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Today we will complete the last lecture topic complication of exodontia.

We said how to deliver a tooth out from its socket after we finish the extraction ? we need suction , for laxation we can use an elevator , for the delivery of the tooth we always use a forceps and for that you should have a proper grip either with a forceps or with other instrument which can grip the tooth well like fricklings instrument not sure a!out the spelling" ". ( the most important thing that we cant use elevators for eliver! " #ow , if you extracted a tooth and there are a remnant from the !one or the tooth , you should do a proper irrigation not $ust in this case , we alwa!s do irrigation after tooth extraction !c% it decreases the rate of retention of fragment , increases the rate of healing , reduces the pain after extraction, and irrigation &with like normal saline- can flush any fragments out " . so to remove fragments you can use irrigation , you can use the crier elevator triangular tip elevator used to remove remaining root " , ape#o elevator , en o files we can insert it in the socket if the remaining root is minimal to engage either the root itself or try to $ust dig it !etween the root fragments and try to move it out . now the other option is leaving the fragment . sometimes if leaving the fragment is !etter then take it out we will favour it .now there are an re$uirements for that ' - when the risk & !enefit ratio favours leaving the fragment - when ( will cause more destruction !y getting the fragment out

- when ( will traumati%e vital structure , for example the tooth is near mental nerve so when ( remove !one to remove the fragments ( can traumati%e the mental nerve ,or while ()m searching on the root ( can displace it somewhere that is more difficult to take it out from , or it can lead to some serious pro!lems like push the root !etween the maxillary sinus -for example- and that cause chronic sinusitis . - the remaining root should !e less than one third of the original root . so if it is more than the half of the root &for example- we cant leave it in the situ . - the remaining root shouldn)t !e infected . * epri ement % we knew that when can we remove the fragment and when leave it , now epri ement is one of the !enefits of flushing during irrigation , you will take any loose !one out . they inserted this flushing - depridement techni+ue in the handpiece instrument !y normal saline to take any sort of depree out . we can -as will- depride the sharp specules not !y flushing , !ut !y a file or !y a large roun &ur to remove any sort of !one that you think it will hold you from doing a proper prosthetic management , for example you need to make a complete denture for a patient and to do you should extract a tooth, and after that you saw a deep undercut in the socket so we should depride this undercut to make sure that the prosthetic treatment will !e fine . ' suturing % -fter we made a flap and extract the tooth , the flap shoul return to its normal place and this is the aim of suturing . so

the suturing isn)t covering every thing !y the flap , its $ust covering the area that was covered !efore , $ust put the soft tissue over !one . you shouldn)t make any sort of retention on the edges of the soft tissue !c% this can cause necrosis in that area , so $ust position the soft tissue in its place . .ometimes we use suturing to hold the clot , when ?? mainly when we extract an upper six and we suspect that there is an oroantral communication !etween the sinus and the oral cavity - we can do suturing over the socket and the aim of this suturing mainly is to make sure there is a clot can !e sta!ili%ed under the suture and this clot can close that sort of communication . (uture t!pes , There are a lot of classifications and the !etter is ' resor&a&le an nonresor&a&le ) *esor&a&le+ the !ody can take that suture out eat it " !y en%ymes or whatever , the main idea that it should !e eaten !y the !ody itself !y any reaction like inflammatory reaction that happened !ecause of the suture itself " . #ow the types of resor!a!le sutures are ' - gut (,-./( sutures ' it)s a natural and resor!a!le sutures . we can take it from sheep and cat . the cat gut is de!ata!le and some people said its mainly from a sheep or goat" - 0ol!galactic an pol!galactin 'its resor!a!le !ut not natural synthetic ", its stronger and last for a longer time . The pro!lem of the naturall! resor&a&le gut" that it can !e easily get resor!ed . now they treat this naturally resor!a!le !y

some sort of materials to make these sutures more dura!le stay for longer time " like instead of staying for / days , it will stay for a week . The synthetic resor!a!le 0olygalactic and polygalactin its more common name is vicr!l"" is stronger and stay longer , and now it)s the main source of suture used for oral surgery ,why ? !c% ' - strong and stay 1 or 2 weeks - you don)t need give a patient appointment for review . now if it nonresor!a!le the patient will come !ack to remove it after some time, !ut in our case its resor!a!le so we can $ust dismissed the patient. .ome old people said that the rate of infection is higher in resor!a!le !c% we will leave the suture in its place and this can accumulate !acteria and other infectant , !ut now new studies said there is slight difference !etween resor!a!le and nonresor!a!le in hygienic . so the nonresor!a!le is more hygienic !ut the patient will need a review appointment . #ow when we look to this pic !elow we should !e a!le to know ' - the name of the suture arrow " - the length of the thread 34 , 54 ," arrow " - the curvature of the needle ,it will detect the ark of the needle and its part of a circle /67 circle , 162 circle ," arrow " - the tip of the needle , it might !e round or cutting or reverse cutting . the &est for oral surger! is reverse cutting ,!c% the cutting edge of it is straight and will not tear the flap arrow "

.ome company will write if the suture is monofilament or multifilament . 1onresor&a&le + - sil2 + its used in the oral cavity and we said its more hygienic than resor!a!le . - n!lon + its multifilament it has 2 types multi and mono filament" like threads that are tightened together . multifilament is always less esthetic than monofilament , so on the skin we use monofilament not to cause !ig scar at the area of suturing . - pol!ester an pol!prop!lene + monofilament so we can use them extraorally . * techni$ue of suturing % we need to use '

- nee le hol er ' should !e held !y putting the thump in one eye of the holder and the ring the finger next to the middle " on the other eye pic !elow "

#ow we catch the last 26/ or 16/" of the needle !y the tip of the needle holder , and if you catch the middle of the needle its not wrong !ut we prefer the last thirds . the needle should !e 89 degree with the needle holder then you leave one edge of the flap and go to the other we should start from the mo!ile part of the flap not the nonmo!ile " and the needle should go in the flap vertically and go out vertically !y the twee%er , and then you will do the knot :;< . !ut how much knots should ( do ?? =very suture material have a special num!er of knots and we should make sure that each knot is sta!le . for e#ample the n!lon nee 3 2nots % vicr!l nee 4 2nots ) * suturing t!pes + 1- interrupte suture (universal the most common t!pe in oral surger! " + you should know how to do it once you graduated , every suture knot is alone .

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

now the good thing in continuous suture that its stronger than interrupted suture !ut if one part is torn all the flap will open , not like in interrupted $ust that torn area of the flap will open . /- continuous loc2ing ' the aim of this suture is to make sure its water dried , that)s mean it close the flap in away that inhi!it water to go in it . this description is not real !c% it cant inhi!it water from going in !ut this description tell us how much this suture is tight ".

3-

hori5ontal mattress + there are 2 lines on each side of the flap and tightened in one side . they are hori%ontal on the flap . This suture will give good closure of small flaps .
http'66www.youtu!e.com6watch?v>.vcau43.vyg"

4-

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

''' the octor sai + these part of the lecture is never learne theoreticall! % !ou shoul google it )

#ow after all of this steps we reached post operative care , and this steps is vital as extraction . after you dismissed the patient home you should know what is going on ,for example we tell the patient today there will !e some sort of pain , swelling, and all of this not to surprise the patient then you will loose his6her trust in you . now if there will !e pain you need to give analgesics or pain killer , if there will !e infection give anti!iotics . swelling the patient should tolerate it . and this is a list of some complications that might !e happened ' ecchimoses : its mean !lood accumulation large hematoma " , it could !e in the site of extraction or could !e outside . petechiae : small hematoma like points . swelling : its something normal and you cant inhi!it swelling after extraction ,!ut you can reduce it !y '

- in the extraction day first day" tell the patient to put some col compressors DEFG HFI JKDFLM , !c% this will decrease the !lood that come to the area of extraction so decrease edema - in the second day tell the patient to put hot compressors !c% its already now theres edema and we want to remove it !y vasodilatation - we can give anti-inflammatory !efore the procedure to reduce the patients reaction toward this swelling . this antiinflammatory is cortisol steroids like dexamethasone " trismus : it)s a reduction of mouth opening . the reason of it mainly is the muscle get spasmatic . after extraction there might !e some !lood that reached the muscle around the face and that cause an inflammation in them so they wont work properly and that cause trismus . not $ust the !lood cause that , any manipulation of the muscles cause trismus . ' patients foo ' (n the first day we till the patient to drink soaps should !e not too hot" and don)t eat solid food . (n the days after the patient can eat any thing that he6she want and focus on high calories food to recover very soon . ' oral h!giene ' We need to make sure that the extraction area is kept clean as possi!le . also we need to make sure that pain is controlled and the patient pain free as possi!le . we need to prevent infection !y giving anti!iotics &ut not to all patients $ust to those who are immune compromised even it was simple extraction .

-lways we give a patient a recall after any dental procedure to make sure that every thing is fine . 1ow how can we use an elevator 66 The elevator)s !lade should !e wedged !etween the tooth and the !one that support the same tooth , never ever think to rely on the ad$acent tooth !c% you could laxate it . 7he elevators t!pes +
89 :9 <9 49 coplan elevator ;r!er elevator =pe#o elevator >arwic2 elevator

?ultiple e#traction +
=s we 2now we shoul start &! ma#illar! teeth %wh! 6 &c5 the e#traction of most of the upper is &! &ucco9paltal movement % the lower &! some sort of vertical movement so !ou can hit the upper if the! were not e#tracte ) the secon reason to prevent an! &loo or whatever from going own into the lower soc2et ) 7he octor prefer to start &! the man i&le % wh!6 @c5 when we e#tract the lower teeth first% the &loo will go own an the area will &e clear ) Aor sure we start e#traction from posterior to anterior teeth e#cept first molar an canine % so the e#traction se$uence is li2e this + (from left to right" B C D 3 4 : < 8 >h! is that 66 &c5 3 has &ig roots so when we e#tract the surroun ing teeth we will have more space an &etter manipulation % an < has the longest root so we can manipulate it easil! )

EF G ' (orr! for an! mista2e % H trie m! &est to ma2e the lecture simple as possi&le )

Ione &! + Jah!a al Kmar!