Cysts of the jaws symptoms

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Cysts of The Jaws
Symptoms
Pathological fracture
Mistaken for abscess
Displacement of denture
Displacement of teeth
Discoloration of tooth

Cysts of the Jaws
Marsupialisation – Rationale

By making a small cystic
Contents are evacuated thereby
Causing decompression of the
Cyst.

How often are teeth Impacted
Only 17% of people over 20 years
Have an impacted tooth
Maxillary third molars
Mandibular third molars
Maxillary canine
Ref:- Dachi S.F,Hovell over surg
14:1165.1961

22%
18%
0.9%

• What is so special about third molars ?!

• last tooth to erupt
• More likely to be impacted
• More likely to cause complication


ETIOLOGICAL THEORIES
PHYLOGENIC
MENDELIAN
ENDOCRINE DISORDERS
SKELETAL GROWTH
DISTURBANCES
SYSTEMIC CONDITIONS
LOCAL FACTORS

INDICATION FOR REMOVAL
Recurrent Pericoronitis
Periodontal
Orthodontic Reasons
Dental Caries
Resorbtion Of Second Molar

INDICATIONS FOR REMOVAL
1.Reffered pain
2. Cyst Formation
3. Prophylactic Reasons
4. Edentulous Mandible
5. In the line of fractures

IMPACTED LOWER THIRD MOLAR
Classification :
George Winter’s
Pell and Gregory’s
Kay’s


GERGE WINTER’S CLASSIFICATION
Based on the relationship of the long
Axis of impacted 3rd molar with the
Long axis of 2nd molar:Vertical
Mesioangular
Distoangular
Horizontal
Buccoangular
Aberrant Positons

Pell & Gregory(1942) Classification
Based on Three Aspects
Position & Angulation
Space between second molar and ramus
Depth of the third molar in the bone


Pell & Gregory
Position & Angulation
George Winter’s Classification
is adopted

Kay’s Classification
( Based on three aspects)
1.Position & Angulation - Winter’s Classification
States of Eruption
-a) Erupted
b) Partly erupted
c) Unerupted
3. Number & Pattern - Fused
of Roots
Two
Multiple
Favourable
Unfavourable

Difficulty index Pederson)
Minimal

3-4

Moderate

5-7

Very difficult

7-10


Difficulty index values(Pederson)
Mesioangular
1
horizontal
2
vertical
3
distoangular
4
level A
level B
level C

1
2
3

Class I 1
Class II 2
Class III 3

WINTER’S IMAGINARY LINES
White Line - Indicates position of 3rd
molar
Amber Line - Indicates margin of
alveolar bone
Red Line - Indicates dept of 3rd molar

Clinical Assissment
General Factors
- Age
- Medical Condition
- Temperament


Assessment of Impacted Third
Molar
Purpose of Assessment
Possible Difficulties & Complications
Facilities Available
Necessary Surgical Skill
Decision to remove or to refer to
A specialist

Radiological Assessment
- Radiograptus Required
- Periapical Film
- Lateral oblique view of mandible
- Orthopantomogram

Clinical Assessment
Local factors
Small Factors
Small mouth
Mandibula retrusion
Relationship of external
Oblique eidue to the 3rd molar

Radiological Assessment
Points to be noticed in radiograph:Augulation and depth
Number and shape of rooths
Relationship with mandibular canal
Condition of crown & rooth of 2nd molar
Density of the bone
Bone loss around the tooth
Presence of first molar

Relationship with mandibular
canal
Normal relationship
Variations
- Groove
- Deep Groove
- Perforation

Considerations in perdicting
difficulty
Age
Anatomy
Facial from

Age:- Does it affect surgery ?
Young age

Easy surgery
less morbidity

old age

Difficult surgery
Greater morbidity

Accessibility based on facial from
Tapering

Easy surgery

Square &
Compact

Difficult

Asymptomatic third molar
- let sleeping dogs lie
- don’t bother it, if it does not
bother you
- don’t touch if asymptomatic

Should a general practitioner
remove an impached third molar ?
Answer is yes and no


Operative Plan
- Incision
- Removal of bone]
- Removal of tooth
- To let of the wound
- Closure of the wound

Removel of Third Molar
Careful Assessment
Instruments selection
Choice of anaesthesia
Operative plan
Post operative care

Choice of Anaesthesia
Local
Intravenous sedation And local
- General


Scientific foundations of Minor
oral surgery
Muco Periosteal Flaps
Visibility
Vascularity
Healing

Scientific Foundtions of minor
oral surgery
Access
Mucoperiosteal flaps
Bone Removel

Complication During Surgical Removal
Incision

- Haemorrhage
Lingul Nerve damage
Bone removal - Injury to soft tissues
Damage to 2nd molar
Splitting of ramus
Damage to bone
Elevation of - Fracture of tooth
Damage to 2nd molar
Damage to I.D Bundle
Fracture of mandible
Toilet of the - Damage to I.D Nerve
Wond
And Vessels

Complications
(Postoperative)
- Haemorrhage
- Haematoma
- Oedema
- Pain
- Trismus

Exodontia
Complications :- Dry socket
Synonyms:Alveolitis, Alveolar osteitis,
Etc
Defn:“ A post extraction socket which
lacks a physiological blood clot.”

Exodontia
Dry Socket Etiology
Exact etiology unknown
Trauma
Infection
Vasoconstrictor effect
Mechanical dislodgement
Fibrinolytic theory

Exodontia
Dry Socket :- Clinical Features
Symptoms:Pain, Swelling, Trismus, Halitosis
Signs:Lack of clot in the socket
Exposed bone tender to touch
Inflammed gingival margin
Enlarged lymph nodes

Exodontia
Dry Socket:- Treatment
Aimed at
Control of pain
Sedative dressing
Analgesics
Control of infection
Antibiotics

Exodontia
Post Extraction Bleeding
Investigation
Bleeding time
Plastelet count
Prothrombia time
Partial thrombopiastin time

Exodontia
Causes
Local
Trauma
Infection
Systemic
Defect in vessel wall
Defect in plastelets
Defect in coagulation

Exodontia
Management - local measures
Soft Tissue
Pressure packs, vasoconstrictors
Suturing, chemicals,cautery
Bone
Burnishing,bone wax
Haemostatic agents
Socket plugs

Exodontia
Indications
Impacted, Malposed,
Supernumerary
Attrition, abrasion, erosion
Involved in cysts & tumours
Fractured teeth
In line of fracture

Exodontia
Objectives
To remove the tooth completely
With minimum trauma
Elimination of pathology in the socket
Prepare the socket for proper
Healing & repair

Exodontia
Techniques
Intra alveolar - forceps method
Transalveolar - open method
Elevators metod


Exodontia
Intra Aloveolar- Principles
Parallelism
Beaks placed on cementum
Maximum contact between
Beaks & the root surface
Amount & types of force
Expansion of the bony socket

Exodontia
Intra Alveolar Movements
Primary rotation
Buccolingual or palatal
Buccolingual & secondary
rotation


Exodontia
Trans Alveolar - Indications
Gross destruction of crown
Fallure to extract with forceps
Abnormallties of root
Non vital teeth
Ankylosis of root
Brittle teeth
Increased dentsity of bone

Exodontia
Trans Alveolar Advantages
Good visibility
Prevent laceration of gingival
Minimal trauma to bone
Root fracture prevented
Less post operative discomfort


Exodontia
Trans Alveolar Surgical Step

Anaesthesia
Incision & raising flap
Remove of bone
Removal of tooth or root
Debridement of the socket
Closure of the wound
Post operative care

Exodontia
Complication During Extraction
Fracture of root
Fracture of alveolues
Damage to soft tissues
Damage to adjacent teeth
Haemorrhage


Exodontia
Complication Root Fracture
Fallure to follow principles
Structural weakness of tooth
Bone investing the tooth


Exodontia
Complacations
Maxillary posterior teeth
Oro antral communication
Rooth displacesment in to sinus
Fracture of maxillary tuberoslty
Mandibular posterior teeth
Dislocation of TM joint
Fracture of mandible

Exodontia
Complications- TMJ Dislocation
DEF : Condyle comes out of
glenold fossa
Unllateral or bllateral
CAUSES
Fallure to support mandlble
Excessive mount opening
Use of mount gag under G.A
Use of certain drugs

Exodontia
Complication-post Extraction
Plain
Swelling
Trismus
Dry Socket
Haemorrhage


Scientific Foundations of Minor Oral Surgery
Dental Bacteremla In Children
A study conducted involving patiients who
Underwent variety of dental procedures
Including rubberdam application matrix band
With wedge and tooth brushing revealed
Significant bacteremia.


Post Operative Pain
Influenced By
Pathophysiologic Impact
Site of Surgery
Preoperative Preparation
Physical & Emotional Status
Intra operative management
Post operative team

Scientific Foundation of Minor Oral Surgery
Suture Material And
Bacterial Adherence
A study conducted in vitro to see the
Bacterial adherence to silk and cotton
Sutures revealed significantly higher
Adherence to silk than cotton.cotton should
Be the preferred suture material for skin and
Mucosal closure.

Most feared modality
Pain
Anaesthetic
Injection
Swelling
Numbness
Other

43%
18%
17%
10%
06%
06%


Pain Mechanisms
Peripheral Tissue Injury
Transmission Through The Nerves
Perception Withhin The Brain


Dental Elevators
In Common Use
Coupland Chisel
Cryers
Warwick james
Hospital Pattern
Apexo
Winter’s crossbar


Dental Elevators
Classification
Use:
Removal of teeth
Root broken at C.E junction
Root broken below C.E junction
Form:
Straight
Curved
Crossbar

Dental Elevators
Principles
Lever
Wedge
Wheel & axle


Scientific Foundations of Oral Surgery
Surgical Gloves
How often They Puncture
The incidence may be as high as 50 to
70% when the operations last more
Than 2 hours. The left index finger is
The most common site of perforation


Scientific Foundation of Minor Oral Surgery
Face Mask is it Essential ?
A prospective randomised study,
From sweden found no difference in
Wound infection rates when masks
Were climinated


Diagnosis In Oral Surgery
Components

History taking
Clinical examination
Investigations


Diagnosis:- Definition
“ Careful investigation of the facts
To determine the nature of a think”


History Taking
General information
Chief complaint
History of present illness
Personal, medical & Dental histories
Family & Social histories


Singn:- Definition

“ Any change I the body or its
Function which is perceptible to a
Trained observer and may indicate
Disease.”


Singn:- Definition

•General examination
•Local examination
• Extra oral
• Intra oral

Examination:- Extra Oral
•T.M. Joints
•Maxillary sinuses
•Lymph nodes
•Lips
•Lesion

Examination:- Extra Oral

Soft tissues
Hard tissues
Occlusion
Special pathology
(lession of interest)

Investigation:- General
Temperature
Pulse & B.P
Urine analysis
Haemogram
Tests for haemorrhage
Blood chemistry

Investigation:-Dental
X-Rays
Percussion
Vitality tests
Aspiration
Bacteriology
Biopsy

Antibiotics
Principles of Treatment
Diagnosis
Choice of drug
Dosage and route
Accompanying treatment
Combination of drugs
Hypersensitivity

Antibiotics
Site of Action
Cell Wall
Cell Membrane
Protein Synthesis
Nucleic acid synthesis


Antibiotics
Site of Action:-Cell Wall
Prevention of cross linkage of peptide
strands
e.g. Penicillins
Cephalosporins

Antibiotics
Site of Action
Selective permeability of the
Membrance is affected
e.g. Polymyxins
Nystatin
Amphotericin-B


Antibiotics
Site of Action:-Protein Synthesis
Block of amino acid transfer
Tetracyclins
Block of transpeptidation
Chloremphenicol
Interference with MRNA function
Aminoglycosides
Block of traslocation
Macrolids

Antibiotics
Site of Action:- Nucleic Acid Metabolism
Interference in the production of DNA
Or RNA
e.g. Sulphonamides
Trimethoprim


Antibotics
Uses
Therapeutic
Prophylactic
General
Specific

Impacted Maxillary Canine
classification
Labial Position
Palatal Position
Intermediate Position
Unusual Position


Localization-Clinical
Evidence of eruption
Bulge on labial aspect
Bulge on palatal aspect


Localization-Radiological

Vertex occlusal view
Lateral skull radiograph
Parallox method of clark


Management

No surgical intervention
Surgical exposure & othodontic
alignment
Surgical removal & auto
transplantation
Surgical removal

Strategies for Pain Control

Use of A Long Acting L.A, Agent
e.g. Bupivicaine
Etidocaine


Supression At Higher Sites In CNS
Use of Oploids
Morphine
Pethidine
Codeine

Strategies For Pain Control
Pre operative Administration
Of Nsaids

There is sufficient scientific evidence
Suggesting delay and low pain levels after
Preoperative administration of nsaids

Scientific Foundations of Minor Oral Surgery
Influence of socket closure on post
operative pain and swelling
Complete closure of third molar socket lead to
increased post
Operative pain and swelling experience compared
with maintaining
The socket partially open with a dressing

Strategies For Pain Control
Use of Oplods
Codeine 60 mgs.
Oxycodone 5 to 10 mgs.


Seientific Foundations of Minor oral Surgery
Anxiety
Measures To Overcome
Information
Procedural
Sensation
Modeling
Distraction
Relaxation
Hypnosis

Scientific Foundations of Minor oral Surgery
Preoperative Visits To Reduce Patient Anxiety
A Study to evaluate the effect of
Preoperative visits by health
Professionals showed a significant
Decrease in anxiety during the post
Operative period A Positive relationship
Between preoperative anxiety levels and
The level of pain was found.

Post Operative Pain Management In Childern
A study conducted to assess the efficacy
Of pre-operative administration of
Acetaminophen indicated a high prevalence
Of post operative pain irrespective of the
Procedure used and there was a trend
Toward reduced pain in acetaminophen pre
Treatment group.

Reduction of Post Operative Pain

“ irrigation of third molar socket
With Bupivacaine 0.75% produced
Significant reduction in pain on the
First post operative day”


Reduction of alveolar osteitis
incidence

“ a prospective double blind placebo
Controlled study to determine the effect
Preoperative 0.1% chlorhexidine gluconate
Rinse showed 60% reduction in the
Incidence of alveolar osteitis”

Post Operative Pain In Oral Surgery
Aspirin, Mefenamic Acid and
Their Combination
A double-bind randomized single
Dose study of the effects of 650 mgs
Aspirin, 250 mgs mefenamic acid, the
Combination of the both in same dosage
Indicated relief from pain in each group
Compared to the placebo and the combination
Appeared more effective than both drugs alone.

Do All Intraoral Incission require
Suturing

With proper understanding of surgical
Principal and appropriate modification
The indication for suturing and post
Operative inconvenience to the patient
Can be reduced


The value of bupivavaine and
Presurgical treatment with
Nsaids and steroids in the
Management of postoperative
Complication
Dr. Neelima

Prof.C.B.Roa


Post Operative Pain
The study indicated that the group which had
Third molars removed with bupivacaine as the
L.A. agent and pretreatment administration
Of lbuprofen 400 mg and 8 mgs of dexamethasone
Have experienced less and delayed pain.

Post Operative
Management
- Pain
- Swlling
Infection


Post Operative
Management
Pain
Swlling
Infection


Is antibiotic Prophylaxis Necessary

“ A clinical double blind placebo study to
Test the value of prophylactic use of
Phenoxy methyl penicillin and tinidazole
Indicated that neither of them have more
Effect on post op complications than placebo”

Antibiotic Prophylaxis
Who needs it ?
-In minor oral surgery – unnecessary
-In evidence that it is necessary in
Surgical removal of third molars
Rood (1970) reported that the use of prophylaxis
confers no advantages even when surgically
removing
Third molar in the presence of acute pericoronitis or
Acute ulcerative gingivitis

Antibiotics-Prophylactic Use
“ A Clinical trail with prophylactic use of
Phenoxymethy1 Penicillin and tinidazole
In mandibular third molar surgery had no
Effect on the reduction of post operative
Complications”

Who Needs It ?
1. Patients with impaired host defense
2. Patients undergoing surgical procedure where
The risk of infection is small but
Consequences are very serious e.g.. Infective
Endocarditis.
3. Patients undergoing surgical procedures which
Have a high rate of infections (normal host
defense mechanisms), But the nature of surgery
vulnerable to infection.

Has Timing Any Influence
Administration of antibiotic immediately
Prior to surgical incision incision should be
Effective prophylaxis for surgical wound
Infections.

What should Be The Duration of
Administration ?
A study conducted using three different
Antibiotic regimens suggested that a
Single done of preoperative antibiotic is
Sufficent for prophylaxis when surgery
Is completed with in 3 hours. Antibiotic
Converage should extend for operation
Of longer duration no value of antibiotic
After the operation.

T.M.Joint MPDS
Treatment
•Reassurance
•Occlusal Correction
•Anterior bite splint
•Full occlusal splints
•Soft splints

•Drug therapy
•Intermaxillary fixation
•Inter articular
injection
•Phychiatric
consultation
•Surgery


T.M.Joint MPDS
Locking Joint
•Increased muscle load
•Alteration in the articular surface
•Interference with free sliding of
Upper joint comoartment
•Disc fails to slide forwaed, remains
stuck
•Locking of the jaw

T.M. Joint MPDS
Clicking Joint
•Muscular overloading of joint
•Frictional hesitation of movements of disc
•Disc sticks in early opening
•On further opening suddenly
Recommences its forward movement
Resulting in click

T.M.Joint MPDS
Signs

•Joint tenderness
•Muscle tenderness
•Abnormalities of mandibular
movement

T.M.Joint MPDS
Symptoms
Pain
Limitation of mandibular movement
Clicking


T.M.Joint MPDS
Evidence In Support Of Theory
Higher level of steroids &
Catecholamines
Reaction to stress by somatization &
repression
Electromyography

T.M.Joint MPDS
Psychophysiologic Theory
Stress
Clenching & grinding
Muscle – fatigue spasm
Pain


T.M.Joint MPDS
Etiological Concepts

Over closure hypothesis
Defects in dental occlusion
Abnormalities in muscle & muscle activities


T.M.Joint MPDS
Synonyms
Costen syndrome (1934)
T.M.J pain dysfunction syndrome
Schwartz (1956)
Myo facial oain dysfunction
Syndrome
Laskin (1969)

T.M.Joint MPDS
Surgical Procedures
Condylotomy – Ward (1960)
Myotomy – Laskin & Cooper (1972)
High condylectomy – Henny & Bald ridge (1967)
Reduction of articular eminence – lrby (1980)
Menisectomy – Lanz (1909)
Capsular rearrangement.

Haemorrhage
Classification :- Depending on vessel

Arterial
Bright red, spurting as a jet
Venous
Dark red, steady flow
Capillary
Bright red ooze

Haemorrhage
Classification

External
Visible or revealed
Internal
Invisible or concealed

Haemorrhage
Classification :- Time of occurence

Primary
At the time of injury
Reactionary
Within 24 hours
Secondary
After 7 to 14 days

Haemorrhage
Acute Blood Loss :- Clinical Features

•Increasing Pallor
•Increasing Pulse rate
•Restlessness
•Deep inspiration
•Cold clammy skin
•Empty veins, thirst

Shock
Definition

“ Inadequate blood flow to vital
Organs or failure of the cells of vital
Organs to utilise oxygen”
Shift from aerobic to anaerobic
Metabolism by the cells

Shock
Recognition :- compensatory Changes

Desreased cardiac output
Cool clammy extremities
Tachycardia & Tachypnea
Arterial blood pressure
Postural hypotension is early
Sensitive sign

Shock
Recognition :- Compensatory Changes
Central venous pressure
Decreased because of poor venous
Return & reduced volume
Arterial blood gases
Renal function
Haematocrit

Shock
Treatment:- Monitoring
Vital singns
Renal flow
Arterial blood gases
Central venous pressure
Haematocrit
Drugs

Shock
Treatment :- Principles

Oxygen exchange
Ensure and maintain homeostasis
Position
Relief of symptoms
Monitoring

Cardiovascular Disease
Amoxycillin 3gm, oral, 1 hour before
Erythromycin 1gm, 0.5gm 6 hours later
Vancomycin 1gm I.V
Penicillin v 2gm, oral, 1gm 6 hours later
Amplcillin 1gm I.V or I.M
Gentamycin 80gm

Cardiovascular Disease
Conditions requiring Prophylaxis

Congenital heart disease
Rheumatic fever
Valvular heart disease
Prosthetic replacements

Medical Emergencies
Epileptic Seizure:- Recognition

Generalized convulsions
Loss of consciousness
Urinary & fecal incontinence
Injuries
Jerky www.indiandentalacademy.com
respiration

General Practitioner – Guide lines
Steroids could be used in the management
Of post operative pain and swelling
Antibiotics to be employed only with
Specific indications
Strict adherence to basic surgical principles is
mandatery for successful outcome.

Conclusions
General practitioners should undertake minor
Surgical procedures based on certain
determinants
-Minimal & moderately difficult third molars
-May be removed after accurate assesment.

-Effective post operative pain control with availabl
- stratagies.
-Exercise caution with the used of sterolds in
-Post operative managament of pain and
-Swelling.

Post Operative Pain
Control

Objectives
Minimise discomfort
Facilitate recovery
Avoid Treatment Related
Side effects

Who Needs Prophylaxis ?
Three groups of patients :i. Patients with impaired host defence mechanisms
ii. Patients under going surgical procedures where
the risk Of infection is small but cosequences are
very serious.Eg. Infective endocarditis Patients with
orthopaedic joint prosthesis
iii. Patients under going surgical procedures
which have a High rate of infectious complications.
( Normal host defence mechanisms.
But the nature of surgery vulnerable to infections)

Minor Oral Surgery
Basic Surgical Principles

- Asepsis
- Pain less surgery
- Access
- Control of Haemorrhage
- Wound Closure
- Post operative care

Successful Management sepends on
Proper pre surgical planning
Careful diagnosis
Good surgical execution
Well managed post operative care

Scientific foundation of minor oral surgery
Incidence of Infection After
Periodontal Surgery
A stady conducted to evaluate the incidence of
Clinical Infection after periodontal surgery with
and without antibiotic cover did not show any
difference between the two groups.

Impacted tooth and I. Dent canal
Radiological signs
On the root

Appearance
Of canal

- darkening
- Deflected roots
- narrowing
- Dark & bifid root
- interruption of white lines
- Diversion of I.D canal
- Narrowing of I.D canal


Tooth Extraction
&
Bacteremia

Bacterial Isolates
Aerobes – 1.6%
Anaerobes – 71.1%
Facultative Anaerobes – 27,3%

Prevention: Antibiotic Prophylaxis
Defn: Prevention of infection by the
administration of
Antibiotics.

Efficacy: several studies have shown that prophylactic
Antibiotics reduce the incidence of postoperative
woundinfection after Compound mandibular or maxillary fractures.
Timing: animal and clinical surveys have clearly established
That anyibiotics should be administered so that peak serum and tissue
Concentrations coincide with the operation or Induced bactermia.
Therefore: It is anachronistic to startantibiotics postoperatively
A delay of three hours after contamination
result in infection Rate essentially
Prolonged antibiotic administration beyond a day or more
is not Beneficial and may actually increase the resistant bacteria.

Should a General Fractitioner
Do Surgery ?
If So To What Extent ?



- Cystic Lessions
- Dento – Alveolar Fractures
- Odontogenic Infections
- Biopsy

Radiological Signs Of Significance

Diversion of the canal
Darkening of the root
Interruption of white lines

Commonly Performed Procedures

Removal of Buried Roots
Impacted Teeth
Preprosthetic surgery
Surgical Exposure of teeth

Acute Dento-Alveolar
Abscess-Microbiology

Recent Studies
Poly Microbial
Co2 dependent streptococcl
Anarobic gram + coccl
Anaerobic gram – bacilli

Tooth Extraction
&
Bacteremia
Favouring Factors
- Inflammed dental disease
- More number of teeth
- Age of the patient
- More than 50 ml blood loss
- Operating time > 100 Mins

Acute Dento Alveolar
Abcess Antibiotic
Strategy

Amoxycillin
And / Or
Metronidazole

Pain is a perfect misery,
The worse all evils,
And excessive, overturns all
Patience,


Trigeminal Neuralgia

Acute paroxysmal facial pain
Experienced in the areas supplied by
One or more branches of trigeminal
Nerve.


Maxillary Sinus
Caldwell- Luc:- surgical procedure

Anaesthesia
Incision
Bony window
Removal of lining,root,cyst
etc
Haemostasis
Closure
Post operative care

Maxillary Sinus
Caldwell – Luc Advantages

# Easy access
# Thin bone
# No vital structures


Maxillary Sinus
Caldwell – Luc:- Indications

Chronic sinusitis
Root in the sinus
Cysts & tumours
Biopsy
Orbital floor fractures
Foreign bodies

Maxillary Sinus
Disease

- Sinusitis
- Oro antral fistula
- Root displacement
- Cysts involving sinus
- Tumours

Maxillary Sinus
Surgical Approaches

Through the tooth socket
Caldwell – Luc approach
Denker’s

Maxillary Sinus
Oro Antral Fistula:- Management

Buccal advancement
Palatal rotation
Palatal island flap
Buccal pad of fat
Palatal flap anterior based
Tongue flap

Maxillary Sinus
Oro Antral Fistula :- Clinical Features
Chronic:
Sinusitis
Change in voice
Nasty smell & taste
Mucosal polyps protrude out of
Opening.

Maxillary Sinus
Oro Antral Fistula :- Cauese

-Extraction of maxillary posterior
Teeth
- Root displaced in to sinus
- Chronic osteomyelitis
- Malignancy
- Trauma

Maxillary Sinus
Oro Antral Fistula :- Clinical Features

Acute :
Unilateral epistaxis
Escape of fluids through nose
Air escapes through opening
While blowing.

Clinical Features
More in females
Over the age of 45
Unilateral, rarely bilateral
More on right side
Second & third division involved
more

Etiology
Exact etiology unknown
Pathilogic change in the nerve
Angiospasm of gasserian ganglion
Allergic concept
Loss of myelin sheath
Vascular compression

Intra Cranial Surgery

Retrogasserian Neurectomy
Trigeminal tractotomy
Microvascular decompression

Clinical Features
Pain Characteristics
Intensity – severe, lancinating
Duration – Few seconds only
Area- Trigeminal didtribution
Initiated by – Touching trigger
Zones
Between attacks – free from pain
Does not cross midline

Peripheral Neurectomy

Mental nerve
Inferior dental nerve
Infra orbital nerve

Chemical Neurectomy

Hot Water
Phenol
Alcohol
Glycerol

Pharmacotherapy

Phenytoin – 300 to 400 mg daily
Carbamazepine – 200 to 1200 mg
Baclofen – 8mg daily

Management

Pharmacotherapy
Chemical neurectomy
Peripheral neurectomies
Intracranial surgery
Radiofrequency lesion

Post Operative
Management
- Pain
- Swelling
- Infection


Pain
Definition

“ An unpleasant sensory and emotional
Experience associated with actual or
Potential tissue damage or described in terms
Of such damage”

Relationship Between
Postoperative Pain
&
Operative Trauma
No significant relationship was qbserved
Between operative trauma & pain from day
One to day seven period


Does Pericoronitis
Contribute to more
Post operative pain ?

‘ Patients with a history of
Paricoronitis experienced
Significantly higher pain scores
Through out seven day period’

Influence of suturing on post
Operative pain and swelling
‘ A study comparing the influence of
Complete closure partial closure and
Dressing of lower third molar sockets
Showed more pain and swelling when the
Socket is closed completely in a significant
Number of patients.”

Influence of socket
Closure on post operative
Pain & Swelling
“ Complete closure of third
Molar sockets leads to
Increased post operative pain
And swelling experience pain
And swelling experience
Compared with maintaining the
Sockets partlassy open with a
Dressing”

Sex And Pain
Score Levels

Over a seven days investigation period of
Overall pain scores females reported
Significantly higher levels of pain than
Males


Haslaser Any Effection
Post Operative Events ?

A study to evaluate local effects of soft laser
Therapy using a helium – neon laser application
For 2 min. following removal of third molars
Did not reveal any advantage over the control
Group.

Has Homeopathy Any Effect On
Post Operative Pain ?
A double blind randomized placebo trial to
Estimate whether homeopathy has any effect
On post operative events following oral
Surgery did not show any significant difference.

Efficiency of methods of removal

A comparison of morbidity following
Removal of impacted third molars
Using lingual split technique and
Surgical bur technique showed no
Difference in either efficieny or
Outcome between the two
methods.

Influence of
Psychological Factors
On post operative pain

“ Psychiatric morbidity, neuroticism and
Anxiety were related to increased pain
Which tended to persist longer than
Normal”

Acute post surgical Pain
Long Term Memory
There is a positive correlation
Between experienced and
Remembered intensities of
Postsurgical pain upto 3 years
After surgery

Pain Mechanisms

Peripheral tissue injury
Transmission through the nerves
Perception within the brain


Tissue Injury
Inflammatory Mediators
Synthesis of prostaglandins
Release of bradykinin
Release of histamine
Excite and sensitise
Peripheral Nerve Endings

Pain Transmission
Chemical Basis
Prostaglandins (PGE2)
Leukotrienes (LTB4)
Neuropeptides (Substance P)

Stimulus
Damage of cell membrane
Phospholipids
Arachidonic Acid

Cyclo - Oxygenase

Lipoxygenase

Prostaglandins
PGE2 , PGI2

Leukotrienes
LTB4


Tissue Injury
Neuropeptides
Release of substance p from
Nerve endings
(Highly concentrated In Dental Pulp Nerves)


Tissue Injury
Neuropeptides
Release of Substance p from
Nerve endings
( Health concentrated in dental pulp nerves)


Pain Transmission
Three Major Nociceptive Afferents
Type

Diameter Myelination

Conduction

Polymodal 0.3-3µm

Un
Myelinated

0,5-2m/s

A-delta

2-5µm

Thinly
Myelinated

5-30m/s

A-beta

6-22µm

Heavity
Myelinated

33-75m/s


Target Areas For pain Control
Blockade of Prostaglandin
Synthesis
Intervening Peripheral Nerve
conduction
Suppression of higher sites in CNS

Pain Transmission
Modulation
Gate Control Theory
Endogenous Peptides

Leucine
Enkephalin
Beta Endorphin

Classification of Nsaids
Weak
Paracetamol
Mild To Moderate
Ibuprofen
Mefenamic Acid
Strong
Aspirin
Phenyl Butazone
Diclofenac
Piroxicam

Blockade of
Prostaglandin Synthesis
Use of Nsaid

Ibuprofen
Ketorolac

Fluriprofen
Diclofenac


Intervention At
Peripheral Nerve Level
Use of longer acting L.A agents
Duration
Short
Intermediate

Agents
Procaine
Lignocaine, Prilocaine

Prolonged- Amethocaine, Bupivacaine, Etidocaine

Steroids In
Minor Oral Surgery

Use of peri operative corticosteroids
Appeared to be safe and rational method
Of reductiing postoperative complications
Following minor surgery

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