Root removal needs to be finished by using hammer, drill, or chisel.finished by using hammer, drill, or chisel.

When ensured, that tooth is fully removed, a sharp When ensured, that tooth is fully removed, a sharp spoon is necessary to clear a cell of small splinters of a spoon is necessary to clear a cell of small splinters of a bone, granulations or a bone cover. External and bone, granulations or a bone cover. External and internal edge of a cell shoud be squeezed by fingers internal edge of a cell shoud be squeezed by fingers through gauze tampons. On a wound impose one or through gauze tampons. On a wound impose one or several gauze tampons and ask the patient to compress several gauze tampons and ask the patient to compress jaws strongly. In 10-15 minutes a tampon delete’s to jaws strongly. In 10-15 minutes a tampon delete’s to make sure of clot preservation. When there’s no make sure of clot preservation. When there’s no bleeding, the patient can leave a medical institution. It bleeding, the patient can leave a medical institution. It is recommended to eat within 1-2 hours then it is is recommended to eat within 1-2 hours then it is possible to consume cool meal. In the first day after possible to consume cool meal. In the first day after operation, it is not recommended to rinse oral cavity by operation, it is not recommended to rinse oral cavity by solutions of antiseptic tanks, except those cases when solutions of antiseptic tanks, except those cases when purulent - inflammatory process is present. Rinsings by purulent - inflammatory process is present. Rinsings by weak solutions furacilimun, chlorheksidinum, weak solutions furacilimun, chlorheksidinum, hydrocarbonate sodium, or permanganate potassium is hydrocarbonate sodium, or permanganate potassium is allowed only on 2-3rd day. Usually the wound after tooth allowed only on 2-3rd day. Usually the wound after tooth removal heals by a secondary tension, thanks to removal heals by a secondary tension, thanks to formation of blood clot. Putting a gauze in a sonorous formation of blood clot. Putting a gauze in a sonorous impregnated with a solution of iodoform, is possible only impregnated with a solution of iodoform, is possible only with the purpose of preventing the infication of a clot if with the purpose of preventing the infication of a clot if inflammatory process has developedinflammatory process has developed

Complication, that can occur during, and after Complication, that can occur during, and after tooth exraction.tooth exraction.

Root crisis can be prevented by using the method of Root crisis can be prevented by using the method of section and separation of gums, with the following section and separation of gums, with the following chisel debridement of cell wall, to one third of length, chisel debridement of cell wall, to one third of length, and also by using forceps for root extraction.and also by using forceps for root extraction.

Damage of soft tissues, occurs during careless, rough Damage of soft tissues, occurs during careless, rough manipulations of physician, disorder of tooth manipulations of physician, disorder of tooth extraction technique. extraction technique.

When insufficient gums dislayering, before tooth When insufficient gums dislayering, before tooth extraction, rupture of mucous membrane often occurs extraction, rupture of mucous membrane often occurs during operation;during operation;

In case of wrong tooth extraction technique, when a In case of wrong tooth extraction technique, when a doctor imposes forceps directly on a mucous doctor imposes forceps directly on a mucous membrane, dislayered it not enough from the cell membrane, dislayered it not enough from the cell process, or a part.process, or a part.

In case of careless dislocating of roots, by direct In case of careless dislocating of roots, by direct elevator, tissue damage of the bottom of oral cavity, elevator, tissue damage of the bottom of oral cavity, tongue(when removing the roots of lower molars) and tongue(when removing the roots of lower molars) and palate(when removing the roots of upper molars) palate(when removing the roots of upper molars) occurs. occurs.

On a background of the damage of On a background of the damage of soft tissues, bleeding occurs, which soft tissues, bleeding occurs, which complicates the work of a doctor, complicates the work of a doctor, while tooth extracting; In while tooth extracting; In postoperative period, inflammatory postoperative period, inflammatory complications can occur.complications can occur.

A technique of granting of the A technique of granting of the urgent help: a stop of a bleeding urgent help: a stop of a bleeding and suturing the wound.and suturing the wound.

a fragment break of cell parts (more often on the bottom jaw) - a fragment break of cell parts (more often on the bottom jaw) - damage of tisses arises: damage of tisses arises:

-- Under condition of an union of a tooth root with cell Under condition of an union of a tooth root with cell walls;walls;

-- In case of deep imposing cheeks of nippers on cell walls In case of deep imposing cheeks of nippers on cell walls - thus tooth removes together with a bone tissues.- thus tooth removes together with a bone tissues.

Technique of granting the urgent medical aid: to smooth down Technique of granting the urgent medical aid: to smooth down (if necessary - to remove) sharp, unequal edges of a cell of (if necessary - to remove) sharp, unequal edges of a cell of tooth, to suture a mucous membrane.tooth, to suture a mucous membrane.

Break of a tuber of the top jaw arises during removal of the Break of a tuber of the top jaw arises during removal of the third top molar, as a result of deep imposing forceps cheeks on third top molar, as a result of deep imposing forceps cheeks on walls of a cell, or a rough dislocation of tooth by straight walls of a cell, or a rough dislocation of tooth by straight elevator:elevator:

In such case, there is a broken off fragment of a tuber of the In such case, there is a broken off fragment of a tuber of the top jaw on extracted tooth (roots)top jaw on extracted tooth (roots)

-a considerable bleeding occurs;-a considerable bleeding occurs; -If the maxillar sinus is damaged, vials of air from the extracted -If the maxillar sinus is damaged, vials of air from the extracted

tooth cell occure during attempt to blow air through closed tooth cell occure during attempt to blow air through closed with fingers nose.with fingers nose.

The technique of granting urgent help: smoot keen edges of The technique of granting urgent help: smoot keen edges of tooth cell by bone spoon, mobilize and suture tightly a mucous tooth cell by bone spoon, mobilize and suture tightly a mucous membranem so that a bone wound would be completely membranem so that a bone wound would be completely closed. If the stomatologist cannot independently stop a closed. If the stomatologist cannot independently stop a bleeding, and suture a wound, he put iodoform tampon and bleeding, and suture a wound, he put iodoform tampon and transport’s the patient immediately in a surgical stomatologic transport’s the patient immediately in a surgical stomatologic department.department.

PerforationPerforation of the bottom of maxillar sinus arises during of the bottom of maxillar sinus arises during removal of the first top molar, sometimes - the second and removal of the first top molar, sometimes - the second and premolar.premolar.

It is explained, that tops of the given teeth are closely It is explained, that tops of the given teeth are closely located to the bottom of sinus.located to the bottom of sinus.

Perforation of the bottom of maxillar sinus can occur, when:Perforation of the bottom of maxillar sinus can occur, when: -- Traumatic removal of the named teeth (if rough Traumatic removal of the named teeth (if rough

manipulation in a tooth cell is done), and during careless manipulation in a tooth cell is done), and during careless manipulations;manipulations;

-- Owing to anatomic features, when the root is located Owing to anatomic features, when the root is located under a sinus mucous membrane;under a sinus mucous membrane;

-- When inflammatory process on a top of a root has When inflammatory process on a top of a root has destroyed a sinus bottom.destroyed a sinus bottom.

Diagnostics:Diagnostics: During careful tubage of a cell, the instrument gets for the During careful tubage of a cell, the instrument gets for the

length more than the deepnes of the cell.length more than the deepnes of the cell. On the basis of passage of the air from the oral cavity, into a On the basis of passage of the air from the oral cavity, into a

nasal cavity, ot contrary. The patient, having clamped fingers nasal cavity, ot contrary. The patient, having clamped fingers on his nose, should try to blow the air throughout it. Thus air on his nose, should try to blow the air throughout it. Thus air through an aperture (perforation) of the bottom of maxillar through an aperture (perforation) of the bottom of maxillar sinus leaves it with a whistle and goes into oral cavity, or sinus leaves it with a whistle and goes into oral cavity, or blood vials of air from a cell of extracted tooth occur;blood vials of air from a cell of extracted tooth occur;

Radiological research is conducted (an aim picture).Radiological research is conducted (an aim picture).

Technique of granting urgent medical aid in Technique of granting urgent medical aid in case of perforation of maxillar sinus: case of perforation of maxillar sinus:

-- In the presence of a purulent antritis In the presence of a purulent antritis (pus is goin out from a tooth cell, through a (pus is goin out from a tooth cell, through a perforated aperture) in entrance of cell perforated aperture) in entrance of cell iodoform tampon and hospitalization of the iodoform tampon and hospitalization of the patient in maxillofacial deparment;patient in maxillofacial deparment;

-- In case of pushing a root through in a In case of pushing a root through in a sinus, its removal in the conditions of a sinus, its removal in the conditions of a hospital is indicated;hospital is indicated;

-- In case of a healthy sinus (when In case of a healthy sinus (when radiological research does not reveal a root in radiological research does not reveal a root in a sinus) it is necessary to close a perforated a sinus) it is necessary to close a perforated aperture (a cell of extracted tooth) by a aperture (a cell of extracted tooth) by a mucosial rag, taken from a vestibular surface mucosial rag, taken from a vestibular surface of cell process. If the doctor has not of cell process. If the doctor has not mastered this technique, he should tightly mastered this technique, he should tightly suture a cell (to Impose 2-3 seams of suture a cell (to Impose 2-3 seams of polyamides).polyamides).

TheThe bleedingbleeding arises after operation of arises after operation of removal of tooth. Distinguish early removal of tooth. Distinguish early bleedings and late. Early bleedings, arise bleedings and late. Early bleedings, arise right after removals of tooth (trauma).right after removals of tooth (trauma).

Late bleedings can arise:Late bleedings can arise: 1)1) In some hours after tooth removal, In some hours after tooth removal,

for example in case of adrenaline for example in case of adrenaline overdose.overdose.

2)2) For some days after operation which For some days after operation which becomes complicated by an becomes complicated by an inflammatory process.inflammatory process.