Baba Jaswant Singh Dental College & Research Institute

Department of Oral & Maxillofacial Surgery

Assignment Book

Name of the Student:.…………………………………

Roll No.:…………………………………………

Batch:……………………………
Define Extraction?

Tooth extraction is painless removal of whole tooth or tooth root with minimal trauma to the
investing tissues, so that wound heals uneventfully and no post operative prosthetic
complications is created (Geoffrey L. Howe).

Indications of Extractions:

1. Badly carious or grossly decayed teeth which cannot be saved by endodontic

therapy.
2. Periodontal diseases which cannot be corrected through periodontal treatments.
3. Over retained deciduous teeth.
4. For orthodontic treatments.
5. For prosthodontic consideration like teeth interfering with placement of partial
dentures or implants.
6. Serial extractions.
7. Impacted teeth.
8. Supernumerary teeth.
9. Teeth in line of fractures of jaw bones.
10. Teeth involved in cysts or tumors.
11. Diseased teeth in line of radiation.
12. Teeth acting as foci of infection.
13. Extraction of teeth for esthetic reasons.
14. Financial reasons.

Contraindications of Extractions:

Local -
 Acute Pericoronitis
 Acute Necrotizing ulcerative gingivitis.
 Extraction of teeth in previously irradiated areas /jaws (for less than 6 months).
 Tooth lying in a hemangioma.
  Tooth lying in a malignant growth.

Systemic Factors –

 Uncontrolled diabetes mellitus.

 Uncontrolled hypertension (malignant)
 Adrenal insufficiency.
 Thyrotoxicosis.
 Blood dyscrasias.
 Untreated coagulopathies.
 Myocaordial infarction (for less than 6 months).

Nerve supply of all the teeth:

Maxillary Teeth:

Central Incisor: Anterior superior alveolar Nerve branch of infraorbital nerve branch
of maxillary nerve.
Lateral Incisor: Anterior superior alveolar Nerve branch of infraorbital nerve branch
of maxillary nerve.
Canine: Anterior superior alveolar Nerve branch of infraorbital nerve branch
of maxillary nerve.
First Premolar: Middle superior alveolar Nerve branch of infraorbital nerve branch of
maxillary nerve.
Second Premolar: Middle superior alveolar Nerve branch of infraorbital nerve branch of
maxillary nerve.
First Molar: Mesiobuccal root from middle superior alveolar Nerve.
Distobuccal & Palatal roots from post superior alveolar Nerve branch
of maxillary Nerve.
Second Molar: Post superior alveolar Nerve branch of Maxillary N.
Third Molar: Post superior alveolar Nerve branch of Maxillary N.
Mandibular Teeth:

Central Incisor: Incisive branches from inferior alveolar nerve branch of mandibular
nerve.
Lateral Incisor: Incisive branches from inferior alveolar nerve branch of mandibular
nerve.
Canine: Incisive branches from inferior alveolar nerve branch of mandibular
nerve.
First Premolar: Incisive branches from inferior alveolar nerve branch of mandibular
nerve.
Second Premolar: Incisive branches from inferior alveolar nerve branch of mandibular
nerve.
First Molar: Dental branches from inferior alveolar nerve branch of mandibular
nerve.
Second Molar: Dental branches from inferior alveolar nerve branch of mandibular
nerve.
Third Molar: Dental branches from inferior alveolar nerve branch of mandibular
nerve.

Nerve Blocks to be given for extraction of following teeth:

Maxillary teeth:
Central Incisor: Infra orbital N. Block + Nasopalatine N. Block
Lateral Incisor: Infra orbital N. Block + Nasopalatine N. Block
Canine: Infra orbital N. Block + Nasopalatine N. Block
First Premolar: Infra orbital N. block + Palatal infiltration
Second Premolar: Infra orbital N. block + Palatal infiltration
First Molar: Buccal infiltration for mesiobuccal root + Post superior alveolar N.
block + greater palatine N. block.
Second Molar: Post superior alveolar N. block + greater palatine N. block.
Third Molar: Post superior alveolar N. block + greater palatine N. block.
Mandibular Teeth:
Central Incisor: inferior alveolar N. block + lingual N. block
Lateral Incisor: inferior alveolar N. block + lingual N. block
Canine: inferior alveolar N. block + lingual N. block
First Premolar: inferior alveolar N. block + lingual N. block
Second Premolar: inferior alveolar N. block + lingual N. block
First Molar: inferior alveolar N. block + lingual N. block + long buccal N. block
Second Molar: inferior alveolar N. block + lingual N. block + long buccal N. block
Third Molar: inferior alveolar N. block + lingual N. block + long buccal N. block

DOSES AND REGIME OF VARIOUS COMMONLY PRESCRIBED DRUGS:

S.NO ANTIBIOTICS Dose Duration

1. Amoxycillin 500 mg 8 Hourly
2. Ofloxacin 200 mg 12Hourly
3. Ciprofloxacin 500 mg 12 Hourly
4 Clindamycin 150-300 mg 6 Hourly
5 Inj. Amikacin 500mg TO 01 gm 12 Hourly
6 Erythromycvin 500 mg 8 Hourly

S.NO NSAIDS Dose Duration

1. Paracetamol 500 mg to 01 gm 6Hourly
2. Ibuprofen 200-600 mg 8 Hourly
3. Diclofenac 50-75 mg 8 Hourly
4 Piroxicam 20-40 mg 12 Hourly
5 Ketorolac 10 mg 8 Hourly
6 Aspirin 75-325 mg 4-6 Hourly

S.NO Centrally acting analgesics Dose Duration

1. Pentazocin 50 mg every three to four hours
as needed
2. Tramadol 50 to 100 mg. Not to can be administered as
 exceed 400 mg/day. needed for pain relief
every 4 to 6 hours
3. Carbamazipine Initial dose: 100 mg orally 2 times a day
(immediate or extended release) or 50 mg orally
4 times a day (suspension)
-May increase by up to 200 mg per day using
increments of 100 mg every 12 hours
(immediate or extended release), or 50 mg 4
times a day (suspension), only as needed to
achieve freedom from pain. Do not exceed 1200
mg per day.
-Maintenance dose: 400 to 800 mg per day
4 Baclofen 10 to 20 mg orally three to four times daily.

5 Dextropropoxyphene 65 mg (HCl) orally every 4 hours as needed

or 100 mg
(Napsylate) orally
6 Oxycodone Immediate release form: 5 milligrams (mg) to
15 mg, every four to six hours

Controlled release form: 10 mg every 12 hours

S.NO Muscle relaxants Dose Duration

1. Chlorzoxazone 250-750 mg Orally three to four times
daily reducing the
dose to lowest
effective level once a
response occurs.
 Chlorzoxazone is
typically given for 1
to 4 weeks only.
2. thiocolchicide 4mg Orally twice a day for 5 to 7
days
3. Carisoprodol 250 to 350 mg three to four times
daily for 2 to 3 weeks.

4 Methocarbamol 1500 mg Orally orally three to four

times daily.

5 Tizanidine 2 to 6 mg orally three to four times

daily.

S.NO Antacids Dose Duration

1. Ranitidine 150 – 300 mg Twice daily
2. Omeprazole 20-40mg Once a day
3. Esmeprazole 20-40 mg Once a day
4 Lansaprazole 15-30 mg Once a day
5 Rabeprazole 20 mg Once a day

CHAIR SIDE POSITIONS OF THE DENTAL CHAIR FOR MAXILLARY AND

MANDIBULAR PROCEDURES?
MAXILLARY HEIGHT ANGULATION
Maxillary occlusal plane Maxillary occlusal plane is at
3 inches below shoulder 450 to the floor
level of operator
MANDIBULAR HEIGHT ANGULATION
Mandibular occlusal plane 6 Mandibular occlusal plane is
inches below the level of parallel to the floor
elbow of operator
OPERATOR’S POSITION WHILE GIVING L.A/EXTRACTION OF TEETH?

For L.A
MAXILLARY R QUADRANT 100 clock position
MAXILLARY L QUADRANT 80 clock position
MANDIBULAR R QUADRANT 80 clock position
MANDIBULAR L QUADRANT 100 clock position

For Extractions:
MAXILLARY R QUADRANT 70 clock position
MAXILLARY L QUADRANT 70 clock position
MANDIBULAR R QUADRANT 110 clock position
MANDIBULAR L QUADRANT 70 clock position

POST EXTRACTION INSTRUCTIONS:

(WRITE REASONS FOR EACH OF THESE INSTRUCTIONS)
 To maintain pressure pack for 60 minutes-for hemostasis
 Not to spit and swallow the saliva, as during the act of spitting the jaw moves and
the pressure pack may get disturbed and also it dislodges the clot.
 Not to do forceful gargles or smoke- as the negative pressure generated, while
smoking may dislodge the clot and lead to bleeding. Do not use straw for taking
liquids
 Soft and liquid diet-as more masticatory effort needed to chew on hard food
substances may disturb the wound/clot.
 No hot fomentations but to give cold compressions- in the immediate postoperative
phase, the vascular phase of inflammation is predominant and is manifested by
 vasodilatation, hot fomentations may aggravate it and lead to excessive edema and
discomfort. Hence application of cold compressions helps in reducing the edema by
inducing vasoconstriction. Once the edema sets in the mounting pressure within the
interstitial compartment blocks the lymphatics and venules, which are the draining
channels and helps in reabsorption of the interstitial fluid to reduce the edema. It
leads to stasis of circulation
 Warm saline gargles after 24-48 hours: these induce vasodilatation and facilitates the
reabsorption of interstitial fluid and edema thus, improving local circulation, which
also helps in faster healing and drug delivery.

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Define Local Anaesthetics?

Local anesthetics (LA) are drugs that have little or no irritating effects when injected into
the tissues and that will temporarily interrupt conduction when absorbed into the nerve

Local anesthetics are alkaloid bases that are combined with acids, usually hydrochloric, to
form water soluble salts

Define Local Anaesthesia?

 Local anesthesia has been defined as a loss of sensation in a circumscribed area of the body
caused by depression of excitation in nerve endings or an inhibition of the conduction
process in peripheral nerves. An important feature of local anesthesia is that it produces:
LOSS OF SENSATION WITHOUT INDUCING LOSS OF CONSCIOUSNESS

Write the Composition & Funtion of each ingredient of a typical local anesthetic vial
Answer- Composition & funtion of each ingredient of a typical local anesthetic vial is as
following

a. L.A. Agent: lignocaine HCl 2% (21.3 mg)

Function- conduction blocade.
b. Vasoconstrictor: epinephrine 1: 200,000 (.005 mg)
Function- decrease absorption of local anesthetic into blood, thus increasing the
depth and duration of anesthesia and decreasing toxicity of anesthetic
c. Preservative: Methylparaben (1.0 mg/ml) in all multiple dose vials
Function- preservative to increase shelf life; bacteriostatic, fungistatic and
antioxidant properties.
Repeated exposure to paraben has led to reports of increased allergic reactions in
some patients
d. Reducing agent: sodium metabisulfite (0.5 mg)
Function- antioxidant for vasoconstrictor
 Allergy to bisulfites must also be considered in medical evaluation of all patients
before local anesthetic administration

*addition of vasoconstrictor and reducing agent lowers the PH of the solution to between
3.3 and 4 ,significantly more acidic than solutions not containing vasoconstrictor(5.5).
Patients are more likely to feel burning sensation with these solutions. A further decrease in
PH of the solution results when sodium bisulfate is oxidized to sodium bisulfate. This
response can be minimized by checking the expiration date of all cartridges before use
e. Fungicide: thymol
f. Vehicle: sterile water ( 1.0 ml), 0.9%w/v NACL(6 mg)
Function- sterile water is added as a diluent and NACL is added for isotonicity of the
solution

What is the maximum safe dosage of Lignocaine?

7.0 mg/ kg of body weight for lignocaine HCl in healthy patients
The maximum recommended dose by the FDA of lidocaine with or without epinephrine is
3.2 mg/lb or 7.0 mg/kg of body weight for the adult and pediatric patient, not to exceed a an
absolute maximum dose of 500 mg

Calculate the maximum safe dosage of Lignocaine in a 70 kg healthy man?

490 mg, 24.5 ml in 1.8 ml of cartridge

[Lidocaine: 7 mg/kg= 490 mg in 70 kg

2% lignocaine = 20 mg in 1 ml
36 mg in 1 cartridge (1.8 ml)
1.8/36 X 490 = 24.5 ml
Number of cartridges: 490/36 = 13.6
Also if one cartridge has 1.8 ml then 13.6 cartridges will have 24.5 ml]

What is the maximum safe dosage of lignocaine with adrenaline?

4.4 mg/kg of body weight for lignocaine HCl with epinephrine in healthy patients
The maximum recommended dose by the FDA of lidocaine with or without epinephrine is
3.2 mg/lb or 7.0 mg/kg of body weight for the adult and pediatric patient, not to exceed a an
absolute maximum dose of 500 mg

Calculate the maximum safe dosage of Lignocaine with adrenaline in a 70 kg healthy

man?
4.4 x 70= 308 mg, 15.4 ml in 1.8 ml of cartridge
[Lidocaine 2%(20 mg in 1 ml) = 36 mg/cartridge
Lidocaine: 4.4 mg/kg = 308 mg rounded off to 300 mg (MRD)
So 300 mg in 1.8/36 X 300 = 15 ml
Number of cartridges: 300/36 = 8.3]
[1 ml has .005 mg adrenaline
One (1.8 ml) cartridge has .009 mg adrenaline
Maximum recommended dose of epinephrine in healthy patients is 0.2 mg per appointment
so 0.009 mg in one cartridge
0.2 mg in 22 cartridges]
Therefore maximum 22 cartridges of epinephrine containing local anesthetic solution are
recommended in healthy patients

THE ESSENTIAL COMPONENTS OF ARMAMENTARIUM FOR LOCAL

ANESTHESIA ARE AS FOLLOWS:
a. Syringe
b. Needle
c. Local anesthetic solution in the form of a cartridge or a multidose vial
Syringe
It is an instrument or a vehicle whereby the local anesthetic solution is
delivered through the needle into the tissues of the patient.
Types
I. Non-disposable (Reusable) syringes:
1. Breech-loading, cartridge type syringe. These syringes are available in the following
forms:
(a) Metallic, or plastic, (b) Aspirating, or non-aspirating, and (c) Self-aspirating types.
2. Side loading, aspirating and non-aspirating syringes.
3. Pressure syringe.
4. Jet injector.
5. Luer-Lock syringes.
II. Disposable or plastic syringes.
III. Safety syringes.

Requirements of an Ideal Syringe

The requirements of an ideal syringe include the following:
1. It should be durable and be able to withstand repeated sterilization without deterioration,
and it should allow repeated use.
2. The disposable syringe should be easily sterilizable and be packaged.
3. It should accept a wide variety of cartridges and needles of different manufacture.
4. It should not be expensive.
5. It should be light-weight, and easy to handle with one hand.
6. The aspirating type should have effective aspiration, and should be so designed that the
blood may be easily seen in the cartridge.
Parts of Needle:

Parts
The needles used for administration of local anesthetic solutions have the
following components; (a) bevel, (b) shaft or shank, (c) hub, (d) syringe
adaptor, and (e) cartridge-penetrating end.
a. Bevel: It defines the point or the tip of the needle. The bevels, as described
by manufacturers are: (i) long, (ii) medium, and (iii) short.
The recommended bevel is 12° and it influences the degree of deflection. The greater the
angle of the bevel with the long axis of the needle; the greater will be the deflection as
needle is passed through the soft tissues (Aldous, 1977; Jeske and Boshart, 1985; and
Robison et al, 1984). Bennett advised that the short-beveled needle is superior to the long
tapering bevel for regional analgesia, such as block anesthesia as it is less likely to be
deflected from its intended path during insertion. Needles with point centered on the long
axis, deflect less than beveled point
needles whose point is eccentric.
b. Shank/Shaft: The length of shank is measured from the hub to the point
of the bevel.
c. Hub: It is a plastic or metal piece through which the needle is attached
to the syringe.
The interior surface of plastic syringe adaptor is not prethreaded.
Therefore, to attach a plastic hubbed needle to a syringe, the needle
must be pushed onto syringe while being screwed on. Metallic-hubbed
needles are usually prethreaded.
d. Syringe adaptor: It is adapted to the needle adaptor end of the syringe.
e. Cartridge-penetrating end: It is placed into the needle adaptor of syringe
and perforates the rubber diaphragm of glass cartridge. Its tip rests
within the cartridge.

EXTRACTION TECHNIQUE: - INTRA ALVEOLAR

Five general steps make up the closed extraction procedure.-:
Step1 involves loosening of the soft tissue attachment from the cervical portion of the tooth.
with a sharp instrument such as a scalpel blade or the sharp end of periosteal elevator
Step 2 involves luxation of the tooth with a dental elevator, usually the straight elevator
Step 3 involves adaptation of the forceps to the tooth
Step 4 involves luxation of the tooth with forceps
Step 5 involves removal of the tooth from the socket
Careful preoperative assessment and planning help guide this determination during the
extraction.
.
Principles of forceps extraction.:
The primary instruments used to remove a tooth from the alveolar process are the elevator
and extraction forceps. Elevators help in the luxation of a tooth, and forceps continue that
process through bone expansion and disruption of periodontal attachments. The goal of
forceps use is twofold: (1) expansion of the bony socket by use of the wedge-shaped beaks
of the forceps and the movements of the tooth itself with the forceps, and (2) removal of the
tooth from the socket.
Rules to be observed during the application of forceps
1) Correct forceps for the particular tooth to be extracted must be selected
2) Grasp the forceps at the far ends of the handles so that they are almost covered
by the palm of the hand. Do not grasp the forceps near the beaks.
3) The long axis of the forceps beaks must be parallel to the long axis of the tooth
4) Forceps beaks must be grasped firmly on sound root structure and not on the
enamel of the crown
5) Make certain that the beaks of the forceps do not impinge on adjacent teeth
during the luxation

Technique of forceps extraction – Mention Primary and Secondary tractions

Maxillary teeth: Primary traction applied for all maxillary teeth is apical force
Secondary tractions are as following-:
Central Incisor: labial pressure, then lingual pressure, then labial pressure with mesial
rotation

Lateral Incisor: labial pressure, then lingual pressure, then labial pressure with mesial
rotation

Canine: labial pressure, then lingual pressure, then labial pressure with mesial rotation
First Premolar: buccal pressure, lingual pressure, and removal in the buccal direction
Second Premolar: buccal pressure, lingual pressure, and removal in the lingual or buccal
direction

First Molar: buccal pressure, slight palatal pressure and distal rotation

Second Molar: buccal pressure, slight palatal pressure and distal rotation

Third Molar: buccal pressure, slight palatal pressure and distal rotation

Mandibular Teeth : Primary traction applied for all maxillary teeth is apical force so that
beaks of the forceps rest on the cementum
Secondary tractions are as following-:

Central Incisor: labial pressure, lingual pressure, slight mesial to distal force, and removal in
the labial direction
Lateral Incisor: labial pressure, lingual pressure, slight mesial to distal force, and removal in
the labial direction
Canine: labial pressure, lingual pressure, slight mesial to distal force, and removal in the
labial direction
First Premolar: buccal pressure, with slight mesiodistal rotation
Second Premolar: buccal pressure, with slight mesiodistal rotation
First Molar: buccal pressure, lingual pressure, and removal in the buccal direction.
Second Molar: buccal pressure, lingual pressure, and removal in the buccal direction.
Third Molar: buccal pressure, and removal in the lingual or buccal direction.
Alternative techniques for forceps movement are advocated by some, including a 'figure of
eight' movement to expand the socket for molar teeth.

Functions of Non Dominant (Left) hand during extraction:

During use of the forceps and elevators to luxate and remove teeth, it is important that the
surgeon’s opposite hand play an active role in the procedure. For the right-handed operator,
the left hand has a variety of functions.
The left hand is responsible for reflecting the soft tissues of the cheeks, lips, and tongue to
provide adequate visualization of the area of surgery.
The left hand helps to protect other teeth from the forceps, should it release suddenly from
the tooth socket.
The left hand, and sometimes arm, helps to stabilize the patient’s head during the extraction
process. In some situations, greater amounts of force are required to expand heavy alveolar
bone; therefore, the patient’s head requires active assistance to be held
steady.
The opposite hand plays an important role in supporting and stabilizing the jaw when
mandibular teeth are being extracted.
The opposite hand is often necessary to apply considerable pressure to expand heavy
mandibular bone, and such forces can cause discomfort and even injury to the TMJ unless a
steady hand counteracts them.
A bite block placed on the contralateral side is also used to help open the jaw in this
situation. Finally, the opposite hand supports the alveolar process and provides tactile
information to the operator concerning the expansion of the alveolar process during the
luxation period. In some situations, it is impossible for the opposite hand to perform all of
these functions at the same time, so the surgeon requires an assistant to help with some of
the functions.

Land marks for the Infra Orbital Nerve Block

Second bicuspid technique- supraorbital and infraorbital notches are palpated. An imaginary
line drawn vertically through these landmarks will pass through the pupil of the eyes, the
infraorbital foramen, the bicuspid teeth and the mental foramen. When the infraorbital notch
is located, the palpating finger should be moved downwards about 0.5 cm, where a shallow
depression will be felt. The infraorbital foramen is located within the shallow depression.
In Central incisor technique – direction of insertion bisects the crown of the central incisor
from mesioincisal angle to the distogingival angle.
*needle is inserted 5 mm from the mucobuccal fold and guided into position by thumb
marking the location of the infraorbital foramen

Landmarks for Greater Palatine Nerve block

Second and third maxillary molars
Palatal gingival margin of second and third molars
Midline of the palate
A line approximately 1 cm from the palatal gingival margin toward the midline of the palate

Landmarks for the Incisive nerve block

Central incisor teeth
Incisive papilla in the midline of the palate

Landmarks for the Posterior superior Alveolar nerve block

Mucobuccal fold and its concavity

Zygomatic process of the maxilla
Infratemporal surface of the maxilla
Anterior border and coronoid process of the ramus of the mandible
Tuberosity of the maxilla

Landmarks for the Inferior Alveolar Nerve Block

Mucobuccal fold
Anterior border of the ramus of the mandible
Coronoid Process[3]
Coronoid notch[3]
External oblique ridge
Retromolar triangle
Internal oblique ridge
Pterigomandibular ligament
Buccal sucking pad
Pterigomandibular space
Landmarks for the Long buccal nerve block
External oblique ridge
Retromolar triangle

Alternative techniques for anaesthetizing mandibular teeth

INFERIOR ALVEOLAR NERVE BLOCK-

There are two techniques practiced from time immemorial (Halstead).
1. Direct technique: In this technique the inferior alveolar nerve is
anesthetised first, hence it is known as "direct technique".

Fig. 1: Pterygomandibular
nerve block. Direct technique.
The three positions of the
needle are shown: 1st
position for inferior alveolar
nerve, 2nd position for lingual
nerve, and the 3rd position
for long buccal nerve
2. Indirect technique: In this technique the inferior alveolar is anesthetised
in the third position, hence it is known as "indirect technique" or "threepositional
block technique"

Fig. 2: Pterygomandibular block. Indirect technique. The three positions of the

needle are shown: 1st position for long buccal nerve, 2nd position for lingual nerve,
and the 3rd position for inferior alveolar nerve

NERVE BLOCKS FOR MANDIBULAR NERVE

Intraoral approach
 1. Closed mouth technique (described by Akinosi in 1977)

Fig. 3: Akinosi technique demonstrated on the mandible—The photograph shows the syringe and the needle are parallel to
the occlusal plane of the maxillary teeth at the level of maxillary mucogingival junction

2. Gow gates technique (1973)

Fig. 4: Gow-Gates Mandibular nerve block technique: The position of the point of the needle is
anteromedial to the condyle as seen from the side
Fig. 4: Gow-Gates mandibular nerve block technique: Diagram showing Gow-Gates technique as demonstrated on
mandible as seen from front

1. Extraoral approach
Extraoral mandibular nerve block using lateral approach through the sigmoid notch
or inferiorly from the chin

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PARTS OF DENTAL FORCEPS AND SIGNIFICANCE OF EACH PART

BEAK OR BLADE
The beak is designed to adapt to the tooth root at the junction of crown and root. It is
important to remember the beak of forceps are deigned to be adapted to the root structure of
the tooth and not to the crown of the tooth.
JOINT
The hinge transfers and concentrates the force applied to the handle of beak.
 HANDLE the handles are usually of adequate size to be handled comfortably and deliver
sufficient pressure and leverage to remove the required tooth. The handles have a serrated
surface to allow a positive grip and prevent slippage.
COMPARE AND CONTRAST THESE PAIR OF FORCEPS

MAXILLARY ANTERIOR FORCEPS MANDIBULAR ANTERIOR FORCEPS

BEAKS: Beaks are curved to meet only BEAKS: Beaks are pointed inferiorly for the lower teeth. The
at the tip. Beaks are parallel to handle beaks are smooth and relatively narrow and meet only at the tip.
This allows the beaks to fit at cervical line of the tooth to grasp
JOINT: Horizontal axis the root.

HANDLE: Straight JOINT: Vertical axis

HANDLE: Straight
MAXILLARY PREMOLAR FORCEPS MANDIBULAR PREMOLAR FORCEPS
BEAKS: Beaks are offset to allow good BEAKS: Beaks are set obliquely downwards and have bilateral
positioning, are parallel to handle. Beaks pointed tips in centre to adapt into bifurcation of molar teeth,
have smooth concave surface for parallel because of the pointed forceps it cannot be used for third molar.
root. Beak with a pointed design will fit They have fused conically shaped roots.
into a buccal bifurcation.

JOINT: Horizontal axis JOINT: Vertical axis

HANDLE: Straight HANDLE: Straight

BAYONET FORCEPS MANDIBULAR THIRD MOLAR FORCEPS

BEAKS: offset narrow forceps with a BEAKS: shorter.

narrow beak Do not have pointed tips

JOINT: Horizontal axis

HANDLE: Straight usually but may be JOINT: Horizontal axis

curved.
HANDLE: Straight usually but may be curved.

COWHORN FORCEPS MANDIBULAR MOLAR FORCEPS

BEAKS: Long accentuated pointed BEAKS: 2 pointed heavy beaks that enter into the bifurcation of
Beaks to reach deeper into trifurcation to the lower molar.
sound dentin `
JOINT: Vertical axis

JOINT: Horizontal axis

HANDLE: Straight
HANDLE: Straight usually but may be
curved. This provides sense of better fit.

Things to keep in mind before starting extraction:

If you want to gain patients confidence, do not fumble for instruments in front of him. It is
ylur responsibility to reduce his tension and make him comfortable while giving the
injection. Talking to a patient is a good way of alleviating tension.

Introduce yourself, ask the patient’s name occupation etc before taking a history. Maintain
eye contact and do not be in a hurry.

When feeling for the landmarks for giving an injection, be gentle. Giving an injection
confidently requires practice, so it is a good idea to take a syringe. Giving an injection
confidently requires practice, so it is a good idea to take a syringe home and practice holding
it correctly.

Dont’s

 Do not display the syringe prominently.

  Do not prick the patient at te same site repeatedly.
 Do not spill the solution in the patient’s mouth- it is extremely bitter.
 Do not try and recap the needle with both hands

Do’s

 Do adjust the chair correctly

 Do explain to the patient what you are about to do
 Do keep the bevel upwards
 Do ask the patient to relax and take deep breath while you are injecting.
 Do aspirate before injecting
 Do inject slowly.

Practice makes the man perfect! So practice the correct technique for the beginning and
you shall hit the bulls eye every time.

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ORAL SURGERY IN MEDICALLY COMPROMISED PATIENTS

(Formulate a plan for oral surgical procedure if the patient is assessed to be medically
compromised on the basis of following diseases or condition)

1. HYPERTENSION
Management of Patient with Hypertension
Mild to Moderate Hypertension (Systolic>140 mm Hg; Diastolic >90 mm Hg)
1. Recommend that the patient seek the primary care physician’s
guidance for medical therapy of hypertension. It is not necessary
to defer needed dental care.
 2. Monitor the patient’s blood pressure at each visit and whenever
administration of epinephrine-containing local anesthetic
surpasses 0.04 mg during a single visit.
3. Use an anxiety-reduction protocol.
4. Avoid rapid posture changes in patients taking drugs that cause
vasodilation.
5. Avoid administration of sodium-containing intravenous solutions.
Severe Hypertension (Systolic >200 mm Hg;Diastolic >110 mm Hg)
1. Defer elective dental treatment until the hypertension is better
controlled.
2. Consider referral to an oral-maxillofacial surgeon for emergent
problems.
2. ANGINA PECTORIS[1]
Management of Patient with History of Angina Pectoris
1. Consult the patient’s physician.
2. Use an anxiety-reduction protocol.
3. Have nitroglycerin tablets or spray readily available.Use nitroglycerin
premedication, if indicated.
4. Ensure profound local anesthesia before starting surgery.
5. Consider the use of nitrous oxide sedation.
6. Monitor vital signs closely.
7. Consider possible limitation of amount of epinephrine used
(0.04 mg maximum).
8. Maintain verbal contact with patient throughout the procedure
to monitor status.
3. MYOCARDIAL INFACTION[1]
Management of Patient with a History of Myocardial Infarction
1. Consult the patient’s primary care physician.
2. Check with the physician if invasive dental care is needed
before 6 months since the myocardial infarction (MI).
3. Check whether the patient is using anticoagulants (including
aspirin).
4. Use an anxiety-reduction protocol.
5. Have nitroglycerin available; use it prophylactically if the
 physician advises.
6. Administer supplemental oxygen (optional).
7. Provide profound local anesthesia.
8. Consider nitrous oxide administration.
9. Monitor vital signs, and maintain verbal contact with the
patient.
10. Consider possible limitation of epinephrine use to 0.04 mg.
11. Consider referral to an oral-maxillofacial surgeon.
4. BACTERIAL ENDOCARDITIS
Amoxicillin may be used for prophylaxis of endocarditis and late
prosthetic joint infections, according to the formal guidelines of the
ADA in conjunction with the AHA and the American Academy of
Orthopaedic Surgeons (AAOS).

Antibiotic Regimens for Prophylaxis of Bacterial Endocarditis

REGIMEN
30–60 MIN BEFORE
PROCEDURE
Situation Agent Adults Children*
Oral Amoxycillin 2g 50 mg/kg
Parenteral Ampicillin 2 g IM or IV
50 mg/kg IM or IV
Cefazolin/ ceftriaxone†
1 g IM or IV 50 mg/kg IM or IV

Penicillin Cephalexin† 2g 50 mg/kg

allergy,
oral 600 mg 20 mg/kg
Clindamycin 500 mg 15 mg/kg
Azithromycin/ clarithromycin

Penicillin Cefazolin/ ceftriaxone† 1 g IM or IV 50 mg/kg IM or IV

allergy,
parenteral 600 mg IM or IV 20 mg/kg IM or IV
Clindamycin

*Total children’s dose should not exceed adult dose.

 †Cephalosporins should not be used in patients with immediate-type
hypersensitivity reaction to penicillins. Other first-generation or secondgeneration
oral cephalosporins may be substituted in equivalent adult or
pediatric doses.
IM, Intramuscularly; IV, intravenously.

5. PATIENT WITH VALVOPLASTY OR VALVE REPLACEMENT

Therapeutic anticoagulation is administered to patients with thrombogenic
implanted devices such as prosthetic heart valves. Patients may also take drugs with
anticoagulant properties such as aspirin, for secondary effect. When elective oral
surgery is necessary, the need for continuous anticoagulation must be weighed
against the need for blood clotting after surgery. This decision should be made in
consultation with the patient’s primary care physician. Drugs such as low-dose
aspirin do not usually need to be withdrawn to allow routine surgery. Patients taking
heparin usually can have their surgery delayed until the circulating heparin is
inactive (6 hours if IV heparin is given, 24 hours if given subcutaneously).
Protamine sulfate, which reverses the effects of heparin, can also be used if
emergency oral surgery cannot be deferred until heparin is naturally inactivated.
Patients on warfarin for anticoagulation and who need elective oral surgery benefit
from close cooperation between the patient’s physician and the dentist. Warfarin has
a 2- to 3-day delay in the onset of action; therefore, alterations of warfarin
anticoagulant effects appear several days after the dose is changed. The INR is used
to gauge the anticoagulant action of warfarin. Most physicians will allow the INR to
drop to about 2 during the perioperative period, which usually allows sufficient
coagulation for safe surgery. Patients should stop taking warfarin 2 or 3 days before
the planned surgery. On the morning of surgery, the INR value should be checked; if
it is between 2 and 3 INR, routine oral surgery can be performed. If the PT is still
greater than 3 INR, surgery should be delayed until the PT approaches 3 INR.
Surgical wounds should be dressed with thrombogenic substances, and the patient
should be given instruction in promoting clot retention. Warfarin therapy can be
resumed the day of surgery
 Prosthetic valve endocarditis occurs when the tissue around the cardiac valve
implant becomes infected. Such infections are caused by the same bacteria that cause
typical native valve endocarditis. Prosthetic valve endocarditis is a much more
serious illness than native valve endocarditis because loosening of the heart valve
may result in death. The 1-year survival rate for patients who have prosthetic valve
endocarditis is about 50%. The AHA currently states that the standard oral regimens
are adequate for most patients with prosthetic heart valves.

6. PATIENT WITH CARDIAC PACEMAKER

Pacemakers pose no contraindications to oral surgery, and no evidence exists that shows the
need for antibiotic prophylaxis in patients with pacemakers. Electrical equipment such as
electrocautery and microwaves should not be used near the patient. As with other medically
compromised patients, vital signs should be carefully monitored.

7. HYPERTHYRODISM
. Manifestations and Management of Acute Thyroid Storm Manifestations
• Abdominal pains
• Cardiac dysrhythmias
• Hyperpyrexia (i.e., fever)
• Nausea and vomiting
• Nervousness and agitation
• Palpitations
• Partial or complete loss of consciousness
• Tachycardia
• Tremor
• Weakness
Management
1. Terminate all dental treatment.
2. Have someone summon medical assistance.
3. Administer oxygen.
4. Monitor all vital signs.
5. Initiate basic life support, if necessary.
6. Start an intravenous line with drip of crystalloid solution
 (150 mL/h).
7. Transport the patient to an emergency care facility.

8. DIABETES MELLITUS
Non–Insulin-Dependent (Type 2) Diabetes
1. Defer surgery until the diabetes is well controlled.
2. Schedule an early morning appointment; avoid lengthy appointments.
3. Use an anxiety-reduction protocol.
4. Monitor pulse, respiration, and blood pressure before, during, and after surgery.
5. Maintain verbal contact with the patient during surgery.
6. If the patient must not eat or drink before oral surgery and will have difficulty
eating after surgery, instruct him or her to skip any oral hypoglycemic medications
that day.
7. If the patient can eat before and after surgery, instruct him or her to eat a normal
breakfast and to take the usual dose of hypoglycemic agent.
8. Watch for signs of hypoglycemia.
9. Treat infections aggressively.

9. PATIENT ON STEROID THERAPY

. If a patient with primary or secondary adrenal suppression requires complex oral
surgery, the primary care physician should be consulted about the potential need for
supplemental steroids. In general, minor procedures require only the use of an
anxiety reduction protocol. Thus, supplemental steroids are not needed for most
dental procedures. However, more complicated procedures such as orthognathic
surgery in an adrenally suppressed patient usually necessitate steroid
supplementation
Management of Patient with Adrenal Suppression Who Requires Major
Oral Surgery*
If the patient is currently taking corticosteroids:
1. Use an anxiety-reduction protocol.
2. Monitor pulse and blood pressure before, during, and after surgery.
3. Instruct the patient to double the usual daily dose on the day before, day of, and
day after surgery.
 4. On the second postsurgical day, advise the patient to return to a usual steroid dose.
If the patient is not currently taking steroids but has received at least 20 mg of
hydrocortisone (cortisol or equivalent) for more than 2 weeks within past year:
1. Use an anxiety-reduction protocol.
2. Monitor pulse and blood pressure before, during, and after surgery.
3. Instruct the patient to take 60 mg of hydrocortisone (or equivalent) the day before
and the morning of surgery (or the dentist should administer 60 mg of
hydrocortisone or equivalent intramuscularly or intravenously before complex
surgery).
4. On the first 2 postsurgical days, the dose should be dropped to 40 mg and dropped
to 20 mg for 3 days thereafter. The clinician can cease administration of
supplemental steroids 6 days after surgery.
*If a major surgical procedure is planned, the clinician should strongly consider
hospitalizing the patient. The clinician should consult the patient’s physician if any
questions arise

10. PATIENT ON CANCER CHEMOTHERAPY

The primary concerns for the dentist should be the severity and duration of bone
marrow suppression. The dentist must be aware of the dates of chemotherapy and the
hematologic status of the patient before beginning dental care. If the patient is being
treated for a hematologic neoplasm (e.g., leukemia), both the disease and the
chemotherapy lead to decreases in the functional blood elements. Therefore, these
patients may be at great risk for infection and hemorrhage at any time in the course
of their disease. Consultation with the patient’s physician in these instances is
mandatory. In most cases of nonhematopoietic neoplasm, the patient is at risk for
infection and hemorrhage only during the course of the chemotherapy, after which
recovery of the blood elements occurs. The decision of when to extract teeth before
treatment is based on the condition of the residual dentition, the patient’s past dental
hygiene practices, the immediacy of the need for chemotherapy, and the overall
prognosis of the malignant disease. Prechemotherapy dental measures that should
routinely be performed are a thorough prophylaxis, fluoride treatment, and any
necessary scaling. Unrestorable teeth should be removed before chemotherapy
begins. Patients who have begun chemotherapy must maintain scrupulous oral
 hygiene. This is difficult in the face of mucositis and ulceration, which frequently
occur. No dental procedures should be performed on any patient receiving
chemotherapy when the white blood cell and platelet status is unknown. In general,
patients who have a white blood cell count greater than or equal to 2000/ mm3, with
at least 20% polymorphonuclear leukocytes and a platelet count greater than or equal
to 50,000/mm3, can be treated in routine fashion. Antibiotics should be administered
prophylactically if the patient has had chemotherapy within 3 weeks of dental
treatment. If the white blood cell count and platelet levels fall below those specified,
minimal oral care should be practiced because infection, severe bleeding, or both can
occur. The patient may even need to avoid flossing and to use an extremely soft
toothbrush during these periods. Any removable dental appliance should be left out
at these times to prevent ulceration of the fragile mucosa.

11. PATIENT UNDERGOING RADIOTHERAPY

Extractions are advised for carious, non-vital, periodontally involved teeth or
retained roots and their removal is performed carefully pre-radiotherapy to ensure
rapid healing. Subsequent to radiotherapy, meticulous oral hygiene is essential
especially during treatment when the mouth is inflamed and sore. Dilute
chlorhexidine. Mouthwashes topical fluoride applications saliva substitutes and
active restorative care may all be needed to preserve the remaining dentition. Should
a tooth have to be extracted it is essential that an atraumatic surgical technique is
used, together with antibiotic cover until healing is complete
Traditionally, 7 to 14 days between tooth extraction and radiotherapy have been
suggested
If the patient has a partially erupted mandibular third molar, removal may be prudent
to prevent pericoronal infection. In general, however, allowing a tooth that is totally
impacted within the bone of the mandible to remain in place is more expeditious than
removing it and waiting for it to heal.
It has been demonstrated that the success of implant retention is directly and
positively correlated with the amount of radiation to which bone was exposed. If the
amount of radiation is less than approximately 4500 rad (45 Gy), implants may be
placed with care. When the amount of radiation exceeds this amount, preoperative
 (20 to 30) and postoperative (10) HBO treatments should be considered. HBO
treatments have been shown to be beneficial in such patients

12. PATIENT ON ANTICOAGULANT THERAPY

Management of Patient whose Blood Is Therapeutically Anticoagulated
Patients Receiving Aspirin or Other Platelet-Inhibiting Drugs
1. Consult the patient’s physician to determine the safety of stopping the
anticoagulant drug for several days.
2. Defer surgery until the platelet-inhibiting drugs have been stopped for 5 days.
3. Take extra measures during and after surgery to help promote clot formation and
retention.
4. Restart drug therapy on the day after surgery if no bleeding is
present.
13. Patients Receiving Warfarin (Coumadin)
1. Consult the patient’s physician to determine the safety of allowing the
prothrombin time (PT) to fall to 2.0 to 3.0 INR (international normalized ratio). May
take a few days.*
2. Obtain the baseline PT.
3. (a) If the PT is less than 3.1 INR, proceed with surgery and skip to step 6. (b) If
the PT is more than 3.0 INR, go to step 4.
4. Stop warfarin approximately 2 days before surgery.
5. Check the PT daily, and proceed with surgery on the day when the PT falls to 3.0
INR.
6. Take extra measures during and after surgery to help promote clot formation and
retention.
7. Restart warfarin on the day of surgery.

14. Patients Receiving Heparin

1. Consult the patient’s physician to determine the safety of stopping heparin for the
perioperative period.
2. Defer surgery until at least 6 hours after the heparin is stopped or reverse heparin
with protamine.
3. Restart heparin once a good clot has formed.
 *If the patient’s physician believes it is unsafe to allow the PT to fall, the patient
must be hospitalized for conversion from warfarin to heparin anticoagulation during
the perioperative period.

15. THALLESSEMIA
These inherited diseases are seen in Mediterranean races in whom foetal
haemoglobin continues to be produced after birth. The patients suffer from
haemolytic anaemia and should be treated in hospital
16. HAEMOPHILLIA
Specific factor deficiencies—such as hemophilia A, B, or C; or von Willebrand’s
disease—are usually managed by the perioperative administration of coagulation
factor concentrates and by the use of an antifibrinolytic agent such as aminocaproic
acid (Amicar). The physician decides the form in which factor replacement is given,
on the basis of the degree of factor deficiency and on the patient’s history of factor
replacement. Patients who receive factor replacement sometimes contract hepatitis
virus or HIV. Therefore, appropriate staff protection measures should be taken
during surgery.

17. LEUKEMIA
All forms of leukaemia are a contraindication to any form of oral surgery without
full investigation and advice from a haematologlsl, owing to the difficulty of
controlling post-operative bleeding and infection. In such cases a conservative
approach to dental care should be adopted until the leukaemia is in remission or the
patient is free of the disease.
18. PREGNANT PATIENTS
Management of Patient Who Is Pregnant
1. Defer elective surgery until after delivery, if possible.
2. Consult the patient’s obstetrician if surgery cannot be delayed.
3. Avoid dental radiographs unless information about tooth roots or
bone is necessary for proper dental care. If radiographs must be
taken, use proper lead shielding.
4. Avoid the use of drugs with teratogenic potential. Use local
anesthetics when anesthesia is necessary.
5. Use at least 50% oxygen if nitrous oxide sedation is used.
 6. Avoid keeping the patient in the supine position for long periods,
to prevent vena caval compression.
7. Allow the patient to take trips to the restroom as often as
needed.

19. PATIENT ON ORAL CONTRACEPTIVES

Incidence of alveolar osteitis seems to be higher in female patients who take oral
contraceptives. Its occurrence can be reduced by several techniques, most of which
are aimed at reducing the bacterial contamination of the surgical site. Presurgical
irrigation with antimicrobial agents such as chlorhexidine reduces the incidence of
dry socket by up to 50%.2 Copious irrigation of the surgical site with large volumes
of saline is also effective in reducing dry socket. Topical placement of small
amounts of antibiotics such as tetracycline or lincomycin may also decrease the
incidence of alveolar osteitis.

20. PATIENT ON TRICYCLIC ANTIDEPRESSANTS

They can carry unwanted anticholinergic and hypotensive side effects,
which should be remembered when anesthesia is given. An additional problem with
tricyclic antidepressants is their tendency to cause increased conduction delays in
patients with preexisting heart blocks.

21. PATIENT ON MAO INHIBITORS

They can carry unwanted anticholinergic and orthostatic hypotensive side effects, which
should be remembered when anesthesia is given. Drugs with sympathomimetic action
should be avoided in patients on MAOIs.

22. PATIENT ON ANTI CONVULSANT DRUGS

Abrupt discontinuation should be avoided to prevent the appearance of a withdrawal
phenomenon.
-------------------------------------------------××----------------------------------------------
 HOW WOULD YOU TREAT THE FOLLOWING COMPLICATIONS OCCURING
DUE TO INJECTION TECHNIQUE?

FACIAL PARALYSIS
1 Reassure the patient explain that the situation is transient, will last for a few hours and
will resolve without resident effect.
2 An eye patch should be applied to the effected eye until muscle tone returns if
resistance is offered by the patient, advice the patient to manually close the lower eyelid
periodically to keep the cornea lubricated.
3Contact lenses should be removed until muscle movement returns
4Record the incidents on the patients chart.
5It may be prudent to forgo further dental care at this appointment.
HAEMATOMA when swelling becomes evident during or immediately following a local
anaesthetic injection,direct pressure should be applied to the site of bleeding for not less
than two minutes as blood vessel lies btw skin and bone. Subsequently ice should be
applied to the region immediately on recognition ofa developing haematoma.it acts as both
analgesic and vasoconstrictor so may aid in minimizing the size of hematoma. Time with
or without treatment, hematoma will be present 7 to 14 days. Avoid additional dental
therapy in the region until symptoms and signs resolve.
ANGIOEDEMA Is a localized swelling in response in response to an allergn within 30 to 60
min following application of local anaesthetic agent
1 Administer 0.3mg(0.15mg for a child) epinephrine 1M
2. Administer 1/M or SC histamine blocker 50 mg diphenylhydramine (25mg for a child) or
10 mg chlorpheniramine(15mg for a child). Obtain medical consultation with physician
transfer the pateint to physician for observation before discharge.
NEEDLE BREAKAGE When a needle breaks
1 a] Remain calm, do not panic.
B]Instruct the patient not to move. Keep the patients mouth open, place a bite block in the
mouth.
C] If the fragment is visible,try to remove it with a small hemostat or Magill intubation
forceps.
2 If the needle is lost(not visible) and cannot be readily retrieved.
A] Do not proceed with an incision or probing.
B] Calm the patient.
C] Note the incident on patientschart. Keep the remaining needle fragment.
3 When a needle breaks,consideration should be given to its immediate removal a] If it is
superficial, and easily located through radiological and clinical examination, then removal is
possible.
b] If despite its location attempted retrieval is unsuccessful in a reasonable length of time, it
is prudent to abandon the attempt and allow the needle fragment to remain.
c] If it is located in the deeper tissues or is hard to locate permit it to remain without an
attempt at removal.
PROLONGED ANAESTHESIA1] Reassure to the patient.
2] Examine the patient,
A] Determine the degree and extent of paresthesia
B] Explain the patient that paresthesia normally persists at least for 2 months before
resolution begins and that it may last up to year or longer.
C] Reschedule the patient for examination every 2 months for as long as the sensory deficit
persist.
D] If the sensory deficit is still evident after 1 year also then consultation with neurologist is
recommended.
BLOOD ON ASPIRATION The local anesthetic solution should be deposited at that site
.Aspiration should be performed at least twice prior to administer local anesthesia with the
orientation of the bevel changed(rotate band of syringeabout 45 deg for 2 nd aspiration test) to
ensure that the bevel of the needle is not located inside a blood vessel. This serves two
functions
1. To slow down the rate of anesthetic administration
2] To preclude the deposition of large volumes of anesthetic into cardiovascular system. Use
large gauge needles eg; 25 gauge needle.
-------------------------------------------×----------------------------------------------------

LOCAL AND SYSTEMIC HEAMOSTATIC AGENTS

MECHANISM OF ACTION OF EACH OF FOLLOWING
GELFOAM it is made from gelatin and is sponge like gelfoam has no intrinsic hemostatic
action. Its main activity is related to large surface area which comes in contact with blood
and further swell on absorbing blood.it exerts pressure along with acting as scaffold for
fibrin network. It is absorbed by phagocytosis, should be moistened in saline or thrombin
prior to application, and all the air should be removed from interstices.
SURGICEL It is glucose polymer based sterile knitted fabric prepared by controlled
oxidation of regenerated cellulose. Its local hemostatic mechanism depends upon binding of
hemoglobin to ox cellulose allowing dressing to expand into a gelatinous mass which in
form act as a scaffold for clot formation and stabilization. It can be applied dry and can be
soaked in a thrombin.it is removed by liquefaction and phagocytosis over a period of 1 week
to 1 month. This product does not inhibit epithelization and can be used over epithelial
surface.

ADERNALINE applied topically induces vasoconstriction and thus helps in achieving

hemostasis. Extensive application or undiluted preparation use maybe cause systemic effects
therefore one should be use carefully, with the help of gauze pack in a conc 1;1000 over
oozing sites, it can be used injected along with local anaesthetic solution in a conc of
1;80000 to 1;200000. The drug should be used in pits who have hypertension or previously
existing cardiac disease; this effect is reversible and should be careful to watch the
reoccurrence of bleeding when its effect is cease off.

ETHAMSYLATE reduces capillary bleeding in the presence of normal no of platelets. It

probably act by correcting abnormal platelet adhesion.
RUSSEL VIPER VENOM
This has been classified broadly as posseting coagulant, anticoagulant and hemorrhagic
activity, used as a activator of factor 10 and used for diagnosis of sturat perus disease.[lack
of factor 10 in blood clotting]
VITAMIN K
Required for the synthesis of prothrombin and clotting factors 7,9 and 10 in liver. It is
available as 5mg tablets and emulsion of 2-10 mg/ml for injection.

BONE WAX
When bleeding is occurring from the bony canal, it can be troublesome, because of
inhibiting to occlude the vessel that is confined within bony canal, in such a case small
quantity of bony wax can be applied to the bleeding bone. It acts by mechanical occlusion of
the bony canal.
Large quantity of bone wax can lead to foreign body granuloma and infection therefore it
should be used judiciously.
--------------------------------------------0--------------------------------------------------------------

COMMON EMERGENCIES IN DENTAL PRACTICE

1. SYNCOPE:
Definition:
Syncope also known as vasovagal syncope is the sudden, transient loss of
consciousness that usually occurs secondary to a period of cerebral ischemia.

Pathophysiology:
Most commonly precipitated by decrease in cerebral blood flow below critical level
characterized by a sudden drop in BP and decrease in HR. The pattern of events
which develops is:
PRESYNCOPE: Stress (fear, pain) leads to increase in catecholamine release (fight
or flight response) which leads to decrease in peripheral vascular resistance and
increased blood flow to the peripheral skeletal muscles which causes pooling of
blood and decrease in the circulating blood volume & arterial blood flow. This
activates compensatory mechanism of increase in heart rate and signs of presyncopal
period develop.
SYNCOPE: Critical level of cerebral blood flow for the maintenance of
consciousness (30ml blood/ 100gm of brain tissue/ minute)is impaired which leads
to syncope.
RECOVERY: Hastened by positioning the patient in a supine position with legs
slightly elevated leads to increase in venous return to heart and increase in blood
flow to the brain.

Clinical features :
EARLY: Feeling of warmth, loss of colour (pale or ashen grey skin tone), heavy
perspiration, nausea, BP at baseline or slightly decreased, tachycardia
LATE: pupillary dilatation, yawning, hyperpnoea, cold hands and feet, visual
disturbances, brief and mild convulsive movements of arms or legs, dizziness with
loss of consciousness and breathing is irregular, jerky, gasping, quiet, shallow and
can cease entirely ( apnea)
RECOVERY: Signs and symptoms of weakness, sweating and pallor persist for
hours.

Management:
Step 1: P (Position): Supine with legs elevated and vigorous muscle movements to
increase the return of peripheral blood
Step 2: A-B-C (airway-breathing- circulation) Basic Life Support: Perform the head
tilt-chin lift procedure, assess breathing and if needed administer oxygen. To check
the circulation palpate carotid pulse which is usually weak and thready.
Step 3: D (Definitive):
3a- administer oxygen through a full face mask or nasal cannula
3b- monitor vitals (BP, HR, RR and compare to the preoperative baseline)
3c- additional – loosen tight ties, collars, belts
Respiratory stimulant i.e aromatic ammonia
 Cold towel on the forehead
If bradycardia persists- atropine i/v or i/m (anticholinergic drugs)
Postsyncopal recovery, postpone further treatment and determine the precipitating
factor.
2. CONVULSIONS:
Definition:
It is a paroxysmal disorder of cerebral function characterized by an attack involving
changes in the state of consciousness, motor activity or a sensory phenomenon which
is sudden in onset and usually of brief duration.

Pathophysiology:
Intrinsic intracellular and extracellular metabolic disturbances in the neurons of
epileptic patients produce excessive and prolonged membrane depolarization. This
increase in permeability of neuronal cell membrane changes the sodium and
potassium movement affects resting membrane potential membrane excitability.
Clinical seizure occurs if this abnormal discharge is propagated along the neuronal
pathways and local neuron recruitment occurs.

Clincal features:
PRODROMAL PHASE: Patient exhibits subtle to obvious emotional reactivity
changes and there is immediate onset of aura.
PREICTAL PHASE: Patient looses consciousness and falls to the floor and displays
generalized bilateral myoclonic jerks with epileptic cry. During this phase there is
increase in HR and BP to almost twice the baseline values. There is also increase in
bladder pressure and cutaneous vascular congestion.
ICTAL PHASE: Tonic- sustained generalized skeletal muscle contractions which
have flexion followed by rigidity and dyspnea occurs.
Clonic- heavy strenuous breathing for 2-5 minutes with frothing
POSTICTAL PHASE: Movements cease, breathing normalizes. For the first several
minutes muscular flaccidity occurs and then patient goes into deep sleep or becomes
unconscious.

Management:
Step 1: Terminate procedure, remove any dental equipment or partial dentures form
the oral cavity.
Step 2: P (Position): If the patient is on the dental chair place the chair in supine
position and if not then place the patient in supine position on the floor.
Step 3: A-B- C: Perform the head-tilt-chin-lift procedure, clean the oral cavity of the
blood and secretions. Ensure airway patency, perform suction carefully using soft
rubber or plastic catheters inserting them between buccal surfaces of teeth and
cheeks but not between the teeth.
Step 4:D (Definitive):
4a: Prevention of injury: Mild restrain of arm and legs from major movements and
remove any additional padding from the headrest as it can increase airway
obstruction. Place a towel or gauzepad only if the patient doesn’t have a tighly
closed mouth, Never try to forcefully insert fingers into the oral cavity or open the
mouth as the patient is in tetany.
4b: administer oxygen.
4c: Monitor vitals (BP, HR are increased)
4d: P (Position): Place the patient in supine position only with feet slightly elevated.
A-B-C: Maintain the airway and administer oxygen via face mask or nasal
cannula.
4e: Venipuncture and administration of anticonvulsant drugs: Benzodiazepines
( Diazepam) as a 10mg dose at the rate of 5mg/minute which can be repeated every
10 minutes. For children the dose is 0.3mg/kg also to be repeated every 10 minutes.
Admininstration of 50% dextrose solution to rule out hypoglycemia as the solution
helps to maintain RBS levels needed as the brain uses large amounts of glucose
during the ictal phase.
3. ANGINA PECTORIS:
Definition:
Angina pectoris is a characteristic thoracic pain, usually substernal, precipitated
chiefly by exercise, emotion or a heavy meal; relieved by vasodilator drugs and a
few minutes rest and as a result of a moderate inadequacy of coronary circulation.

Pathophysiology:
Myocardial ischemia leads to release of chemicals like bradykinin, histamine,
serotonin which act on intracardiac sympathetic nerves and ganglia at C 7 to T4. These
impulses are then transmitted to the spinal cord from which they reach the thalamus
and then the cortex. 1-3 minutes prior to the onset of pain changes in ECG set in.
The onset of an anginal episode leads to continued elevation of BP and HR which
produces a feedback system to increase ischemia and this cycle continues.

Clinical Features:
The primary feature is chest pain which is substernal, sudden in onset and causes the
patient to sit upright and presses fist against the chest (Levine sign). The sensation is
dull, squeezing, burning, choking or aching and inspiration doesn’t exaggerate
discomfort.
There is radiation of pain to left shoulder and distally down to the medial surface of
left arm, mandible and side of neck.
On physical examination the HR is markedly elevated, BP up to 200/150 mm Hg
even in normotensive patient. Respiratory difficulty (dyspnea) and feeling of
faintness.

Management:
Step 1: Terminate the dental procedure and immediately ask for emergency medical
assistance
Step 2: P (Position): Allow the patient to be in most comfortable position, sitting or
standing upright.
Step 3: A-B-C: Anginal patient is conscious, breathes spontaneously and has a
palpable pulse in the wrist, antecubital fossa and the carotid artery.
Step 4: D (Definitive care):
4a: Administer vasodilator and oxygen through nasal cannula or hood. Even before
the administration of oxygen give nitroglycerin either transmucosally with a spray or
sublingually using a tablet. The usual dose to be given is 0.3-0.6 mg of 1or 2 metered
sprays with no more than 3 sprays every 15 minutes. It acts via relaxing the vascular
smooth muscles which causes the systemic vascular resistance to decrease. This
leads to decrease in the cardiac output and finally the cardiac workload.
4b: Additional vasodilators: If spasm is a component of the angina episode then
Calcium entry blocking agents like Nifedipine (10-20mg sublingually), Verapamil,
Diltiazem are to be added.
Step 5: Modify the treatment to prevent the recurrence.
 4. ANAPHYLACTIC SHOCK:
Definintion: It is a serious, potentially life-threatening allergic response to an antigen to
which the body has become hypersensitive and is marked by swelling, hives, lowered
blood pressure and dilated blood vessels.
Pathophysiology:
For anaphylaxis to occur 3 conditions must meet.
1. An antigen induced stimulation of immune system with specific IgE antibody
formation.
2. Latent period after the initial antigenic exposure for sensitization of mast cells and
basophils.
3.Subsequent reexposure to that specific antigen.

Clinical features:
Usually the progression of anaphylaxis is from skin- eyes,nose, GIT- respiratory system-
CVS
Respiratory s/s: -Vasodilation and increased vascular permability.
-Increased mucous secreation, laryngeal oedema, angioedema and
asphyxia from upper respiratory tract obstruction.
-Bronchospasm leading to coughing, chest tightness, dyspnea and
wheezing.
CVS s/s: -Decreased vasomotor tone leading to 50% IVF into extravascular space
within 10 minutes
- Hemodynamic collapse
- Lightheadedness, syncope, tachycardia, dysarthmia, orthostatic hypotension
GIT s/s: Cramping, abdominal pain, nausea, vomiting, diarrhea, tenesmus
Fatal anaphylaxis : The most prominent respiratory symptoms are laryngeal oedema,
increased tracheobronchial secreations, pulmonary hyperinflation and perivascular
congestion leading to myocardial damage

Management:
Step 1: Terminate procedure and ask for emergency medical assistance.
Step 2: P (position): Place the unconscious or conscious hypotensive patient into a supine
position with legs slightly elevated.
Step 3: A-B-C: Perform the head tilt chin lift procedure to provide clear airways .
Step 4: D(definitive):
4a: Administer epinephrine in the dose of 0.3 ml of 1:1000 via intramuscular route from a
preloaded syringe. The dose for children is 0.15ml and for infants is 0.075ml in the same
dilution.
Epinephrine can be given via the sublingual (floor of mouth) or intralingual( substance of
tongue) routes which provide more perfusion than the middeltoid or the vastus lateralis.
1 or 2 doses produces clinical improvement leading to correction of respiratory or CVS
symptoms. The breath sounds improve as the bronchospasm decreases and the BP improves.
If the clinical s/s do not improve within 5 minutes of initial epinephrine dose then the 2 nd
dose is given with subsequent doses every 10 minutes.
4c: Oxygen administration: 5-6 L/ minute via nasal hood or full mask
4d: Monitor vital signs ( BP and HR every 5minutes)
4e: Additional drug therapy: It is given if any improvement is seen in the patient ( If BP
improves or the bronchospasm decreases and consciousness is regained) NOT in the acute
phase as these drugs are slow acting. Histamine blockers and corticosteroids are given
through intramuscular or intravascular route.

---------------------------------------------------xx--------------------------------------------------------
CAUSES FOR FRACTURE OF TOOTH DURING EXTRACTION
1. Fracture of crown of a tooth during extraction maybe unavoidable if the tooth is
weakened by caries or a large restoration.
2. Improper application of forceps to the tooth
a: beaks are not below CEJ
b: long axis of the forceps are not parallel to tooth
c: improper forceps selection with blades too broad and only one point
contact which leads to tooth collapse when gripped
d: if forcep handles are not held firmly together blades may slip off the root
and fracture the crown.
3. One of the main causes of fracture of tooth is hurry and when excessive force
application in an effort to overcome resistance.
4. Unfavorable root anatomy or dense and non-elastic bone can also lead to fracture of
tooth during extraction.
POST EXTRACTION BLEEDING

Causes:
1.Primary heamorrhage: Present at the time of extraction: usually due to accidental
tearing of a large artery or vein or in the regions of inflammation where tissues are
excessively hyperemic.
2. Reactionary heamorrhage: Within a few hours after surgery when the
vasoconstriction of damaged blood vessels ceases
2. Secondary heamorrhage( Bleeding that develops upto 14 days after the extraction)
is usually due to infection leading to loss of clot or erosion of vessels in the
granulation tissue.

Management:
Primary hemorrhage:
1. Quickly irrigate with isotonic saline and suction to remove clots.
2. Check vitals (BP, Pulse, RR) if patient displays signs of shock (weak rapid pulse,
low BP, cold clammy skin, pallor) institute supportive treatment immediately.
3. Obtain adequate anesthesia with small amount of vasoconstrictor (1:1,00,000 or
less) examine the extraction wound.
4. If gingival wound control by suturing the margins with a horizontal mattress
suture, if from the bone, pack with gelatin sponge or oxidized cellulose gauze)
and place gauze pack for 15-30minutes.
5. If a single vessel is the site of bleed then tie it off using a suture or coagulated
with diathermy.
Secondary heamorrhage:
1. Similar management as primary but review the wound for foreign bodies.
2. Give antibiotic coverage.
DRY SOCKET

Causes:
It is a condition in which there is loss of the blood clot from the socket leading to radiating
pain of severe intensity beginning from 3-5th postoperative day.
The causes can be:
1. Preexisting infection
2. Trauma to the bone during the extraction
Birn hypothesized that trauma and infection cause inflammation of the bone marrow with
the resultant release of fibrinolytic agents.
Diagnosis is confirmed by:
1. Bare bone is encountered on gentle probing of the extraction wound
2. Extremely tender on probing
3. Foul odour is present

Management:
Treatment is primarily detected towards relief of pain
1. Local therapy consists of irrigation of the socket with warm sterile isotonic saline or
dilute solution of hydrogen peroxide to remove necrotic clots and debris followed by
application of an obtundant (eugenol).
2. In addition to the local therapy, an antipyretic analgesic or a narcotic such as codeine
sulfate can be prescribed to the patient.
3. Reexamine the patient after 24 hours, if the pain has stopped then the local
medication need not be replaced otherwise re-irrigate and replace the medication.
Sutures and suturing Techniques:

Suturing Technique Remarks

Interrupted suturing

Simple contiuous

Figure of “8”

Horizontal Mattress suture

Vertical mattress Suture

Continuous Interlocking Suture

A CASE OF ORO-ANTRAL FISTULA ; EXAMINATION AND CLOSURE

PRE OPERATIVE PREPARATION
RADIOGRAPHIC FINDINGS
X ray PNS shows haziness of sinus when sinusitis sets in /when there is bleeding in the
sinus. Dislodged foreign body may be seen IOPA view show the defect in the bone above
the apices of the roots with loss of cortication of the floor of sinus
OPERATIVE TECHNIQUES
BUCCAL ADVANCEMENTS FLAP
BURGER FLAP
The edges of the socket are trimmed and rounded off. A full thickness mucoperiosteal
trapezoidal flaps designed and reflected on a buccal side.
The periosteum is selectively incised from inside of the flap carefully .
This enhances the elasticity of the flap as the mucosa is elastic. The flap is then advanced to
the palatal side. And sutured with palatal gingival margin.
REHRMANN FLAP
Is a broad based flap and rather than the periosteal scoring liberal undermining is done to
advance the flap. This results into obliteration of buccal vestibular depth.
PALATAL ROTATIONAL FLAP
The palate gets its blood supply from greater palatine arteries which emerges from greater
palatine foramen and run forward in the palate somewhat midway between gingival margin
and midline of the palate, ASHLEY [1939] devised the palatal flap operation where a palatal
flap is rotated across the fistula so that the suture line rests on sound bone on buccal side of
orifice although palatal tissue is less elastic it is thicker than buccal tissue, The abundant
blood supply in the palatal tissue promotes satisfactory healing.
OTHERS
1. COMBINATIONOF BUCCAL AND PALATAL FLAPS
2. REGIONAL FLAPS
A TONGUE FLAPS
B BUCCAL FAT PAD
C RANDOMIZED CHEEK FLAPS
3. DISTANT FLAPS
TEMPORAL MUSCLE FASCIA FLAPS

POST OPEARTIVE CARE/ PRESCRIPTION

Do not ask the patient to blow the nose forcefully and repeatedly.
Prescribe antibiotics and decongestants.
Procedures involving palatal flaps do not affect the buccal vestibular height. Palatal
rotational advancement flap provides adequate mobility and tissue bulk to the flap. However
it required the mobilization of large amount of palatal tissue and it often kinks following the
rotation of the flap, which may predispose to venous congestion.
ASLEYS OPERATION
1. LOCAL ANAESTHESIA
Is given to reduce the bleeding
2. EXCISION OF FISTULOUS TRACT

The tract is dissected out by taking an incision around fistula about 2mm away from
epithelium
3. MARKING OUT OF PROPOSED PALATAL FLAP
4. RAISING A PALATAL MUCOPERIOSTEAL FLAP
care is taken not to damage the greater palatine artery.
5. Maxillary sinus is inspected and cleared of polyps and irrigated with normal
saline or betadine.
6. TRIMMING OF BUCCAL MUCOPERIOSTEUM
Is done in order to give bone support to suture line
7. ROTATIONAL ADVANCEMENT
Of palatal pedicled flap to approximate the buccal margin with interrupted sutures.
FRESH ORO ANTRAL COMMUNICATION
REMEMBER 5 Es
1. ESCAPE OF FLUID
From mouth to nose on the side of extraction. This happens when the patient rinses/ gargles
the mouth following extraction of a tooth.
2. EPISTAXIS [UNILATERAL]
Due to blood in the sinus escaping through osteum into nostril.
3. ESCAPE OF AIR
From mouth into the nose on sucking inhaling or drawing on a cigarette or puffing the
cheeks [inability to blow cheeks. Passage of air into mouth on sucking]
4. ENHANCED COLUMN OF AIR
Causes alteration in vocal resonance and subsequently change in the voice
5. EXCRUCIATING PAIN
 In and around the region of the affected sinus as the local anesthesia begins to wear off

IN LATE STAGE, SYMPTOMS OF ESTABLISHED ORO ANTRAL FISTULA

REMEMBER 5 Ps
1. PAIN
2. PERSISTANT PURULENT FOUL UNILATERAL nasal discharge from the affected
nostril especially when the head is lowered down. Foetid taste and smell.
3. POSTNASAL DRIP
The trickling of the nasal discharge from the posterior nares down the pharynx.
4. POSSIBLE SEQUELE Of general toxemic condition fever malaise anorexia.
5. POPPING out of an antral polyp.

POST –OPERATIVE CARE

 Avoid sneezing
 Avoid exploring the wound with tongue, or deliberately sucking air or fliud through it
 Removal of sutures 7 to 10 days postoperatively
 Restriction to soft diet

PRESCRIPTION
 Antibiotics
 Analgesics
 Nasal decongestants
 inhalations

Nerve course of Maxillary and Mandibular Nerve

There are twelve pairs of cranial nerves and their defining feature is that they exit the cranial
cavity through foramina or fissures. All cranial nerves innervate structures in the head or
neck. In addition, the vagus nerve [X] descends through the neck and into the thorax and
abdomen where it innervates viscera. Parasympathetic fibers in the head are carried out of
the brain as part of four cranial nerves-the oculomotor nerve[III], the facial nerve [VII], the
glossopharyngeal nerve[IX], and the vagus nerve [X]. Parasympathetic fibers in the
oculomotor nerve [III], the facial nerve [VII], and the glossopharyngeal nerve [IX] destined
for target tissues in the head leave these nerves, and are distributed with branches of the
trigeminal nerve [V].The vagus nerve [X] leaves the head and neck to deliver
parasympathetic fibers to the thoracic and abdominal viscera.(Gray’s anatomy)

The maxillary division (V2) travels anteriorly and downward to exit the cranium through the
foramen rotundum into the upper portion of the pterygopalatine fossa. The mandibular
division (V3) travels almost directly downward to exit the skull, along with the motor root,
through the foramen ovale. These two roots then intermingle, forming one nerve trunk that
enters the infratemporal fossa.
On exiting the cranium through their respective foramina, the three divisions of the
trigeminal nerve divide into a multitude of sensory branches. Each of the three divisions of
the trigeminal nerve isdescribed, but more attention is devoted to the maxillary and
mandibular divisions because of their greater importance in pain control in dentistry. 
Maxillary Division (V2)
The maxillary division of the trigeminal nerve arises from the middle of the trigeminal
ganglion. Intermediate in size between ophthalmic and mandibular divisions, it is purely
sensory in function.

Origin.
 The maxillary nerve passes horizontally forward, leaving the cranium through the foramen
rotundum. The foramen rotundum is located in the greater wing of the sphenoid bone. Once
outside the cranium, the maxillary nerve crosses the uppermost part of the pterygopalatine
fossa, between the pterygoid plates of the sphenoid bone and the palatine bone. As it crosses
the pterygopalatine fossa, it gives off branches to the sphenopalatine ganglion, the posterior
superior alveolar nerve, and the zygomatic branches. It then angles laterally in a groove on
the posterior surface of the maxilla, entering the orbit through the inferior orbital fissure.
Within the orbit, it occupies the infraorbital groove and becomes the infraorbital nerve,
which courses anteriorly into the infraorbital canal. The maxillary division emerges on the
anterior surface of the face through the infraorbital foramen, where it divides into its
terminal branches, supplying the skin of the face, nose, lower eyelid, and upper lip.
 The maxillary division gives off branches in four regions: within the cranium, in the
pterygopalatine fossa, in the infraorbital canal, and on the face.

1. Branch within the Cranium.

 Immediately after separating from the trigeminal ganglion, the maxillary division gives off
a small branch, the middle meningeal nerve, which travels with the middle meningeal artery
to provide sensory innervation to the dura mater.

2. Branches in the Pterygopalatine Fossa. 

After exiting the cranium through the foramen rotundum, the maxillary division crosses the
pterygopalatine fossa. In this fossa, several branches are given off : the zygomatic nerve, the
pterygopalatine nerves, and the posterior superior alveolar nerve.
The zygomatic nerve comes off the maxillary division in the pterygopalatine fossa and
travels anteriorly, entering the orbit through the inferior orbital fissure, where it divides into
the zygomatico temporal and zygomatico facial nerves: the zygomatico temporal supplying
sensory innervation to the skin on the side of the forehead, and the zygomatico facial
supplying the skin on the prominence of the cheek. Just before leaving the orbit, the
zygomatic nerve sends a branch that communicates with the lacrimal nerve of the ophthal-
mic division. This branch carries secretory fibers from the sphenopalatine ganglion to the
lacrimal gland. The pterygopalatine nerves are two short trunks that unite in the
pterygopalatine ganglion and are then redistributed into several branches. They also serve as
a communication between the pterygopalatine ganglion and the maxillary nerve (V2).
Postganglionic secretomotor fibers from the pterygopalatine ganglion pass through these
nerves and back along V2 to the zygomatic nerve, through which they are routed to the
lacrimal nerve and the lacrimal gland. Branches of the pterygopalatine nerves include those
that supply four areas: orbit, nose, palate, and pharynx.
1. The orbital branches supply the periosteum of the orbit.
2. The nasal branches supply the mucous membranes of the superior and middle conchae,
the lining of the posterior ethmoidal sinuses, and the posterior portion of the nasal septum.
One branch is significant in dentistry, the naso palatine nerve, which passes across the roof
of the nasal cavity downward and forward, where it lies between the mucous membrane and
the periosteum of the nasal septum. The nasopalatine nerve continues downward, reaching
the floor of the nasal cavity and giving branches to the anterior part of the nasal septum and
the floor of the nose. It then enters the incisive canal, through which it passes into the oral
cavity via the incisive foramen, located in the midline ofthe palate about 1 cm posterior to
the maxillary centralincisors. The right and left nasopalatine nerves emergetogether through
this foramen and provide sensation tothe palatal mucosa in the region of the
premaxilla(canines through central incisors) .
3. The palatine branches include the greater (or anterior)palatine nerve and the lesser
(middle and posterior)palatine nerves . The greater (or anterior)palatine nerve descends
through the pterygopalatine canal, emerging on the hard palate through the greater palatine
foramen (which is usually located about 1 cm toward the palatal midline, just distal to the
second molar). Sicher and DuBrul have stated that the greater palatine foramen may be
located 3 to 4 mm in front of the posterior border of the hard palate. The nerve courses
anteriorly between the mucoperiosteum and the osseous hard palate, supplying sensory
innervation to the palatal soft tissues and bone as far anterior as the first premolar, where it
communicates with terminal fibers of the nasopalatine nerve . It also provides sensory
innervation to some parts of the soft palate. The middle palatine nerve emerges from the
lesser palatine foramen, along with the posterior palatine nerve. The middle palatine nerve
provides sensory innervation to the mucous membrane of the soft palate; the tonsillar region
is innervated, in part ,by the posterior palatine nerve.
4.  The pharyngeal branch is a small nerve that leaves the posterior part of the
pterygopalatine ganglion, passes through the pharyngeal canal, and is distributed to the
mucous membrane of the nasal part of the pharynx, posterior to the auditory (eustachian)
tube.
The posterior superior alveolar (PSA) nerve descends from the main trunk of the maxillary
division in the pterygopalatine fossa just before the maxillary division enters the infraorbital
canal. Commonly there are two PSA branches, but on occasion a single trunk arises. Passing
downward through the pterygopalatine fossa, they reach the inferior temporal (posterior)
surface of the maxilla. When two trunks are present, one remains external to the bone,
continuing downward on the posterior surface of the maxilla to provide sensory innervation
to the buccal gingiva in the maxillary molar region and adjacent facial mucosal surfaces,
whereas the other branch enters into the maxilla (along with a branch of the internal
maxillary artery) through the PSA canal to travel down the posterior or posterolateral wall of
the maxillary sinus, providing sensory innervation to the mucous membrane of the sinus.
Continuing downward, this second branch of the PSA nerve provides sensory innervation to
the alveoli, periodontal ligaments, and pulpal tissues of the maxillary third, second, and first
molars (with the exception [in 28% of patients] of the mesiobuccal root of the first molar).
3. Branches in the Infraorbital Canal.
 Within the infraorbital canal, the maxillary division (V2) gives off two branches of
significance in dentistry: the middle superior and anterior superior alveolar nerves. While in
the infraorbital groove and canal, the maxillary division is known as the infraorbital nerve.
The middle superior alveolar (MSA) nerve branches off the main nerve trunk (V2) within
the infraorbital canal to form a part of the superior dental plexus, composed of the posterior,
middle, and anterior superior alveolar nerves. The site of origin of the MSA nerve varies,
from the posterior portion of the infraorbital canal to the anterior portion, near the
infraorbital foramen. The MSA nerve provides sensory innervation to the two maxillary
premolars and, perhaps, to the mesiobuccal root of the first molar and periodontal tissues,
buccal soft tissue, and bone in the premolar region. Traditionally it has been stated that the
MSA nerve is absent in 30%2 to 54%3 of individuals. Loetscher and Walton found the
MSA nerve to be present in 72% of the specimens examined. In its absence, its usual
innervations are provided by either the PSA or the anterior superior alveolar (ASA) nerve,
most frequently the latter. The anterior superior alveolar (ASA) nerve, a relatively large
branch, is given off the infraorbital nerve (V2) approximately 6 to 10 mm before the latter
exits from the infraorbital foramen. Descending within the anterior wall of the maxillary
sinus, it provides pulpal innervation to the central and lateral incisors and the canine, and
sensory innervations to the periodontal tissues, buccal bone, and mucous membranes of
these teeth. The ASA nerve communicates with the MSA nerve and gives off a small nasal
branch that innervates the anterior part of the nasal cavity, along with branches of the
pterygopalatine nerves. In persons without an MSA nerve, the ASA nerve frequently
provides sensory innervation to the premolars and occasionally to the mesiobuccal root of
the first molar. The actual innervation of individual roots of all teeth, bone, and periodontal
structures in both the maxilla and the mandible derives from terminal branches of larger
nerves in the region. These nerve networks are termed the dental plexus.
The superior dental plexus is composed of smaller nerve fibers from the three superior
alveolar nerves (and in the mandible, from the inferior alveolar nerve). Three types of nerves
emerge from these plexuses: dental nerves, interdental branches, and interradicular
branches. Each is accompanied along its pathway by a corresponding artery. The dental
nerves are those that enter a tooth through the apical foramen, dividing into many small
branches within the pulp. Pulpal innervation of all teeth is derived from dental nerves.
Although in most instances one easily identifiable nerve is responsible, in some cases
(usually the maxillary first molar) more than one nerve is responsible. The interdental
branches (also termed perforating branches) travel through the entire height of the
interradicular septum, providing sensory innervation to the periodontal ligaments of adjacent
teeth through the alveolar bone. They emerge at the height of the crest of the inter alveolar
septum and enter the gingiva to innervate the interdental papillae and the buccal gingiva.
The interradicular branches traverse the entire height of the interradicular or interalveolar
septum, providing sensory innervation to the periodontal ligaments of adjacent roots.They
terminate in the periodontal ligament (PDL) at the root furcations.
4. Branches on the Face. 
The infraorbital nerve emerges through the infraorbital foramen onto the face to divide into
its terminal branches: inferior palpebral, external nasal, and superior labial. The inferior
palpebral branches supply the skin of the lower eyelid with sensory innervation, the external
nasal branches provide sensory innervation to the skin on the lateral aspect of the nose, and
the superior labial branches provide sensory innervation to the skin and mucous membranes
of the upper lip. Although anesthesia of these nerves is not necessary for adequate pain
control during dental treatment, they are frequently blocked in the process of carrying out
other anesthetic procedures.

MANDIBULAR DIVISION (V3)

 The mandibular division is the largest branch of the trigeminal nerve. It is a mixed nerve
with two roots: a large sensory root and a smaller motor root (the latter representing the
entire motor component of the trigeminal nerve). The sensory root of the mandibular
division originates at the inferior angle of the trigeminal ganglion, whereas the motor root
arises in motor cells located in the pons and medulla oblongata. The two roots emerge from
the cranium separately through the foramen ovale, the motor root lying medial to the
sensory. They unite just outside the skull and form the main trunk of the third division. This
trunk remains undivided for only 2 to 3 mm before it splits into a small anterior and a large
posterior division .The areas innervated by V3 are included in the following outline:
1. Sensory root
a. Skin
Temporal region
Auricula
External auditory meatus
Cheek
Lower lip
Lower part of the face (chin region)
b. Mucous membrane
Cheek
Tongue (anterior two thirds)
Mastoid cells
c. Mandibular teeth and periodontal tissues
d. Bone of the mandible
e. Temporomandibular joint
f. Parotid gland
2. Motor root
a. Masticatory muscles
Masseter
Temporalis
Pterygoideus medialis
Pterygoideus lateralis
b. Mylohyoid
c. Anterior belly of the digastrics
d. Tensor tympani
e. Tensor veli palatini
Branches.
 The third division of the trigeminal nerve gives off branches in three areas: from the
undivided nerve,and from the anterior and posterior divisions.
Branches from the Undivided Nerve. 
On leaving the foramen ovale, the main undivided nerve trunk gives off two branches during
its 2- to 3-mm course. These are the nervus spinosus (meningeal branch of the mandibular
nerve) and the medial pterygoid nerve. The nervus spinosus reenters the cranium through the
foramen spinosum along with the middle meningeal artery to supply the dura mater and
mastoid air cells. The medial pterygoid nerve is a motor nerve to the medial (internal)
pterygoid muscle. It gives off small branches that are motor to the tensor veli palatini and
the tensor tympani.
Branches from the Anterior Division. 
Branches from the anterior division of V3 provide motor innervation to the muscles of
mastication and sensory innervation to the mucous membrane of the cheek and the buccal
mucous membrane of the mandibular molars. The anterior division is significantly smaller
than the posterior. It runs forward under the lateral (external) pterygoid muscle for a short
distance and then reaches the external surface of that muscle by passing between its two
heads or, less frequently, by winding over its upper border. From this point, it is known as
the buccal nerve. Although under the lateral pterygoid muscle, the buccal nerve gives off
several branches: the deep temporal nerves (to the temporal muscle)and the masseter and
lateral pterygoid nerves (providing motor innervation to the respective muscles).The buccal
nerve, also known as the buccinator nerve and the long buccal nerve, usually passes between
the two heads of the lateral pterygoid to reach the external surface of that muscle. It then
follows the inferior part of the temporal muscle and emerges under the anterior border of the
masseter muscle, continuing in an anterolateral direction. At the level of the occlusal plane
of the mandibular third or second molar, it crosses in front of the anterior border of the
ramus and enters the cheek through the buccinator muscle. Sensory fibers are distributed to
the skin of the cheek. Other fibers pass into the retromolar triangle, providing sensory
innervation to the buccal gingiva of the mandibular molars and the mucobuccal fold in that
region. The buccal nerve does not iinnervate the buccinator muscle; the facial nerve does.
Nor does it provide sensory innervation to the lower lip or the corner of the mouth. This is
significant because some doctors do not administer the “long” buccal injection immediately
after completing the inferior alveolar nerve block until the patient’s lower lip has become
numb. Their thinking is that the buccal nerve block will provide anesthesia to the lower lip
and therefore might lead them to believe that their inferior alveolar nerve block has been
successful, when in fact it has been missed. Such concern is unwarranted. The buccal nerve
block may be administered immediately after completion of the inferior alveolar nerve
block.
Anesthesia of the buccal nerve is important for dental procedures requiring soft tissue
manipulation on the buccal surface of the mandibular molars.
Branches of the Posterior Division. 
The posterior division of V3 is primarily sensory with a small motor compo-nent. It
descends for a short distance downward and medial to the lateral pterygoid muscle, at which
point it branches into the auriculotemporal, lingual, and inferior alveolar nerves. The
auriculotemporal nerve is not profoundly significant in dentistry. It traverses the upper part
of the parotid gland and then crosses the posterior portion of the zygomatic arch. It gives off
a number of branches, all of which are sensory. These include a communication with the
facial nerve, pro-viding sensory fibers to the skin over areas of innervation of the following
motor branches of the facial nerve: zygomatic, buccal, and mandibular; a communication
with the otic ganglion, providing sensory, secretary, and vasomotor fibers to the parotid
gland; the anterior auricular branches, supplying the skin over the helix and tragus of the
ear; branches to the external auditory meatus, innervating the skin over the meatus and the
tympanic membrane; articular branches to the posterior portion of the temporomandibular
joint; and superficial temporal branches, supplying the skin over the temporal region. The
lingual nerve is the second branch of the posterior division of V3. It passes downward
medial to the lateral pterygoid muscle and, as it descends, lies between the ramus and the
medial pterygoid muscle in the pterygomandibular space. It runs anterior and medial to the
inferior alveolar nerve, whose path it parallels. It then continues downward and forward,
deep to the pterygomandibular raphe and below the attachment of the superior constrictor of
the pharynx, to reach the side of the base of the tongue slightly below and behind the
mandibular third molar. Here it lies just below the mucous membrane in the lateral lingual
sulcus, where it is so superficial in some persons that it may be seen just below the mucous
membrane. It then proceeds anteriorly across the muscles of the tongue, looping downward
and medial to the submandibular (Wharton’s) duct to the deep surface of the sublingual
gland, where it breaks up into its terminal branches. The lingual nerve is the sensory tract to
the anterior two thirds of the tongue. It provides both general sensation and gustation (taste)
for this region. It is the nerve that supplies fibers for general sensation, whereas the chorda
tympani (a branch of the facial nerve) supplies fibers for taste. In addition, the lingual nerve
provides sensory innervation to the mucous membranes of the floor of the mouth and the
gingiva on the lingual of the mandible. The lingual nerve is the nerve most commonly
associated with cases of paresthesia (prolonged or permanent sensory nerve damage).The
inferior alveolar nerve is the largest branch of the mandibular division. It descends medial to
the lateral pterygoid muscle and lateroposterior to the lingua nerve, to the region between
the sphenomandibular ligament and the medial surface of the mandibular ramus, where it
enters the mandibular canal at the level of the mandibular foramen. Throughout its path, it is
accompanied by the inferior alveolar artery (a branch of the internal maxillary artery) and
the inferior alveolar vein. The artery lies just anterior to the nerve. The nerve, artery, and
vein travel anteriorly in the mandibular canal as far forward as the mental foramen, where
the nerve divides into its terminal branches: the incisive nerve and the mental nerve. The
mylohyoid nerve branches from the inferior alveolar nerve before entry of the latter into the
mandibular canal. It runs downward and forward in the mylohyoid groove on the medial
surface of the ramus and along the body of the mandible to reach the mylohyoid muscle.
The mylohyoid is a mixed nerve, being motor to the mylohyoid muscle and the anterior
belly of the digastric. It is thought to contain sensory fibers that supply the skin on the
inferior and anterior surfaces of the mental protuberance. It also may provide sensory
innervation to the mandibular incisors. Evidence suggests that the mylohyoid nerve also
may be involved in supplying pulpal innervation to portions of the mandibular molars in
some persons, usually the mesial root of the mandibular first molar. Once the inferior
alveolar nerve enters the mandibular canal, it travels anteriorly along with the inferior
alveolar artery and vein. The dental plexus serves the mandibular posterior teeth, entering
through their apices and providing pulpal innervation. Other fibers supply sensory
innervations to the buccal periodontal tissues of these same teeth. The inferior alveolar nerve
divides into its two terminal branches: the incisive nerve and the mental nerve at the mental
foramen. The incisive nerve remains within the mandibular canal and forms a nerve
plexus that innervates the pulpal tissues of the mandibular first premolar, canine, and
incisors via the dental branches. The mental nerve exits the canal through the mental
foramen and divides into three branches that innervate the skin of the chin and the skin and
mucous membrane of the lower lip
------------------------------0 --------------------------------------------------------

Attach 5 radiographs and write the positive findings of the same

WIRING TECHNIQUES

1. Figure of eight wiring

Simple wiring technique used to temporarily splint the luxated teeth. It is not used for
intermaxillary fixation. It has got the inherent drawback that it does not offer three
dimensional stability
2. Essig’s wiring
This wiring technique is also used in the management of dentoalveolar fractures and for
splinting the luxated teeth. This is a better technique than figure of eight wiring as it gives
better stability.
In this technique, a piece of 24 gauze stainless steel wire is taken and passed through the
distal embrasure between the adjacent healthy teeth to the site of dentoalveolar fracture i.e;
if the incisors are traumatized than the stay wire is passed through the embrasure between
the healthy canine and the first premolar tooth. The wire is passed from buccal side and is
drawn from the lingual side. The lingual end is passed through the embrasure between the
distal embrasures of the sound adjacent tooth present on the other side of the traumatized
segment from the lingual to the buccal side and then both the sides are tightened by twisting
over each other using a wire twister. The wires are always tightened by twisting in a
clockwise direction and loosened by twisting in anticlockwise direction. The wire ends are
not tightened fully. This wire is called a stay wire. Then pieces of (4’’ inch long) 26 gauze
tie wire are taken, which are passed through the embrasure, between the traumatized teeth
from the labial to the lingual side, first superior to the labial and lingual stay wire and then
drawn lingual to the labial side through the same same embrasure, but inferior to the stay
wires, thus the stay wires are encircled by the tie wires. The tie wire ends are now tightened
by twisting fully. The twisting adapts the labial and lingual stay wires to the contour of the
traumatized teeth. This procedure is repeated in all the adjacent embrasures in the
traumatized segment, thus the stay wires get nicely adapted to all the teeth. Finally, the
incompletely tightened ends of the stay wire are tightened fully, to complete the wiring. The
cut ends of the wires are bent away from the soft tissues so that they do not irritate the soft
tissues.

3. Risdon’s wiring a long piece of 24 gauge stay wire is taken and passed through the
embrasure between the last two standing teeth in the arch and from the buccal to the
 lingual side. The lingual end is now taken circumferentially around the last tooth in
the arch and both the ends are firmly twisted over each other. The same exercise is
repeated on the other side also and the twister wires from both the sides are now
twisted together in the midline. The twisted stay wire is legated to all the teeth in the
arch using separate pieces of number 26 wires like it is done for legating the arch
bar. The risdon’s wiring can be used for splinting the dentoalveolar fractures and for
intermaxillary fixation by passing the intermaxillary wires inferior to the stay wires
placed in both the arches.
4. Ivy loop wiring. It is most commonly practiced wiring technique. The ivy loops are
prepared from 24 to 26ss wire, depending upon the size of the interdental embrasure.
To prepare a ivy loop a 4’’ piece of temporized wire is taken and the loops are
prepared. The free ends of the loop should be of equal size.
5. Continuous ivy loop wiring. The ivy loops are similar to that of the interrupted ivy
loop wiring, only difference being that they are prepared in the oral cavity, while
doing the wiring. Like in the case of the continuous wiring one long 26 number wire
is passed through the interdental embrasure in the arch, from buccal to the lingual
side. The buccal sided wire stays as a stay wire. The lingual wire is drawn through
the adjacent embrasure above the buccal stay wire and then passed again to the
lingual side thorough the same embrasure below th stay wire, keeping the mirror top
handle or a probe in between. The handle is now rotated to twist the wire and an ivy
loop is prepared. The mirror/top probe is removed. The same exercise is repeated in
all the adjacent embrasures to prepare multiple ivy loops. The disadvantage of this
technique is that if the wire breaks at one point the whole wiring becomes loose.
6. Gilmour’s wiring. It is also called single tooth wiring. It is very useful when
adjacent tooth is missing and the ivy loop wiring is not possible. In this technique, a
26’’ inch stainless steel wire is taken and passed around a tooth circumferentially
mesiodiatally and the two ends are twisted till it gets tightly adapted to the tooth near
its cervical line, below the height of the contour. The wires are ligated to all the teeth
in both the arches and then maxillary wires are tightened with the mandibular wires
to achieve intermaxillary fixation.
7. ARCH BARS. The arch bars are more effective means of intermaxillary
fixation.The wires tend to get loose over a period of time, while arch bars provide a
more stable fixation. The arch bars are two basic types:
 Rigid arch bars
They are not commonly used. These arch bars are adapted to the patient’s casts in the
laboratory and then transferred to the patient’s mouth for ligation to the dental arch.

Soft flexible arch bars

They are commonly used. These arch bars can be adapted and contoured to the
dental arch directly due to their flexibility, e.g Erich’s arch bar.
Advantages of arch bars
 Patients who are partially edentulous or have uneven teeth in the upper and
the lower arches, where wiring is difficult to be done
 They can be done in the presence of teeth having diastema or unfavourable
forms
 Periodontally compromised or loose teeth
 These arch bars have brackets that can be very useful for applying
intermaxillary elastics
 The arch bars while providing assistance in intermaxillary fixation
simultaneously helps in reducing and splinting the associated dentoalveolar
injury.

8. SPLINTS
The splints are effective modality for treating the mandibular fractures in edentulous
patients and paediatric patients with deciduous or mixed dentition
CAP SPLINTS IN PAEDIATRIC PATIENTS
The splint is fabricated by making an impression of the fractured jaw and preparation
of the cast. The cast of the upper jaw is also made. The cast of the lowere arch is
split across the fracture line, where the step is present,. The split halves of the lower
cast are articulated with the upper cast in preexisting occlusal relashionship, thus the
fracture gets reduced in vitro. Now the base is poured so that the cast is obtained in
reduced position. The acrylic cap splint is fabricated on this cast, which is finished
and sterilized by chemical sterilization. The patient is operated under general
anesthesia, the splint is adapted to the lower jaw thus, the fracture gets automatically
reduced as the splint is fabricated in reduced position and guides the fractured
segments in same position as established in the laboratory. The splint is secured to
 the mandible with the help of circummandibular wiring, using a bone awl or long
hypodermic needle

GUNNING’S SPLINTS IN EDENTULOUS PATIENTS

This splint is used for for treating edentulous jaw fractures. If the patient is complete
denture wearer same denture can be used as was fabricated when the jaw was intact. If the
patient is not denture wearer, an impression of the upper and lower fractured jaws are made.
The lower cast is split at the fracture site along the step in the ridge. The step is abolished by
approximating the two halves in reduced position arbitrarily. The shellac bases are prepared
as in complete denture, wax rims are also prepared as for jaw relation (JR). The JR is
recorded and the upper and the lower rims are sealed. The rims are made discontinuous by
removing the block of wax intermittently keeping three blocks of wax i.e. two in the
posterior areas and one anteriorly. The gaps in the rims are useful for feeding the patients.
Wire loops or segments of arch bars are incorporated in the splints in each block of wax.
The splint is acrylised, finished and sterilized by chemical sterilization. The lower splint is
secured to the mandible with ciercummandibular wiring and the upper one is fixed to the
maxilla by peralveolar wiring. The IMF is done with the help of wires passing through the
loops of the wire incorporated in the upper and the lower splints during the fabrication.
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