1. Classification of inflammatory processes of MFA
Classification of inflammatory processes of MFA. Periodontitis: etiology, pathogenesis, classification, clinical course, complications, prophylaxis. Odontogenic granuloma of the face: clinic, treatment. Detained and halfdetained teeth. Etiology, clinic, diagnostics, treatment, complications. Pericoronaritis. Odontogenic jaw periostitis: etiology, clinic, diagnostics, treatment, complications, prophylaxis.

2. PERIAPICAL DISEASE Classified as: Acute Apical Periodonitis
Acute Apical Abscess
Chronic Apical Periodontitis
(Diffuse, Suppurative Apical Periodontitis with sinus tract, Apical cyst)
Condensing Osteitis

3. Definition
The fundamental lesion of chronic periapical inflammation is known as ´´chronic apical periodontitis´´
While this designation is the preferred one, most dentists know it by the term ´´dental granuloma´´
The lesion is not a granuloma at all because it is not composed of granulomatous chronic inflammation.

4. Classification 1) Diffuse type:
- small, recurrent amount of tissue damage
- cellular infilltration with lymphocytes,
plasma cells, phagocytic mononuclear
cells, fibroblasts which produce
granulation tissues for repair of damaged
area
GRANULOMA: formation of large nodule of
granulation tissue that is slowly increase in size
Resorption of hard tissue, granulation tissue
around apex (outlined by capsule of fibrous
tissue)

5. 2) Chronic suppurative periodontitis
- central cavity which is accompanied
with fistula and stroma
- its known as chronic apical abscess
( chronic alveolar abscess)
3) Apical cyst
- true cyst: pathologic cavity which
contain fluid or semi-fluid substance
that is lined by epithelium and
surrounded by connective tissue
capsule

6. Measurement of the tooth canal length
Case 1, fig.1a
21-years old woman-non successful endodontic treatment tooth N.22,apical clear radiolucency confirming an established lesion bigger than 3mm,it shows features of lamina dura disruption and bone structural changes
Case 1, fig.1b
Measurement of the tooth canal length

7. Final endodontic treatment Foredent and gutapercha
Case 1,fig.1c
Final endodontic treatment Foredent and gutapercha
Case 1,fig.1d
5 months after the endodontic treatment without any surgical procedure,intraoral x-ray shows chronic apical periodontitis, partial restitution of the periapical region

8. Orthopantogram image,unsuccessful endodontic treatment d.N.22,
Case 2,fig.2a
Orthopantogram image,unsuccessful endodontic treatment d.N.22,
Cystis radicularis D.N.22

9. Case 2,fig.2c
3months after the therapy-Cystectomio sec.PARTSCH II. et resectio apicis dentis N Retrograde root canal endodontic therapy with amalgam Egalisatio,suturae
Case 2,fig.2b
Intraoral image D.22-Cystis radicularis processus alveolaris maxillae reg.frontalis purulenta

10. Granuloma periapicalis and infection transmission paths
Fig.B
Granuloma periapicalis and infection transmission paths

11. Chronic apical periodontitis
Chronic apical periodontitis. Extensive tissue destruction in the periapical region of a mandibular first molar occurred as a result of pulpal necrosis. Lack of symptoms together with presence of a radiographic lesion is diagnostic.

12. Periapical radiolucencies associated with mandibular incisors
Periapical radiolucencies associated with mandibular incisors. These teeth were vital, and a diagnosis of cemental dysplasia was made.

13. Periodontitis chronica circumscripta d.41

14. PULPITIS PATHWAYS

15. PATHOGENESIS OF PULPAL INFLAMMATION

16. SPREAD TO ADJACENT STRUCTURES

17. SPREAD TO ADJACENT STRUCTURES

18. SPREAD TO ADJACENT STRUCTURES

19. CLINICAL FEATURES HYPERSENSITIVE TOOTH UPON BITING OR PERCUSSION
NEGATIVE RESULTS IN BOTH ELECTRIC OR THERMAL STIMULI
BEING ACUTE IN NATURE, ON RADIOGRAPH THERE IS MILD THICKENING OF THE APICAL PERIODONTAL LIGAMENT SPACE.
IN CASES OF RECURRING CHRONIC EVENTS, PERIAPICAL CHANGES (LUCENCIES) MAYBE SEEN (PERIAPICAL GRANULOMA)

20. PERIAPICAL GRANULOMA
IN CASES OF LOW GRADE BUT CHRONIC INFLAMMATION AT THE APEX OF A NON VITAL TOOTH GRANULOMA IS USED ON AGAINST THE TERM ABSCESS WHICH IS OF ACUTE IN NATURE.

22. PULP ABSCESS

23. TREATMENT
DRAINAGE ESTABLISHMENT WITHIN THE TOOTH ITSELF OR ON THE SURROUNDING SOFT TISSUES
ANTIBIOTIC THERAPY
SKILLED AND THOUGHTFUL MANAGEMENT MUST BE EMPLOYED SINCE ANY DELAY MAY CAUSE ANY LETHAL CONSEQUENCE.

24. COMPLICATIONS
PUS MAY DRAIN ON NATURALLY OCCURING DRAINS TERMED AS FISTULAS OR SINUS TRACTS WHICH MAY BE SEEN ON SKIN OR ON THE PALATE
IF THERE IS NO DRAIN MADE CELLULITIS ENSUES AFTER THE PUS BUILDUP.
IT IS AN ACUTE INFLAMMATORY SPREAD ON THE NEARBY SOFT TISSUES
ENZYMES ARE PRODUCED BY HIGHLY VIRULENT MICROORGANISMS PRESENT

25. COMPLICATIONS
BILATERAL SUBMANDIBULAR AND SUBLINGUAL SPACES ARE KNOWN AS “LUDWIG'S ANGINA”
FATALITIES USUALLY RESULTS FROM BACTEREMIA FROM INFECTION SPREADING INTO THE MAJOR BLOOD VESSELS OR THROUGH A RETROGRADE SPREAD OF INFECTION INTO THE FACIAL EMISSARY VEINS INTO THE CAVERNOUS SINUS, CAVERNOUS SINUS THROMBOSIS

26. CAVERNOUS SINUS

27. Severe Ludwig's Angina

29. IMPACTED TEETH
An impacted tooth is one that is partially erupted or unerupted and will not eventually assume a normal arch relationship withother teeth and tissues.

30. Causes of Impacted Teeth
Role of civilization
Local causes of Impaction
Systemic causes of impaction

32. Local causes of Impaction
Lack of space in the dental arch for eruption;
The density of the overlying or surrounding bone ;
Long continued chronic inflammation with resultant increase in the density of the overlying mucous membrane ;
Premature loss of the primary teeth ;
Acquired diseases, such as necrosis due to infection or abscesses, and inflammatory changes in the bone due to exanthematous diseases in children;

33. Lack of space in the dental arch for eruption

34. Impacted teeth occur in the following order
Mandibular third molars
Maxillary third molars
Maxillary cuspids
Mandibular bicuspids
Mandibular cuspids
Maxillary bicuspids
Maxillary central incisors
Maxillary lateral incisors
Maxillary or mandibular first molars are rarely impacted

35. Impacted teeth

36. Classification of impacted mandibular third molars
A. Relation of the tooth to the ramus of the mandible and the second molar ;
B. Relative depth of the third molar in bone;
C. The position of the long axis of the impacted mandibular third molar in relation to the long axis of the second molar : vertical, horizontal, inverted, mesioangular, distoangular, buccoangular, linguangular.

37. Classification of impacted mandibular third molars

38. Radiographic visualization of impacted teeth

39. The removal of impacted mandibular third molars

40. Scheme of Periconitis

41. Scheme of Periostitis ( upper jaw )

42. Scheme of Periostitis ( lower jaw )

43. Acute Periostitis left upper jaw

44. Acute Periostitis left lover jaw

45. Acute Periostitis of hard pallate

46. Surgical treatment of periostitis

47. Treatment of abscess of hard pallatine

49. Class1
the space between the anterior part of the ascending ramus and the distal surface of the 2nd molar is sufficient to accommodate the mesiodistal diameter of the crown of the third molar.

50. Class2
the space between the anterior part of the ascending ramus and distal surface of the 2nd molar is less than the mesiodistal diameter of the crown of the third molar (part of the tooth located within the ramus)

51. Class3
all the third molar is located within the ascending ramus of the mandible.

52. B - Relative depth of the third molar in bone:
- this show the superior inferior relationship of the tooth in relation to the occlusal plan. (Pell & Gregory)
Position A:
the highest portion of the tooth is on level with or above the occlusal plane.
Position B:
the highest portion is below the occlusal
plane but above the cervical margin of the 2nd molar
Position C:
the highest point of the tooth is below the
cervical margins of the 2nd molar (deep impaction)

53. 3-mesioangular impaction. 4-destoangular impaction:
C - the position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar (winter's classification):
1-vertical: the long axis of the third molar is parallel to that of the 2nd molar.
2-horizontal:the long axis of the third molar is at right angle to that of the 2nd molar .
3-mesioangular impaction.
4-destoangular impaction:
all the previous four classes can come in:
a - lingual deflection.
b - buccal deflection.
5-inverted impaction

56. 1- gaining access to impacted tooth:
A- elevation of an adequate mucoperosteal flap to expose the field of surgery:
Pyramidal flap used in all third molar impaction, the anterior incision of the flap could extend from the distal aspect to 2nd molar running at 45 degree angel and extend to the mucobucal fold.
In deep impaction ,a bigger flap is advisable. the anterior incision could start from the mesial aspect of 2nd molar

57. Surgical Extraction of Impacted Molars
Envelope Incision and reflection
When more accessibility is needed , a releasing incision is made.

58. Envelope Flap Incision and Reflection
Triangular Flap Incision and Reflection

59. extraction of
impacted maxillary
3rd molar

60. with palatally impacted maxillary cuspid
- exposure of the field of surgery can be done by gingival incision extending from the palatal side of premolar in one side to other side all around the palatal gingiva of the present teeth.
with labially placed impaction
- a labial pyramidal flap is adequate

61. 2- bone removal This is done for :- A- exposure of impaction
B- reduction of resistance
C- making a point for application of the elevator

62. Bone Removal With a Fissure Surgical Bur

63. 3- tooth delivery
1- total delivery by application of force using elevators:
a- mesial application of force :straight elevators and pot's elevators.
b- buccal application of force :winter elevator
2-delivery of the tooth after tooth division :
- division is indicated to reduce resistance ,create a space or remove interlocked cusps of the tooth
a- decapitation:- division of the crown of the tooth at cervical margin level .
- indicated in horizontal mandibular and maxillary third molar impaction and pallataly impacted maxillary cuspid
b- longitudinal tooth division:
- indicated when the impacted tooth has a widely divergent straight roots, or when one root is straight and the other is curved
c- division of the interlocking cusp:
- this is done with mesioangular impaction ,removal of the inter locking segment of the tooth usually located under the distal surface of 2nd molar

64. Bone is removed with the surgical bur to expose the whole crown
Decapitation is then performed
A purchase point is prepared in the root, which is then removed with an elevator
The second root is removed in the same way

66. Preparation for wound closure:
- after removal of the tooth from it's socket the wound is gently irrigated with sterile normal saline solution and inspected for:
a- any remnant of the residual tooth sac is removed
b- remnant of tooth structure or fragments of bone debris is gently removed
c- small fragments of the detached bone
d- sharp edges of interseptal or alveolar bone is trimmed and smoothed
- then final irrigation and wound now is ready for closure.

67. closure of the wound: post operative care:
well designed and properly reflected flap fall back easily into place. using have circle a traumatic needle and 000 black silk suture to hold flap into place
post operative care:
a pressure pack is held in place for 1hour
post operative instruction given to pt:
cold packs on outside of face 20 min/h 5 time daily
proper antibiotic therapy
mouth wash
soft diet
patient return back for check up after two days
suture removal after 5 days

68. post operative complication:
pain.
infection
heamoraghe
anesthesia or parenthesis of the lingual or inferior alveolar nerve
trismus,limitation of jaw movement
osteomylitis
pain at tmj
pain on swallowing due to edema of pharynx and hematoma formation.

69. Thank you