Anatomical and physiological features of the development and structure of tissues and organs maxillofacial area (SCHLD) in children. Local and general.

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

Anaesthesia is the loss of consciousness and all form of sensation. Anaesthesia is the loss of consciousness and all form of sensation. Local Anaesthesia is the local loss of pain, temperature, touch, pressure and all other sensation. Local Anaesthesia is the local loss of pain, temperature, touch, pressure and all other sensation. In dentistry, Only loss of pain sensation is desirable. Local Analgesia. In dentistry, Only loss of pain sensation is desirable. Local Analgesia.

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

Methods: Methods: Reducing temperature. Reducing temperature. Is used only to produce surface anaesthesia e.g. ethyl chloride spray. Is used only to produce surface anaesthesia e.g. ethyl chloride spray. Physical damage to nerve trunk e.g. nerve sectioning. Physical damage to nerve trunk e.g. nerve sectioning. Unsafe for therapeutic uses, only in Trigeminal Neuralgia. Unsafe for therapeutic uses, only in Trigeminal Neuralgia. Chemical damage to nerve trunk e.g. neurolytic agents. Chemical damage to nerve trunk e.g. neurolytic agents. Silver nitrate, Phenol - Unsafe for therapeutic use. Silver nitrate, Phenol - Unsafe for therapeutic use.

Methods: Cont Methods: Cont Anoxia or hypoxia resulting in lack of oxygen to nerve. Anoxia or hypoxia resulting in lack of oxygen to nerve. Unsafe as well. Unsafe as well. Stimulation of large nerve fibres, blocking the perception of smaller diameter fibres. Stimulation of large nerve fibres, blocking the perception of smaller diameter fibres. includes Acupuncture and TENS (Transcutaneous Electronic Nerve Stimulation) includes Acupuncture and TENS (Transcutaneous Electronic Nerve Stimulation) Drugs that block transmission at sensory nerve endings or along nerve fibres. Drugs that block transmission at sensory nerve endings or along nerve fibres. There action is fully reversible and without permanent damage to the tissues. There action is fully reversible and without permanent damage to the tissues.

Properties of Ideal local Anaesthetic: Properties of Ideal local Anaesthetic: Possess a specific and reversible action. Possess a specific and reversible action. They stabilize all excitable membrane including motor neurones They stabilize all excitable membrane including motor neurones CNS is extremely sensitive to its action. CNS is extremely sensitive to its action. Non-irritant with no permanent damage to tissues. Non-irritant with no permanent damage to tissues. No Systemic toxicity No Systemic toxicity High therapeutic ratio. High therapeutic ratio. Rapid onset and long duration Rapid onset and long duration Active Topically or by injection Active Topically or by injection

Chemistry: Chemistry: They are weak bases, insoluble in water They are weak bases, insoluble in water converted into soluble salts by adding Hcl for clinical use. converted into soluble salts by adding Hcl for clinical use. They are composed of three parts : They are composed of three parts : Aromatic (lipophilic) residue with acidic group R 1. Aromatic (lipophilic) residue with acidic group R 1. Intermediate aliphatic chain, which is either ester or amide link R 2. Intermediate aliphatic chain, which is either ester or amide link R 2. Terminal amino (hydrophilic) group R 3 and R 4. Terminal amino (hydrophilic) group R 3 and R 4. R 3 R 3 R 1 CO R 2 N R 4 R 4

Classified according to their chemical structures and the determining factor is the intermediate chain, into two groups: Classified according to their chemical structures and the determining factor is the intermediate chain, into two groups: Ester Amide Ester Amide They differ in two important respect: They differ in two important respect: Their ability to induce hypersensitivity reaction. Their ability to induce hypersensitivity reaction. Their pharmacokinetics - fate and metabolism. Their pharmacokinetics - fate and metabolism.

These are very important for local anaesthetic activity. These are very important for local anaesthetic activity. Ionization: Ionization: They are weak base and exist partly in an unionized and partly in an ionized form. They are weak base and exist partly in an unionized and partly in an ionized form. The proportion depend on: The proportion depend on: the pK a or dissociation constant the pK a or dissociation constant The pH of the surrounding medium. The pH of the surrounding medium. Both ionizing and unionizing are important in producing local anaesthesia. Both ionizing and unionizing are important in producing local anaesthesia.

pK a is the pH at which the ionized and unionized form of an agent are present in equal amounts. pK a is the pH at which the ionized and unionized form of an agent are present in equal amounts. The lower the pK a, the more the unionized form, the greater the lipid solubility. The lower the pK a, the more the unionized form, the greater the lipid solubility. The higher the pK a, the more the ionized form and the slower the lipid solubility The higher the pK a, the more the ionized form and the slower the lipid solubility

Cont: Cont: Unionized form is able to cross the bi- lipid nerve membrane. Unionized form is able to cross the bi- lipid nerve membrane. The ionized form then blocks conduction. The ionized form then blocks conduction. Some of the unionized inside the cell will become ionized depending upon the pK a and the intracellular pH (lower than extracellular) Some of the unionized inside the cell will become ionized depending upon the pK a and the intracellular pH (lower than extracellular)

Cont: Cont: In general the amide type have lower pK a, and greater proportion of the drug is present in the lipid-soluble (unionized) form at the physiological pH In general the amide type have lower pK a, and greater proportion of the drug is present in the lipid-soluble (unionized) form at the physiological pH This produces faster onset of action. This produces faster onset of action. Lignocaine 1 – 2 minutes Lignocaine 1 – 2 minutes Procaine 2 – 5 minutes. Procaine 2 – 5 minutes. The lower the pK a the faster the onset. The lower the pK a the faster the onset.

Partition coefficient: Partition coefficient: This measures the relative solubility of an agent in fat and water. This measures the relative solubility of an agent in fat and water. High numerical value means: High numerical value means: High lipid-soluble High lipid-soluble less water-soluble. less water-soluble. More fat solubility, means rapid crossing of the lipid barrier of the nerve sheath. More fat solubility, means rapid crossing of the lipid barrier of the nerve sheath. The greater partition coefficient, The faster the onset The greater partition coefficient, The faster the onset

Protein binding: Protein binding: Local anaesthetic agents bind with: Local anaesthetic agents bind with: α 1 -acid glycoprotein, which possess high affinity but low capacity. α 1 -acid glycoprotein, which possess high affinity but low capacity. Albumin, with low affinity but high capacity Albumin, with low affinity but high capacity The binding is simple, reversible and tend to increase in proportion to the side chain. The binding is simple, reversible and tend to increase in proportion to the side chain. Lignocaine is 64% bound, Bupivacaine is 96% Lignocaine is 64% bound, Bupivacaine is 96% The duration of action is related to the degree of binding. The duration of action is related to the degree of binding. Lignocaine 15 – 45 minutes, Bupivacaine 6 hours Lignocaine 15 – 45 minutes, Bupivacaine 6 hours

Vasodilatory ability: Vasodilatory ability: Most Local anaesthetics possess a vasodilatory action on blood vessels except Cocaine. Most Local anaesthetics possess a vasodilatory action on blood vessels except Cocaine. It influence the duration of action of the agent. It influence the duration of action of the agent. Prilocaine is 50% bound to proteins but has a longer duration than Lignocaine (64%) since it possess no strong vasodilatory effect. Prilocaine is 50% bound to proteins but has a longer duration than Lignocaine (64%) since it possess no strong vasodilatory effect. Affect the duration of action of the agent Affect the duration of action of the agent

Summary Summary Rapid Onset: Rapid Onset: Low pK a value– more unionized – Amides Low pK a value– more unionized – Amides Higher Partition coefficient – more lipid soluble Higher Partition coefficient – more lipid soluble Long duration of action: Long duration of action: High protein binding. High protein binding. Low vasodilating property. Low vasodilating property.

Agent pK a %base pH 7.4 P-CP-B t 0.5 (m) Max dose mg/kg Lignocaine7.925364904.4 Prilocaine7.925150906.0 Mepivacaine7.6331771204.4 Bupivacaine8.11728961601.3 Etidocaine7.925141941608.0 Procaine9.020.6666.0

Reversible block of conduction in nerve. Reversible block of conduction in nerve. Direct relaxation of smooth muscle & inhibition of neuro-muscular transmission in skeletal muscle producing vasodilatation. Direct relaxation of smooth muscle & inhibition of neuro-muscular transmission in skeletal muscle producing vasodilatation. Intra-arterial procaine reverse arteriospasm during I.V. Sedation Intra-arterial procaine reverse arteriospasm during I.V. Sedation Class I antidysrhythmic-like action on the heart. Class I antidysrhythmic-like action on the heart. Stimulation and/or depression of the CNS. Stimulation and/or depression of the CNS.

The site of action is the nerve cell membrane The site of action is the nerve cell membrane Theories : Theories : The membrane expansion theory. The membrane expansion theory. The specific binding theory. The specific binding theory.

Membrane expansion theory: Membrane expansion theory: A non-specific mechanism similar to the action of general anaesthetic agents. A non-specific mechanism similar to the action of general anaesthetic agents. Relies upon the lipophilic moiety of local anaesthetic agent. Relies upon the lipophilic moiety of local anaesthetic agent. The molecules of the agent are incorporated into the lipid cell membrane. The molecules of the agent are incorporated into the lipid cell membrane. The resultant swelling produces physical obstruction of the sodium channels, preventing nerve depolarization. The resultant swelling produces physical obstruction of the sodium channels, preventing nerve depolarization.

Specific receptor theory: Specific receptor theory: Local anaesthetic drug binds to specific receptor within the sodium channel producing physical obstruction to entry of sodium ions. Local anaesthetic drug binds to specific receptor within the sodium channel producing physical obstruction to entry of sodium ions. The act of binding produces a conformational changes within the channel. The act of binding produces a conformational changes within the channel. It bind to a closed gate and maintain it in the closed position. It bind to a closed gate and maintain it in the closed position. It is, then, essential that the nerve fires, and the gate assumes the closed position. (Use-dependant phenomenon It is, then, essential that the nerve fires, and the gate assumes the closed position. (Use-dependant phenomenon

Absorption: Absorption: Many factors influence entry of local anaesthetic into the circulation: Many factors influence entry of local anaesthetic into the circulation: Vasodilating ability of the drug. Vasodilating ability of the drug. Volume and concentration. Volume and concentration. Vascularity of the tissues. Vascularity of the tissues. The route of administration. The route of administration. The presence of vasoconstrictor. The presence of vasoconstrictor.

Cocaine : Cocaine : The first and most potent local anaesthetic agent, rarely used because of the problems of misuse. The first and most potent local anaesthetic agent, rarely used because of the problems of misuse. It is unique in it is ability to produce intense vasoconstriction. Half life 30 minutes. It is unique in it is ability to produce intense vasoconstriction. Half life 30 minutes. Dosage: Dosage: Used as topical 4 – 10% solution Used as topical 4 – 10% solution Maximum dose is 1.5 mg/kg – 100mg max. Maximum dose is 1.5 mg/kg – 100mg max. Used intranasally during apical surgery. Used intranasally during apical surgery.

Procaine: Procaine: The only indication for its use in dentistry is in patients with proven allergy to the amide group. The only indication for its use in dentistry is in patients with proven allergy to the amide group. Used intra-arterially, as part of the recognized regimen, to treat the arteriospasm which might occur during intravenous sedation. Used intra-arterially, as part of the recognized regimen, to treat the arteriospasm which might occur during intravenous sedation. It has an excellent vasodilatory properties. It has an excellent vasodilatory properties.

Onset & duration of Action: Onset & duration of Action: Has a very shot duration (5 minutes) and a long onset time of 10 minutes Has a very shot duration (5 minutes) and a long onset time of 10 minutes Dosages: Dosages: The maximum dose is 6 mg/kg, 400 mg max. The maximum dose is 6 mg/kg, 400 mg max. Used as 2% with 1:80 000 epinephrine to increase efficacy. Used as 2% with 1:80 000 epinephrine to increase efficacy. Metabolism: Metabolism: Rapidly by plasma esterase. Rapidly by plasma esterase.

Benzocaine : Benzocaine : Used mainly as topical, due to its poor water solubility, and because of its low toxicity, it is used in concentration up to 20%. Used mainly as topical, due to its poor water solubility, and because of its low toxicity, it is used in concentration up to 20%. Hydrolyzed rapidly by plasma esterase to p-aminobenzoic acid accounting for its low toxicity. Hydrolyzed rapidly by plasma esterase to p-aminobenzoic acid accounting for its low toxicity.

Metabolism of Ester drugs: Metabolism of Ester drugs: Metabolized in plasma by peudocholinesterase enzyme, and some in the liver. Metabolized in plasma by peudocholinesterase enzyme, and some in the liver. People, who lack the enzyme, are at risk of an overdose by the ester type local anaesthetic People, who lack the enzyme, are at risk of an overdose by the ester type local anaesthetic Para-aminobenzoic acid (PABA) is the major metabolite of ester with no anaesthetic effect. Para-aminobenzoic acid (PABA) is the major metabolite of ester with no anaesthetic effect. It is the agent responsible for ester allergies. It is the agent responsible for ester allergies. Rapid metabolism procaine half-life is 2 minutes Rapid metabolism procaine half-life is 2 minutes

Lignocaine (Lidocaine): Lignocaine (Lidocaine): Synthesized in 1943 and used in dentistry since 1948 and is also known as Xylocaine Synthesized in 1943 and used in dentistry since 1948 and is also known as Xylocaine It highly lipophilic (partition coefficient 3), rapidly absorbed. It highly lipophilic (partition coefficient 3), rapidly absorbed. Metabolized only in the liver and its metabolites are less toxic with no action. Metabolized only in the liver and its metabolites are less toxic with no action. Has half-life ( t 0.5 ) of 90 minutes Has half-life ( t 0.5 ) of 90 minutes

Dosage: Dosage: 4.4 mg/kg – 300 mg max 4.4 mg/kg – 300 mg max Used as 2% plain or with 1:80 000 epinephrine Used as 2% plain or with 1:80 000 epinephrine 4 and 10% spray, 2% gel and 5% ointments. 4 and 10% spray, 2% gel and 5% ointments. Onset & duration of action: Onset & duration of action: Rapid onset 2 – 3 minutes Rapid onset 2 – 3 minutes Plain- short duration (10 minutes) Plain- short duration (10 minutes) With epinephrine- intermediate duration (45 – 60 minutes) With epinephrine- intermediate duration (45 – 60 minutes)

Prilocaine: Prilocaine: A very potent local anaesthetic and is less toxic than Lignocaine. A very potent local anaesthetic and is less toxic than Lignocaine. It produces less vasodilatation than lignocaine It produces less vasodilatation than lignocaine Rate of clearance is higher than other amide- types, suggesting extra-hepatic metabolism with relatively low blood concentration. Rate of clearance is higher than other amide- types, suggesting extra-hepatic metabolism with relatively low blood concentration. It’s metabolite o-toluidine lead to methaemo- globinaemia (more than 600 mg in adults) It’s metabolite o-toluidine lead to methaemo- globinaemia (more than 600 mg in adults)

Used either plain 4% or 3% combined with 0.03IU/mL of Felypressin as vasoconstrictor. Used either plain 4% or 3% combined with 0.03IU/mL of Felypressin as vasoconstrictor. Onset & Duration: Onset & Duration: Slower onset – 4 minutes. Slower onset – 4 minutes. It’s duration of action is similar to Lignocaine. It’s duration of action is similar to Lignocaine. Dosage; Dosage; 6.0 mg/kg – max. 400 mg. 6.0 mg/kg – max. 400 mg. Combined with Lignocaine as a topical anaesthetic agent to be used prior to vene- section and during dental sedation in children. Combined with Lignocaine as a topical anaesthetic agent to be used prior to vene- section and during dental sedation in children.

Mepivacaine: Mepivacaine: Possess the least vasodilating effect. Possess the least vasodilating effect. Metabolized in the liver and has t 0.5 of 120 minutes. Metabolized in the liver and has t 0.5 of 120 minutes. It’s main indication is when local anaesthetic without vasoconstrictor is needed. 3% plain is more effective than lignocaine. It’s main indication is when local anaesthetic without vasoconstrictor is needed. 3% plain is more effective than lignocaine. Onset & duration: Onset & duration: Rapid onset but slightly shorter duration. Rapid onset but slightly shorter duration.

Bupivacaine : Bupivacaine : A long-acting local anaesthetic agent, with a t 0.5 of 160 minutes due grater binding capacity to plasma protein and tissue proteins A long-acting local anaesthetic agent, with a t 0.5 of 160 minutes due grater binding capacity to plasma protein and tissue proteins Metabolized in the liver. Metabolized in the liver. Used mainly in Oral surgical procedures for its long-lasting pain control. Used mainly in Oral surgical procedures for its long-lasting pain control. Longer onset and longer duration (Regional 6 – 8 hors) Longer onset and longer duration (Regional 6 – 8 hors) Dosage: Dosage: 1.3 mg/kg – Max 90 mg 1.3 mg/kg – Max 90 mg 0.25 – 0.75% with or without adrenaline 1:200 000 0.25 – 0.75% with or without adrenaline 1:200 000

Etidocaine : Etidocaine : A long-acting agent similar to Bupivacaine but with faster onset. A long-acting agent similar to Bupivacaine but with faster onset. Metabolized in the liver. Metabolized in the liver. Dosage: Dosage: 8 mg/kg – Max 400 mg 8 mg/kg – Max 400 mg 1.5% with 1:200 000 epinephrine. 1.5% with 1:200 000 epinephrine. Lignocaine is the most common used agent both topically and by injection as 2% with or without adrenaline, with a maximum dose of 4.4 mg/kg. Lignocaine is the most common used agent both topically and by injection as 2% with or without adrenaline, with a maximum dose of 4.4 mg/kg.

Amide Drugs: Amide Drugs: metabolized in the liver, except Prilocaine which undergo some biotransformation in the kidney and lungs. metabolized in the liver, except Prilocaine which undergo some biotransformation in the kidney and lungs. Some of the metabolites possess local anaesthetic and sedative properties. Some of the metabolites possess local anaesthetic and sedative properties. Normal local anaesthetic dose in patient with impaired liver function will result in relative overdosage. Normal local anaesthetic dose in patient with impaired liver function will result in relative overdosage. Old age patient shows reduction in liver function Old age patient shows reduction in liver function Reduce dose Reduce dose

Originally added to reduce systemic uptake in an attempt to limit toxicity. Originally added to reduce systemic uptake in an attempt to limit toxicity. Prolong the duration Prolong the duration Produces profound anaesthesia. Produces profound anaesthesia. Reduce operative bleeding. Reduce operative bleeding. Two types: Two types: Sympathomimetic naturally occurring. Sympathomimetic naturally occurring. Synthetic polypeptides, Felypressin Synthetic polypeptides, Felypressin

Epinephrine : (Adrenaline) Epinephrine : (Adrenaline) Uses in dentistry: Uses in dentistry: Local anaesthetic solution. Local anaesthetic solution. Gingival retraction cords. Gingival retraction cords. In the ER as life-saving drug in anaphylaxis. In the ER as life-saving drug in anaphylaxis. Mechanism of action: Mechanism of action: Interact with adrenergic receptors in the vessels Interact with adrenergic receptors in the vessels α 1 & α 2 producing vasoconstriction in skin & MM α 1 & α 2 producing vasoconstriction in skin & MM β 2 stimulation causing vasodilatation in skeletal muscles. β 2 stimulation causing vasodilatation in skeletal muscles.

Metabolism: Metabolism: Appears very rapidly in the systemic circulation !!! Appears very rapidly in the systemic circulation !!! Exogenously administered epinephrine is metabolized extraneuronal and 1% is excreted in the urine unchanged. Exogenously administered epinephrine is metabolized extraneuronal and 1% is excreted in the urine unchanged. Dosage: Dosage: 1:80,000 is the commonest dose used, 12.5 µg/ml 1:80,000 is the commonest dose used, 12.5 µg/ml

Systemic effect: Systemic effect: Being a naturally occurring hormone, it exert a number of physiological responses on the different systems. Being a naturally occurring hormone, it exert a number of physiological responses on the different systems. The heart: The heart: Has direct and indirect action. Has direct and indirect action. Direct action on β 1 receptors increases the rate and force of contraction raising cardiac output. Direct action on β 1 receptors increases the rate and force of contraction raising cardiac output. Indirect action, increase pulse and cardiac output, lead to rise in systolic blood pressure, (not with dental dose) Indirect action, increase pulse and cardiac output, lead to rise in systolic blood pressure, (not with dental dose)

Blood vessels: Blood vessels: Contain α 1, α 2 and β 2 adrenoreceptors in the vessels of the skin, mucous membrane and skeletal muscles. Contain α 1, α 2 and β 2 adrenoreceptors in the vessels of the skin, mucous membrane and skeletal muscles. α 1 receptors causes vasoconstriction since they are susceptible to endogenous nor-epinephrine and exogenous epinephrine. Reduce operative bleeding α 1 receptors causes vasoconstriction since they are susceptible to endogenous nor-epinephrine and exogenous epinephrine. Reduce operative bleeding

α 2 receptors are only susceptible to circulating epinephrine. α 2 receptors are only susceptible to circulating epinephrine. β 2 found in the skeletal muscles, and very uncommon in the skin and mucous membrane. β 2 stimulation result in vasodilatation, lowering peripheral resistance and a fall in the diastolic blood pressure. (with dental dose) β 2 found in the skeletal muscles, and very uncommon in the skin and mucous membrane. β 2 stimulation result in vasodilatation, lowering peripheral resistance and a fall in the diastolic blood pressure. (with dental dose)

Haemostasis: Haemostasis: The vasoconstricting effect. The vasoconstricting effect. Adrenaline promote platelets aggregation in the early stages. Adrenaline promote platelets aggregation in the early stages. Fibrinolytic activity compromise clot stability. Fibrinolytic activity compromise clot stability. Lungs: Lungs: Stimulation of β 2 receptors in the lung lead to bronchial muscle relaxation, life-saving in bronchial (spasm) constriction during anaphylactic reaction. Stimulation of β 2 receptors in the lung lead to bronchial muscle relaxation, life-saving in bronchial (spasm) constriction during anaphylactic reaction. Wound healing: Wound healing: Reduced local tissue oxygen tension. Reduced local tissue oxygen tension. Epinephrine-induced fibrinolysis. Epinephrine-induced fibrinolysis.

Felypressin: Felypressin: It is an analogue of the naturally occurring Vasopressin. It is an analogue of the naturally occurring Vasopressin. Bind to vasopressin V 1 receptor in the vascular smooth muscle producing vaso-constriction and reduce local blood flow. Bind to vasopressin V 1 receptor in the vascular smooth muscle producing vaso-constriction and reduce local blood flow. Less potent than the catecholamines &poorer control of bleeding during operative procedures. Less potent than the catecholamines &poorer control of bleeding during operative procedures. Acts on the venous side rather than the arterial side. Acts on the venous side rather than the arterial side. Dose: Dose: 0.03 IU/ml (0.54 µg/ml) 0.03 IU/ml (0.54 µg/ml)

1. Local infiltration - type of injection that anesthetizes a small area (one or two teeth and asscociated areas) - anesthesia deposited at nerve terminals 2. Nerve block - type of injection that anesthetizes a larger area - anesthesia deposited near larger nerve trunks

Maxillary Maxillary A. posterior superior alveolar block B. middle superior alveolar block C. anterior superior alveolar block D. greater palatine block E. infraorbital block F. nasopalatine block Mandibular Mandibular A. inferior alveolar block B. buccal block C. mental block D. incisive block E. Gow-Gates mandibular nerve block

dental procedures can usually commence after 3 – 5 minutes dental procedures can usually commence after 3 – 5 minutes failure requires re-administration using another method failure requires re-administration using another method never re-administer using the same method never re-administer using the same method keep in mind the total # of injections and the dosages keep in mind the total # of injections and the dosages never inject into an area with an abcess, or other type of abnormality never inject into an area with an abcess, or other type of abnormality

Chart 9-1 Chart 9-1 pulpal anesthesia: through anesthesia of each nerve’s dental branches as they extend into the pulp tissue (via the apical foramen) pulpal anesthesia: through anesthesia of each nerve’s dental branches as they extend into the pulp tissue (via the apical foramen) periodontal: through the interdental and interradicular branches periodontal: through the interdental and interradicular branches palatal: soft and hard tissues of the palatal periodontium (e.g. gingiva, periodontal ligaments, alveolar bone) palatal: soft and hard tissues of the palatal periodontium (e.g. gingiva, periodontal ligaments, alveolar bone) PSA block: recommended for maxillary molar teeth and associated buccal tissues in ONE quadrant PSA block: recommended for maxillary molar teeth and associated buccal tissues in ONE quadrant MSA block: recommended for maxillary premolars and associated buccal tissues MSA block: recommended for maxillary premolars and associated buccal tissues ASA block: recommended for maxillary canine and the incisors in ONE quadrant ASA block: recommended for maxillary canine and the incisors in ONE quadrant greater palatine block: recommended for palatal tissues distal to the maxillary canine in ONE quadrant greater palatine block: recommended for palatal tissues distal to the maxillary canine in ONE quadrant nasopalatine block: recommended for palatal tissues between the right and left maxillary canines nasopalatine block: recommended for palatal tissues between the right and left maxillary canines

figures 9-2 through 9-7 figures 9-2 through 9-7 pulpal anesthesia of the maxillary 3 rd, 2 nd and 1 st molars pulpal anesthesia of the maxillary 3 rd, 2 nd and 1 st molars required for procedures involving two or more molars required for procedures involving two or more molars sometimes anesthesia of the 1 st molar also required block of the MSA nerve sometimes anesthesia of the 1 st molar also required block of the MSA nerve associated buccal periodonteum overlying these molars associated buccal periodonteum overlying these molars including the associated buccal gingiva, periodontal ligament and alveolar bone including the associated buccal gingiva, periodontal ligament and alveolar bone useful for periodontal work on this area useful for periodontal work on this area

target: PSA nerve target: PSA nerve as it enters the maxillar through the PSA foramen on the maxilla’s infratemporal service – Figure 9-2 & 9-3 as it enters the maxillar through the PSA foramen on the maxilla’s infratemporal service – Figure 9-2 & 9-3 into the tissues of the mucobuccal fold at the apex of the 2 nd maxillary molar ( figures 9-4 and 9-5 ) into the tissues of the mucobuccal fold at the apex of the 2 nd maxillary molar ( figures 9-4 and 9-5 ) mandible is extended toward the side of the injection, pull the tissues at the injection site until taut mandible is extended toward the side of the injection, pull the tissues at the injection site until taut needle is inserted distal and medial to the tooth and maxilla needle is inserted distal and medial to the tooth and maxilla depth varies from 10 to 16 mm depending on age of patient depth varies from 10 to 16 mm depending on age of patient no overt symptoms (e.g. no lip or tongue involvement) no overt symptoms (e.g. no lip or tongue involvement) can damage the pterygoid plexus and maxillary artery can damage the pterygoid plexus and maxillary artery

limited clinical usefulness limited clinical usefulness can be used to extend the infraorbital block distal to the maxillary canine can be used to extend the infraorbital block distal to the maxillary canine can be indicated for work on maxillary pre-molars and mesiobuccal root of 1 st molar ( Figure 9-8 ) can be indicated for work on maxillary pre-molars and mesiobuccal root of 1 st molar ( Figure 9-8 ) if the MSA is absent – area is innervated by the ASA if the MSA is absent – area is innervated by the ASA blocks the pulp tissue of the 1 st and 2 nd maxillary premolars and possibly the 1 st molar + associated buccal tissues and alveolar bone blocks the pulp tissue of the 1 st and 2 nd maxillary premolars and possibly the 1 st molar + associated buccal tissues and alveolar bone useful for periodontal work in this area useful for periodontal work in this area to block the palatine tissues in this area – may require a greater palatine block to block the palatine tissues in this area – may require a greater palatine block

target area: MSA nerve at the apex of the maxillary 2 nd premolar ( figures 9-8 and 9- 9 ) target area: MSA nerve at the apex of the maxillary 2 nd premolar ( figures 9-8 and 9- 9 ) mandible extended towards injection site mandible extended towards injection site stretch the upper lip to tighten the injection site stretch the upper lip to tighten the injection site needle is inserted into the mucobuccal fold needle is inserted into the mucobuccal fold tip is located well above the apex of the 2 nd premolar tip is located well above the apex of the 2 nd premolar figure 9-11 figure 9-11 harmless tingling or numbness of the upper lip harmless tingling or numbness of the upper lip overinsertion is rare overinsertion is rare

figures 9-12 through 9-14 figures 9-12 through 9-14 can be considered a local infiltration can be considered a local infiltration used in conjunction with an MSA block used in conjunction with an MSA block the ASA nerve can cross the midline of the maxilla onto the opposite side! the ASA nerve can cross the midline of the maxilla onto the opposite side! used in procedures involving the maxillary canines and incisors and their associated facial tissues used in procedures involving the maxillary canines and incisors and their associated facial tissues pulpal and facial tissues involved – restorative and periodontal work pulpal and facial tissues involved – restorative and periodontal work blocks the pulp tissue + the gingiva, periodontal ligaments and alveolar bone in that area blocks the pulp tissue + the gingiva, periodontal ligaments and alveolar bone in that area

target: ASA nerve at the apex of the maxillary canine – figures 9-12 & 9-13 target: ASA nerve at the apex of the maxillary canine – figures 9-12 & 9-13 at the mucobuccal fold at the apex of the maxillary canine – figure 9-13 at the mucobuccal fold at the apex of the maxillary canine – figure 9-13 harmless tingling or numbness of the upper lip harmless tingling or numbness of the upper lip overinsertion is rare overinsertion is rare

figures 9-15 through 9-17 figures 9-15 through 9-17 anesthetizes both the MSA and ASA anesthetizes both the MSA and ASA used for anesthesia of the maxillary premolars, canine and incisors used for anesthesia of the maxillary premolars, canine and incisors indicated when more than one premolar or anterior teeth indicated when more than one premolar or anterior teeth pulpal tissues – for restorative work pulpal tissues – for restorative work facial tissues – for periodontal work facial tissues – for periodontal work also numbs the gingiva, periodontal ligaments and alveolar bone in that area also numbs the gingiva, periodontal ligaments and alveolar bone in that area the maxillary central incisor may also be innervated by the nasopalatine nerve branches the maxillary central incisor may also be innervated by the nasopalatine nerve branches

target: union of the ASA and MSA with the IO nerve after the IO enters the IO foramen – figure 9-15 target: union of the ASA and MSA with the IO nerve after the IO enters the IO foramen – figure 9-15 also anesthesizes the lower eyelid, side of nose and upper lip also anesthesizes the lower eyelid, side of nose and upper lip IO foramen is gently palpated along the IO rim IO foramen is gently palpated along the IO rim move slightly down about 10mm until you feel the depression of the IO foramen – figure 9-16 move slightly down about 10mm until you feel the depression of the IO foramen – figure 9-16 locate the tissues at the mucobuccal fold at the apex of the 1 st premolar locate the tissues at the mucobuccal fold at the apex of the 1 st premolar place one finger at the IO foramen and the other on the injection site – figure 9-17 place one finger at the IO foramen and the other on the injection site – figure 9-17 locate the IO foramen, retract the upper lip and pull the tissues taut locate the IO foramen, retract the upper lip and pull the tissues taut the needle is inserted parallel to the long axis of the tooth to avoid hitting the bone the needle is inserted parallel to the long axis of the tooth to avoid hitting the bone harmless tingling or numbness of the upper lip, side of nose and eyelid harmless tingling or numbness of the upper lip, side of nose and eyelid

figures 9-19 through 9-21 figures 9-19 through 9-21 used in restorative procedures that involve more than two maxillary posterior teeth or palatal tissues distal to the canine used in restorative procedures that involve more than two maxillary posterior teeth or palatal tissues distal to the canine also used in periodontal work – since it blocks the associated lingual tissues also used in periodontal work – since it blocks the associated lingual tissues anesthetizes the posterior portion of the hard palate – from the 1 st premolar to the molars and medially to the palate midline anesthetizes the posterior portion of the hard palate – from the 1 st premolar to the molars and medially to the palate midline does NOT provide pulpal anesthesia – may also need to use ASA, PSA, MSA or IO blocks does NOT provide pulpal anesthesia – may also need to use ASA, PSA, MSA or IO blocks may also need to be combined with nasopalatine block may also need to be combined with nasopalatine block

target: GP nerve as it enters the GP foramen target: GP nerve as it enters the GP foramen located at the junction of the maxillary alveolar process and the hard palate – at the maxillary 2nd or 3 rd molar – figure 9-19 located at the junction of the maxillary alveolar process and the hard palate – at the maxillary 2nd or 3 rd molar – figure 9-19 palpate the GP foramen – midway between the median palatine raphe and lingual gingival margin of the molar tooth – figure 9-21 palpate the GP foramen – midway between the median palatine raphe and lingual gingival margin of the molar tooth – figure 9-21 can reduce discomfort by applying pressure to the site before and during the injection can reduce discomfort by applying pressure to the site before and during the injection produces a dull ache to block pain impulses produces a dull ache to block pain impulses also slow deposition of anesthesia will also help also slow deposition of anesthesia will also help needle is inserted at a 90 degree angle to the palate – figure 9-22 needle is inserted at a 90 degree angle to the palate – figure 9-22

figure 9-23 through 9-26 figure 9-23 through 9-26 useful for anesthesia of the bilateral portion of the hard palate useful for anesthesia of the bilateral portion of the hard palate from the mesial of the right maxillary 1 st premolar to the mesial of the left 1 st premolar from the mesial of the right maxillary 1 st premolar to the mesial of the left 1 st premolar for palatal soft tissue anesthesia for palatal soft tissue anesthesia periodontal treatment periodontal treatment required for two or more anterior maxillary teeth required for two or more anterior maxillary teeth for restorative procedures or extraction of the anterior maxillary teeth – may need an ASA or MSA block also for restorative procedures or extraction of the anterior maxillary teeth – may need an ASA or MSA block also blocks both right and left nerves blocks both right and left nerves

target: both right and left nerves as they enter the incisive foramen from the mucosa of the anterior hard palate – figure 9-23 & 9-25 target: both right and left nerves as they enter the incisive foramen from the mucosa of the anterior hard palate – figure 9-23 & 9-25 posterior to the incisive papilla posterior to the incisive papilla injection site is lateral to the incisive papilla – figure 9-26 injection site is lateral to the incisive papilla – figure 9-26 head turned to the left or right head turned to the left or right inserted at a 45 degree angle about 6-10 mm – gently contact the maxillary bone and withdraw about 1mm before administering inserted at a 45 degree angle about 6-10 mm – gently contact the maxillary bone and withdraw about 1mm before administering can reduce discomfort by applying pressure to the site before and during the injection can reduce discomfort by applying pressure to the site before and during the injection produces a dull ache to block pain impulses produces a dull ache to block pain impulses also slow deposition of anesthesia will also help also slow deposition of anesthesia will also help can anesthetize the labial tissues between the central incisors prior to palatal block can anesthetize the labial tissues between the central incisors prior to palatal block can block some branches of the nasopalatine prior to injection can block some branches of the nasopalatine prior to injection

Chart 9-2 Chart 9-2 infiltration is not as successful as maxillary anesthesia infiltration is not as successful as maxillary anesthesia substantial variability in the anatomy of landmarks when compared to the maxilla substantial variability in the anatomy of landmarks when compared to the maxilla pulpal anesthesia: block of each nerve’s dental branches pulpal anesthesia: block of each nerve’s dental branches periodontal: through the interdental and interradicular branches periodontal: through the interdental and interradicular branches Inferior Alveolar block: for mandibular teeth + associated lingual tissues and for the facial tissues anterior to the mandibular 1 st molar Inferior Alveolar block: for mandibular teeth + associated lingual tissues and for the facial tissues anterior to the mandibular 1 st molar Buccal block: tissues buccal to the mandibular molars Buccal block: tissues buccal to the mandibular molars Mental block: facial tissues anterior to the mental foramen (mandibular premolars and anterior teeth) Mental block: facial tissues anterior to the mental foramen (mandibular premolars and anterior teeth) Incisive block: for teeth and facial tissue anterior to the mental foramen Incisive block: for teeth and facial tissue anterior to the mental foramen Gow-Gates: most of the mandibular nerve Gow-Gates: most of the mandibular nerve for quadrant dentistry for quadrant dentistry

also called the mandibular block also called the mandibular block most commonly used in dentistry most commonly used in dentistry for restorative, extraction and periodontal work for restorative, extraction and periodontal work pulpal anesthesia for extractions and restorative pulpal anesthesia for extractions and restorative lingual periodonteal anesthesia lingual periodonteal anesthesia facial periodonteal anesthesia of anterior mandibular teeth and premolars facial periodonteal anesthesia of anterior mandibular teeth and premolars may be combined with the buccal block may be combined with the buccal block can overlap with the incisive block can overlap with the incisive block local infiltrations in the anterior area are more successful than posterior injections local infiltrations in the anterior area are more successful than posterior injections variability in the location of the mandibular foramen on the ramus can lessen the success of this injection variability in the location of the mandibular foramen on the ramus can lessen the success of this injection usually avoid bi-lateral injections since they will completely anesthetize the entire tongue and can affect swallowing and speech usually avoid bi-lateral injections since they will completely anesthetize the entire tongue and can affect swallowing and speech

target: slightly superior to the mandibular foramen – figure 9-27 target: slightly superior to the mandibular foramen – figure 9-27 the medial border of the ramus the medial border of the ramus will also anesthetize the adjacent anterior lingual nerve – figure 9-30 will also anesthetize the adjacent anterior lingual nerve – figure 9-30 injection site is found using hard landmarks injection site is found using hard landmarks palpate the coronoid notch – above the 3 rd molar palpate the coronoid notch – above the 3 rd molar imagine a horizontal line from the coronoid notch to the pterygomandibular fold which covers the pterygomandibular raphe – figure 9- 32 imagine a horizontal line from the coronoid notch to the pterygomandibular fold which covers the pterygomandibular raphe – figure 9- 32 this fold becomes more prominent as the patient opens their mouth wider this fold becomes more prominent as the patient opens their mouth wider refer to video notes refer to video notes figure 9-33 figure 9-33 needle is inserted into the pterygomandibular space until the mandible is felt – retract about 1 mm needle is inserted into the pterygomandibular space until the mandible is felt – retract about 1 mm average depth: 20-25mm average depth: 20-25mm diffusion of anesthesia will affect the lingual nerve diffusion of anesthesia will affect the lingual nerve

symptoms: harmless tingling and numbness of the lower lip due to block of the mental nerve symptoms: harmless tingling and numbness of the lower lip due to block of the mental nerve tingling and numbness of the body of the tongue and floor of mouth – lingual nerve involvement tingling and numbness of the body of the tongue and floor of mouth – lingual nerve involvement complications: complications: failure to penetrate enough can numb the tongue but not block sufficiently failure to penetrate enough can numb the tongue but not block sufficiently lingual shock – involuntary movement as the needle passes the lingual nerve lingual shock – involuntary movement as the needle passes the lingual nerve transient facial paralysis – facial nerve involvement if inserted into the deeper parotid gland – figure 9-34 transient facial paralysis – facial nerve involvement if inserted into the deeper parotid gland – figure 9-34 inability to close the eye and drooping of the lips on the affected side inability to close the eye and drooping of the lips on the affected side hematoma can occur hematoma can occur some muscle soreness some muscle soreness patient-inflicted trauma – lip biting etc... patient-inflicted trauma – lip biting etc...

figures 9-36 and 9-37 figures 9-36 and 9-37 for buccal periodonteum of mandibular molars, gingiva, periodontal ligament and alveolar bone for buccal periodonteum of mandibular molars, gingiva, periodontal ligament and alveolar bone for restorative and periodontal work for restorative and periodontal work buccal nerve is readily located on the surface of the tissue and not within bone buccal nerve is readily located on the surface of the tissue and not within bone

target: buccal nerve as it passes over the anterior border of the ramus through the buccinator – figure 9-36 target: buccal nerve as it passes over the anterior border of the ramus through the buccinator – figure 9-36 injection site is the buccal tissues distal and buccal to the most distal molar – on the anterior border of the ramus as it meets the body – figure 9-37 injection site is the buccal tissues distal and buccal to the most distal molar – on the anterior border of the ramus as it meets the body – figure 9-37 pull the buccal tissue tight and advance the needle until you feel bone – only about 1 to 2mm pull the buccal tissue tight and advance the needle until you feel bone – only about 1 to 2mm figure 9-38 patient-inflicted trauma – lip biting etc... patient-inflicted trauma – lip biting etc...

figures 9-39 through 9-41 figures 9-39 through 9-41 for facial periodonteum of mandibular premolars and anterior teeth on one side for facial periodonteum of mandibular premolars and anterior teeth on one side for restorative work – incisive block should be considered instead for restorative work – incisive block should be considered instead

target site: mental nerve before it enters the mental foramen where it joins with the incisive nerve to form the IA nerve – figure 9-39 target site: mental nerve before it enters the mental foramen where it joins with the incisive nerve to form the IA nerve – figure 9-39 palpate the foramen between the apices of the 1 st and 2 nd premolars palpate the foramen between the apices of the 1 st and 2 nd premolars palpate it intraorally – find the mucobuccal fold between the apices of the 1 st and 2 nd premolars – figure 9- 42 palpate it intraorally – find the mucobuccal fold between the apices of the 1 st and 2 nd premolars – figure 9- 42 in adults, the foramen faces posterosuperiorly in adults, the foramen faces posterosuperiorly may be anterior or posterior may be anterior or posterior can be found using radiographs can be found using radiographs insertion site is the mucobuccal fold tissue directly over or slight anterior to the foramen site insertion site is the mucobuccal fold tissue directly over or slight anterior to the foramen site avoid contact with the mandible with the needle avoid contact with the mandible with the needle depth is 5 to 6mm depth is 5 to 6mm no need to enter the foramen no need to enter the foramen

for pulp and facial tissues of the teeth anterior to the mental foramen for pulp and facial tissues of the teeth anterior to the mental foramen same as the mental block except pulpal anesthesia is provided also same as the mental block except pulpal anesthesia is provided also restorative and periodontal work restorative and periodontal work IA block indicated for extractions – no lingual anesthesia with an incisive block IA block indicated for extractions – no lingual anesthesia with an incisive block target: mental foramen – figure 9-43 target: mental foramen – figure 9-43

injection site: figure 9-44 injection site: figure 9-44 same as for the mental block same as for the mental block directly over or anterior to the mental foramen directly over or anterior to the mental foramen in the mucobuccal fold at the apices of the 1 st and 2 nd premolars in the mucobuccal fold at the apices of the 1 st and 2 nd premolars pull the buccal tissues laterally pull the buccal tissues laterally more anesthesia is used for this block when compared to the mental block more anesthesia is used for this block when compared to the mental block pressure is applied during the injection – forces for anesthetic solution into the foramen and block the deeper incisive nerve pressure is applied during the injection – forces for anesthetic solution into the foramen and block the deeper incisive nerve the increased injection solution may balloon the facial tissues the increased injection solution may balloon the facial tissues

figures 9-45 through 9-50 figures 9-45 through 9-50 blocks the IA, mental, incisive, lingual, mylohyoid, auriculotemporal and buccal nerves – figure 9-28 and 9-45 blocks the IA, mental, incisive, lingual, mylohyoid, auriculotemporal and buccal nerves – figure 9-28 and 9-45 used for quadrant dentistry used for quadrant dentistry buccal and lingual soft tissue from most distal molar to the midline buccal and lingual soft tissue from most distal molar to the midline greater success than an IA block greater success than an IA block

target site: anteromedial border of the mandibular condylar neck – figure 9-46 target site: anteromedial border of the mandibular condylar neck – figure 9-46 just inferior to the insertion of the lateral pterygoid muscle just inferior to the insertion of the lateral pterygoid muscle injection site is intraoral injection site is intraoral locate the intertragic notch and labial commisure extraorally locate the intertragic notch and labial commisure extraorally draw a line from the tragus/intertragic notch to the labial commisure – figure 9-47 draw a line from the tragus/intertragic notch to the labial commisure – figure 9-47 place your thumb on the condyle (just in front of the tragus when the mouth is open) place your thumb on the condyle (just in front of the tragus when the mouth is open) pull buccal tissue away pull buccal tissue away place the needle inferior to the mesiolingual cusp of the MAXILLARY 2 nd molar place the needle inferior to the mesiolingual cusp of the MAXILLARY 2 nd molar the needle penetrates distal to the maxillary 2 nd molar the needle penetrates distal to the maxillary 2 nd molar see the video see the video

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

Indications and contra-indications to removal of permanent teeth. Indications and contra-indications to removal of permanent teeth. Indications to planned tooth removal: Indications to planned tooth removal: 1.)Unsuccessfulness of endodonthyc treatment with presence of the chronic inflammation of periodontium and adjoining tissues of a bone. This intervention is especially indicated in case of chronic intoxications of the patient with odontogenic intoxication centres (chroniosepsis) 1.)Unsuccessfulness of endodonthyc treatment with presence of the chronic inflammation of periodontium and adjoining tissues of a bone. This intervention is especially indicated in case of chronic intoxications of the patient with odontogenic intoxication centres (chroniosepsis) 2.) Impossibility of conservative treatment through considerable crown destruction or the technical obstacles connected with anatomic features, treatment errors, caused by root perforation. 2.) Impossibility of conservative treatment through considerable crown destruction or the technical obstacles connected with anatomic features, treatment errors, caused by root perforation.

3.) Total destruction of crown part of the tooth, impossibility of using the root for tooth prosthetics. 3.) Total destruction of crown part of the tooth, impossibility of using the root for tooth prosthetics. 4.) Mobility of ІІІ degree and tooth promotions as a result of resorption of bone round a cell with presence of heavy forms of a periodontosis and parodontitis. 4.) Mobility of ІІІ degree and tooth promotions as a result of resorption of bone round a cell with presence of heavy forms of a periodontosis and parodontitis. 5.) Atypically placed teeth which injure a mouth mucous membrane, tongue, and which can't be treated by ortodonthic treatment. 5.) Atypically placed teeth which injure a mouth mucous membrane, tongue, and which can't be treated by ortodonthic treatment. 6.) Unteethed in time or partially teethed teeth which predetermine inflammatory processes in adjoining tissues, which cannot be liquidated some other way. 6.) Unteethed in time or partially teethed teeth which predetermine inflammatory processes in adjoining tissues, which cannot be liquidated some other way.

7.) Placed in crisis cracks, teeth do impossible reposition of fragments and can't be treated by conservative treatment. 7.) Placed in crisis cracks, teeth do impossible reposition of fragments and can't be treated by conservative treatment. 8.) Outstanding as a result of loss of the antagonist teeth, teeth which convergence and divergence, disturb embarrass the process of manufacturing tooth prosthetics. treatment. For elimination of anomalies of a bite (occlusion) during the orthodontic treatment, intact teeth removal is also indicated. 8.) Outstanding as a result of loss of the antagonist teeth, teeth which convergence and divergence, disturb embarrass the process of manufacturing tooth prosthetics. treatment. For elimination of anomalies of a bite (occlusion) during the orthodontic treatment, intact teeth removal is also indicated.

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

Relative contra-indications to operations of tooth removal are: Relative contra-indications to operations of tooth removal are: 1.) Cardiovascular diseases (preinfarction conditions and 3-6 month after the infarction of a myocardium, hypertonic illness in crisis. IHD(ischemic heart disease), paroxysm, blinking arhythmia, paroxysmal tachycardia, acute septic endocarditis); 1.) Cardiovascular diseases (preinfarction conditions and 3-6 month after the infarction of a myocardium, hypertonic illness in crisis. IHD(ischemic heart disease), paroxysm, blinking arhythmia, paroxysmal tachycardia, acute septic endocarditis); 2.) Acute diseases of parenchymatosic organs - liver, kidneys, pancreas (an infectious hepatitis, (glomerunonephritis); 2.) Acute diseases of parenchymatosic organs - liver, kidneys, pancreas (an infectious hepatitis, (glomerunonephritis); 3.) Haemorragical diseases (a hemophilia, illness of Verlgof, agranulocytosis, acute leukemia); 3.) Haemorragical diseases (a hemophilia, illness of Verlgof, agranulocytosis, acute leukemia); 4.) acute infectious diseases (a flu, ARVD(acute respiratoric virus disease), a pneumonia); 4.) acute infectious diseases (a flu, ARVD(acute respiratoric virus disease), a pneumonia);

5.) disease of CNS (central neuronic system), (acute disorder of encephal blood circulation, a meningitis); 5.) disease of CNS (central neuronic system), (acute disorder of encephal blood circulation, a meningitis); 6.) Mental (psychological) diseases in an aggravation period (a schizophrenia, a psychosis, an epilepsy); 6.) Mental (psychological) diseases in an aggravation period (a schizophrenia, a psychosis, an epilepsy); 7.) acute radiation sickness І - ІІІ degrees; 7.) acute radiation sickness І - ІІІ degrees; 8.) disease of a mucous membrane of a mouth (a stomatitis, gingivitis, cheilitis). 8.) disease of a mucous membrane of a mouth (a stomatitis, gingivitis, cheilitis).

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

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

Forceps and elevetaors for teeth removal: Forceps and elevetaors for teeth removal: Forceps. Under the process teeth removal a lever principle is used. Forceps consists of: cheeks, handles and the lock. In some kind’s of forceps between cheeks and the lock there is a transitive part. Cheeks are used to cover the root or a crown. The handle – a part which is used to hold the forceps. The lock is placed between the handle and a cheek. Forceps. Under the process teeth removal a lever principle is used. Forceps consists of: cheeks, handles and the lock. In some kind’s of forceps between cheeks and the lock there is a transitive part. Cheeks are used to cover the root or a crown. The handle – a part which is used to hold the forceps. The lock is placed between the handle and a cheek. For the best fixing of tooth or a root, cheeks have fillets with longitudinal cutting from the inside. The external surface of handles on significant length is relief, internal - smooth. The form of forceps is not the same. Construction depends on anatomical structure of the tooth and it’s place in row of teeth. For the best fixing of tooth or a root, cheeks have fillets with longitudinal cutting from the inside. The external surface of handles on significant length is relief, internal - smooth. The form of forceps is not the same. Construction depends on anatomical structure of the tooth and it’s place in row of teeth.

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

2.) Forceps for removal of teeth with the kept crown (crown forceps) and for root removal (root forceps). Cheeks for removal of a crowned teeth do not converge, for removal of roots - converge; 2.) Forceps for removal of teeth with the kept crown (crown forceps) and for root removal (root forceps). Cheeks for removal of a crowned teeth do not converge, for removal of roots - converge; 3.) Forceps for removal of separate groups of teeth of the top and bottom jaw. They differ by width and features of a structure of cheeks, their placing in relation to handles, the form of handles; 3.) Forceps for removal of separate groups of teeth of the top and bottom jaw. They differ by width and features of a structure of cheeks, their placing in relation to handles, the form of handles;

4.) Forceps for removal of the first and the second molars of the top jaw on the right and at the left. The left and right cheeks of these nippers are constructed unequally; 4.) Forceps for removal of the first and the second molars of the top jaw on the right and at the left. The left and right cheeks of these nippers are constructed unequally; 5.) Forceps for removal of teeth of the bottom jaw in case of the limited opening of a mouth. They have a bend of cheeks in a horizontal direction. 5.) Forceps for removal of teeth of the bottom jaw in case of the limited opening of a mouth. They have a bend of cheeks in a horizontal direction.

Forceps for maxilla Forceps for maxilla

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

Forceps for mandibula Forceps for mandibula

Structure of the forceps, about the surface Structure of the forceps, about the surface

Types of correct forceps handling Types of correct forceps handling

Luxation and rotation during teeth removal Luxation and rotation during teeth removal

Correct and incorrect forceps positions Correct and incorrect forceps positions

To execute operation successfully, it is necessary to apply the forceps, which design to anatomic features of removable tooth. To execute operation successfully, it is necessary to apply the forceps, which design to anatomic features of removable tooth. Removal of the central incisor, lateral incisor and canine of top jaw, is being done by forceps which have the direct form, - direct forceps. Longitudinal axes of cheeks and handles are in one plane and coincide. Both cheeks are identical by the form, from the inside fillets, round off the ends. Forceps can have big and small width cheeks. Removal of the central incisor, lateral incisor and canine of top jaw, is being done by forceps which have the direct form, - direct forceps. Longitudinal axes of cheeks and handles are in one plane and coincide. Both cheeks are identical by the form, from the inside fillets, round off the ends. Forceps can have big and small width cheeks. Removal of small root teeth of the top jaw is being made by nippers which have S-like bend. Cheeks are placed with them at an obtuse angle to handles. Such form of forceps allows to impose them correctly on tooth and during its removal to prevent obstacles from the bottom jaw. Removal of small root teeth of the top jaw is being made by nippers which have S-like bend. Cheeks are placed with them at an obtuse angle to handles. Such form of forceps allows to impose them correctly on tooth and during its removal to prevent obstacles from the bottom jaw.

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

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

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

Removal of teeth and roots of the lower jaw is being made by forceps, which are bent on an edge and have beaklike form. The axis of brushes and an axis of handles form a corner, which is direct or close to direct. All components of forceps are allocated in a vertical plane, handles - one over the second. Removal of teeth and roots of the lower jaw is being made by forceps, which are bent on an edge and have beaklike form. The axis of brushes and an axis of handles form a corner, which is direct or close to direct. All components of forceps are allocated in a vertical plane, handles - one over the second. Cheeks of forceps for removal of incsors of the lower jaw, are narrow with fillets on inside, they are rounded on the end, during interlocking they do not converge. Canines and small molars are deleted buy such forceps, but with wider cheeks. Cheeks of forceps for removal of incsors of the lower jaw, are narrow with fillets on inside, they are rounded on the end, during interlocking they do not converge. Canines and small molars are deleted buy such forceps, but with wider cheeks.

Forceps for removal of the big molars have wide cheeks which do not converge. Each of them ends by triangular bend(thorn). From the inside both cheeks have a dimple. During superimposing on tooth bends enter the furrow between front and back roots that provides good fixing of forceps on tooth. Forceps for removal of the big molars have wide cheeks which do not converge. Each of them ends by triangular bend(thorn). From the inside both cheeks have a dimple. During superimposing on tooth bends enter the furrow between front and back roots that provides good fixing of forceps on tooth. In case of restricted opening of a mouth,big molars are deleted by the horizontal forceps, bent on a plane. They are constructed differently, than beaklike. Handles and the lock are allocated at an angle which comes nearer to direct and is in a vertical plane. A working part of brushes is the same, as the beaklike forceps for removal of the big molars, bent on an edge. Roots of all teeth of the lower jaw are deleted by forceps of the same form, as incisors, canines and small molars, only by cheecks that converge. In case of restricted opening of a mouth,big molars are deleted by the horizontal forceps, bent on a plane. They are constructed differently, than beaklike. Handles and the lock are allocated at an angle which comes nearer to direct and is in a vertical plane. A working part of brushes is the same, as the beaklike forceps for removal of the big molars, bent on an edge. Roots of all teeth of the lower jaw are deleted by forceps of the same form, as incisors, canines and small molars, only by cheecks that converge.

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

Elevators. Elevators. Extracting teeth by elevetaors, as well as by forceps, use the lever principe. Elevator consists of three parts: Extracting teeth by elevetaors, as well as by forceps, use the lever principe. Elevator consists of three parts: The working part, the connective rod and the handle. There are many different constructions of elevetaors, however the most widespread are three types: straight, angular and beaklike elevator. The working part, the connective rod and the handle. There are many different constructions of elevetaors, however the most widespread are three types: straight, angular and beaklike elevator. Straight elevator. Its working part is a continuation of the connective rod and together with the handle are allocated on one direct line. The cheek on the one hand convex, semicircular, from the other – bent, also looks like a fillet, the end is refined and rounded. Straight elevator. Its working part is a continuation of the connective rod and together with the handle are allocated on one direct line. The cheek on the one hand convex, semicircular, from the other – bent, also looks like a fillet, the end is refined and rounded.

Straight elevators are intended for removal of roots of teeth,of the upper jaw which have one root. They are intented for removal of teeth of the upper jaw allocated out of a tooth arc, rarely - the lower third molar. Straight elevators are intended for removal of roots of teeth,of the upper jaw which have one root. They are intented for removal of teeth of the upper jaw allocated out of a tooth arc, rarely - the lower third molar. Angular elevator. The working part (cheek) is bent on an edge and allocated to longitudinall axis by the elevator at an angle, approximately 120 ⁰. Angular elevator. The working part (cheek) is bent on an edge and allocated to longitudinall axis by the elevator at an angle, approximately 120 ⁰.

Cheek small.One of its surface is convex, the second - slightly bent with longitudinal edges. The concave surface of a cheek at one elevator is turned to left (to itself), in others - to the right - from itself. Cheek small.One of its surface is convex, the second - slightly bent with longitudinal edges. The concave surface of a cheek at one elevator is turned to left (to itself), in others - to the right - from itself. In an elevator operation time, the concave surface of a cheek is directed to a root, which is being deleted, convex - to a cell wall. In an elevator operation time, the concave surface of a cheek is directed to a root, which is being deleted, convex - to a cell wall. Angular elevator is used for removal of the lower teeth. Angular elevator is used for removal of the lower teeth. Bayonetlike elevator (Lekljuz Elevator).Connective rod of elevator is bayonetlike, curve. The working part has spearlike form. It is narrowed and thiner in finite department. The handle is round, thicker in the middle part, allocated perpendicular to connective rod and to working part. Elevator is intended for removal of the third lower molar. Bayonetlike elevator (Lekljuz Elevator).Connective rod of elevator is bayonetlike, curve. The working part has spearlike form. It is narrowed and thiner in finite department. The handle is round, thicker in the middle part, allocated perpendicular to connective rod and to working part. Elevator is intended for removal of the third lower molar.

Types of elevators:

Lekljuz elevator

Types of elevators: Types of elevators:

Stages of operation of removal of tooth: Stages of operation of removal of tooth: Operations of removal of tooth,are being led by forceps, also consists of several serial stages: Operations of removal of tooth,are being led by forceps, also consists of several serial stages: 1.) Superimposing of forceps 1.) Superimposing of forceps 2.) Advancement of forceps 2.) Advancement of forceps 3.) Interlocking of forceps (fixing) 3.) Interlocking of forceps (fixing) 4.) A tooth Dislocation (luxation or tooth rotation) 4.) A tooth Dislocation (luxation or tooth rotation) 5.) Deduction of tooth from a cell (traction) 5.) Deduction of tooth from a cell (traction)

Extraction of teeth, and it’s roots using drill, hammer and chisel. Extraction of teeth, and it’s roots using drill, hammer and chisel. In such cases, when tooth or the root can’t be removed by using forceps or elevator, it is necessary to use drill, hammer or chisel. as an indication to such operation could be presence of a root or tooth which was not erupt, or a root with the curved top, and also expressed hypercementosis. This method is used more often, when extracting of the bottom wisdom tooth is needed. In such cases, when tooth or the root can’t be removed by using forceps or elevator, it is necessary to use drill, hammer or chisel. as an indication to such operation could be presence of a root or tooth which was not erupt, or a root with the curved top, and also expressed hypercementosis. This method is used more often, when extracting of the bottom wisdom tooth is needed. Processing of a wound after tooth removal. After the termination of operation of removal of tooth it is necessary to examine it carefully. Presence of keen edges in the root channel testify a root crisis. It’s unallowed to leave the broken root in a cell, especially if removal was spent concerning a sharp purulent periodontitis. Root removal needs to be finished by using hammer, drill, or chisel. Processing of a wound after tooth removal. After the termination of operation of removal of tooth it is necessary to examine it carefully. Presence of keen edges in the root channel testify a root crisis. It’s unallowed to leave the broken root in a cell, especially if removal was spent concerning a sharp purulent periodontitis. Root removal needs to be finished by using hammer, drill, or chisel.

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

Complication, that can occur during, and after tooth exraction. Complication, that can occur during, and after tooth exraction. Root crisis can be prevented by using the method of section and separation of gums, with the following chisel debridement of cell wall, to one third of length, and also by using forceps for root extraction. Root crisis can be prevented by using the method of section and separation of gums, with the following chisel debridement of cell wall, to one third of length, and also by using forceps for root extraction. Damage of soft tissues, occurs during careless, rough manipulations of physician, disorder of tooth extraction technique. Damage of soft tissues, occurs during careless, rough manipulations of physician, disorder of tooth extraction technique. When insufficient gums dislayering, before tooth extraction, rupture of mucous membrane often occurs during operation; When insufficient gums dislayering, before tooth extraction, rupture of mucous membrane often occurs during operation; In case of wrong tooth extraction technique, when a doctor imposes forceps directly on a mucous membrane, dislayered it not enough from the cell process, or a part. In case of wrong tooth extraction technique, when a doctor imposes forceps directly on a mucous membrane, dislayered it not enough from the cell process, or a part. In case of careless dislocating of roots, by direct elevator, tissue damage of the bottom of oral cavity, tongue(when removing the roots of lower molars) and palate(when removing the roots of upper molars) occurs. In case of careless dislocating of roots, by direct elevator, tissue damage of the bottom of oral cavity, tongue(when removing the roots of lower molars) and palate(when removing the roots of upper molars) occurs.

On a background of the damage of soft tissues, bleeding occurs, which complicates the work of a doctor, while tooth extracting; In postoperative period, inflammatory complications can occur. On a background of the damage of soft tissues, bleeding occurs, which complicates the work of a doctor, while tooth extracting; In postoperative period, inflammatory complications can occur. A technique of granting of the urgent help: a stop of a bleeding and suturing the wound. A technique of granting of the urgent help: a stop of a bleeding and suturing the wound.

a fragment break of cell parts (more often on the bottom jaw) - damage of tisses arises: a fragment break of cell parts (more often on the bottom jaw) - damage of tisses arises: -Under condition of an union of a tooth root with cell walls; -Under condition of an union of a tooth root with cell walls; -In case of deep imposing cheeks of nippers on cell walls - thus tooth removes together with a bone tissues. -In case of deep imposing cheeks of nippers on cell walls - thus tooth removes together with a bone tissues. Technique of granting the urgent medical aid: to smooth down (if necessary - to remove) sharp, unequal edges of a cell of tooth, to suture a mucous membrane. Technique of granting the urgent medical aid: to smooth down (if necessary - to remove) sharp, unequal edges of a cell of tooth, to suture a mucous membrane. Break of a tuber of the top jaw arises during removal of the third top molar, as a result of deep imposing forceps cheeks on walls of a cell, or a rough dislocation of tooth by straight elevator: Break of a tuber of the top jaw arises during removal of the third top molar, as a result of deep imposing forceps cheeks on walls of a cell, or a rough dislocation of tooth by straight elevator: In such case, there is a broken off fragment of a tuber of the top jaw on extracted tooth (roots) In such case, there is a broken off fragment of a tuber of the top jaw on extracted tooth (roots) -a considerable bleeding occurs; -a considerable bleeding occurs; -If the maxillar sinus is damaged, vials of air from the extracted tooth cell occure during attempt to blow air through closed with fingers nose. -If the maxillar sinus is damaged, vials of air from the extracted tooth cell occure during attempt to blow air through closed with fingers nose. The technique of granting urgent help: smoot keen edges of tooth cell by bone spoon, mobilize and suture tightly a mucous membranem so that a bone wound would be completely closed. If the stomatologist cannot independently stop a bleeding, and suture a wound, he put iodoform tampon and transport’s the patient immediately in a surgical stomatologic department. The technique of granting urgent help: smoot keen edges of tooth cell by bone spoon, mobilize and suture tightly a mucous membranem so that a bone wound would be completely closed. If the stomatologist cannot independently stop a bleeding, and suture a wound, he put iodoform tampon and transport’s the patient immediately in a surgical stomatologic department.

Perforation of the bottom of maxillar sinus arises during removal of the first top molar, sometimes - the second and premolar. Perforation of the bottom of maxillar sinus arises during removal of the first top molar, sometimes - the second and premolar. It is explained, that tops of the given teeth are closely located to the bottom of sinus. It is explained, that tops of the given teeth are closely located to the bottom of sinus. Perforation of the bottom of maxillar sinus can occur, when: Perforation of the bottom of maxillar sinus can occur, when: -Traumatic removal of the named teeth (if rough manipulation in a tooth cell is done), and during careless manipulations; -Traumatic removal of the named teeth (if rough manipulation in a tooth cell is done), and during careless manipulations; -Owing to anatomic features, when the root is located under a sinus mucous membrane; -Owing to anatomic features, when the root is located under a sinus mucous membrane; -When inflammatory process on a top of a root has destroyed a sinus bottom. -When inflammatory process on a top of a root has destroyed a sinus bottom. Diagnostics: Diagnostics: During careful tubage of a cell, the instrument gets for the length more than the deepnes of the cell. During careful tubage of a cell, the instrument gets for the length more than the deepnes of the cell. On the basis of passage of the air from the oral cavity, into a nasal cavity, ot contrary. The patient, having clamped fingers on his nose, should try to blow the air throughout it. Thus air through an aperture (perforation) of the bottom of maxillar sinus leaves it with a whistle and goes into oral cavity, or blood vials of air from a cell of extracted tooth occur; On the basis of passage of the air from the oral cavity, into a nasal cavity, ot contrary. The patient, having clamped fingers on his nose, should try to blow the air throughout it. Thus air through an aperture (perforation) of the bottom of maxillar sinus leaves it with a whistle and goes into oral cavity, or blood vials of air from a cell of extracted tooth occur; Radiological research is conducted (an aim picture). Radiological research is conducted (an aim picture).

Technique of granting urgent medical aid in case of perforation of maxillar sinus: Technique of granting urgent medical aid in case of perforation of maxillar sinus: -In the presence of a purulent antritis (pus is goin out from a tooth cell, through a perforated aperture) in entrance of cell iodoform tampon and hospitalization of the patient in maxillofacial deparment; -In the presence of a purulent antritis (pus is goin out from a tooth cell, through a perforated aperture) in entrance of cell iodoform tampon and hospitalization of the patient in maxillofacial deparment; -In case of pushing a root through in a sinus, its removal in the conditions of a hospital is indicated; -In case of pushing a root through in a sinus, its removal in the conditions of a hospital is indicated; -In case of a healthy sinus (when radiological research does not reveal a root in a sinus) it is necessary to close a perforated aperture (a cell of extracted tooth) by a mucosial rag, taken from a vestibular surface of cell process. If the doctor has not mastered this technique, he should tightly suture a cell (to Impose 2-3 seams of polyamides). -In case of a healthy sinus (when radiological research does not reveal a root in a sinus) it is necessary to close a perforated aperture (a cell of extracted tooth) by a mucosial rag, taken from a vestibular surface of cell process. If the doctor has not mastered this technique, he should tightly suture a cell (to Impose 2-3 seams of polyamides).

The bleeding arises after operation of removal of tooth. Distinguish early bleedings and late. Early bleedings, arise right after removals of tooth (trauma). The bleeding arises after operation of removal of tooth. Distinguish early bleedings and late. Early bleedings, arise right after removals of tooth (trauma). Late bleedings can arise: Late bleedings can arise: 1)In some hours after tooth removal, for example in case of adrenaline overdose. 1)In some hours after tooth removal, for example in case of adrenaline overdose. 2)For some days after operation which becomes complicated by an inflammatory process. 2)For some days after operation which becomes complicated by an inflammatory process.

Anatomical and physiological features of the development and structure of tissues and organs maxillofacial area (SCHLD) in children. Local and general.

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Anatomical and physiological features of the development and structure of tissues and organs maxillofacial area (SCHLD) in children. Local and general.

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Presentation on theme: "Anatomical and physiological features of the development and structure of tissues and organs maxillofacial area (SCHLD) in children. Local and general."— Presentation transcript:

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