PiezoSurgery in Extraction of the lower third molar

The Importance of PiezoSurgery in Extraction of the lower third molar

How to extract upper and lower impacted supernumerary premolars ..!

How to extract the impacted supernumerary Premolars Upper and Lower

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Contraindications of Dental Implants (Absolute, Relative and Local)

1- ABSOLUTE CONTRAINDICATIONS

Implants can not be placed in these situations:

Heart:
• Heart diseases affecting the valves (valvulopathy)
• Recent infarcts
• Severe cardiac insufficiency, cardiomyopathy

Miscellaneous:
• Active cancer, certain bone diseases (osteomalacia, Paget’s disease, brittle bones syndrome, etc.),
• Certain immunological diseases, immunosuppressant treatments, clinical AIDS, awaiting an organ transplant,
• Certain mental diseases,
• Strongly irradiated jaw bones (radiotherapy treatment),
• Treatments of osteoporosis or some cancers by bisphosphonates

Age:
• Children: not before the jaw bones have stopped growing (in general 17-18 years).
On the other hand advanced age does not pose problems if the patient’s general condition is good.

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2- RELATIVE CONTRAINDICATIONS

The indication to place implants will be evaluated on a case-by-case basis, with the greatest caution:

• Diabetes (particularly insulin-dependent),
• Angina pectoris (angina),
• Seropositivity (absolute contraindication for clinical AIDS),
• Significant consumption of tobacco (read pdf)
• Certain mental diseases,
• Radiotherapy to the neck or face (depending on the zone, quantity of radiation, localisation of the cancerous lesion etc.),
• Certain auto-immunes diseases,
• Drug and alcohol dependency,
• Pregnancy.

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3- RELATIVE LOCAL CONTRAINDICATIONS

The indication to place implants will be evaluated on a case-by-case basis, with caution:

• An insufficient quantity of bone.
• Certain diseases of the mucous membranes of the mouth.
• Periodontal diseases (loosening of the teeth); it is necessary to clean up the gums and stabilise the disease first.
• Severe grinding or clenching of the teeth.
• An unbalanced relationship between the upper and lower teeth.
• Infections in the neighbouring teeth (pockets, cysts, granulomas), major sinusitis.
• Poor hygiene of the mouth and teeth.

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Bronchial (Pharyngeal) Arches

:: 1st Pharyngeal Arch (also called "mandibular arch") ::

Muscular contributions

Muscles of mastication, anterior belly of thedigastric, mylohyoid, tensor tympani, tensor veli palatini

Skeletal contributions

Maxilla, mandible (only as a model for mandible not actual formation of mandible), the incus, and the malleus of the middle ear, also Meckel's cartilage

Nerve

Trigeminal nerve(V2 and V3)

Artery

Maxillary artery, external carotid artery

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:: 2nd Pharyngeal Arch (also called the "hyoid arch") ::
Muscular contributions

Muscles of facial expression, buccinator,platysma, stapedius, stylohyoid, posterior belly of the digastric 

Skeletal contributions

Stapes, temporal styloid process, hyoid (lesser horn and upper part of body), Reichert's cartilage 

Nerve

Facial nerve (VII)

Artery

Stapedial artery, hyoid artery

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:: 3rd Pharyngeal Arch ::

Muscular contributions

Stylopharyngeus

Skeletal contributions

Hyoid (greater horn and lower part of body), thymus, inferior parathyroids

Nerve

Glossopharyngeal nerve (IX)

Artery

Common carotid, internal carotid

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:: 4th Pharyngeal Arch ::

Muscular contributions

Cricothyroid muscle, all intrinsic muscles of soft palate (including levator veli palatini) except tensor veli palatini

Skeletal contributions

Thyroid cartilage, superior parathyroids, epiglottic cartilage

Nerve

Vagus nerve (X),superior laryngeal nerve

Artery
Right 4th aortic arch:subclavian artery
Left 4th aortic arch: aortic arch

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:: 6th Pharyngeal Arch ::

Muscular contributions

All intrinsic muscles of larynx except the cricothyroid muscle

Skeletal contributions

Cricoid cartilage, arytenoid cartilages, corniculate cartilage, cuneiform cartilages

Nerve

Vagus nerve (X), recurrent laryngeal nerve

Artery

Right 6th aortic arch: pulmonary artery
Left 6th aortic arch: pulmonary artery and ductus arteriosus

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Muscles of the Face and Scalp

- Those muscles receive motor innervation from branches of the facial nerve (CN VII).

- Rather than inserting into bone, these muscles insert into the dermis of the skin, thus their orchestrated contractions convey various shapes to the face that we interpret as emotions.

Scalp

Muscle	Location	Origin
Frontalis	Forehead	Procerus, corrugator, orbicularis oculi
Occipitalis	Back of the head	Mastoid process and superior nuchal line
Temporoparietalis	Temple	Temporal fascia

Ear

Muscle		Location	Origin
Auricularis anterior	Anterior to ear		Temporal fascia
Auricularis superior	Above ear		Temporal fascia
Auricularis posterior	Behind ear		Mastoid process

Nose

Muscle	Location	Origin
Procerus
Nasalis
Depressor septi

Eye

Muscle		Location	Origin
Orbicularis oculi	Around the orbit		Nasal process of frontal bone, frontal process of maxilla, medial palpebral ligament, and lacrimal bone
Corrugator	Deep to the orbicularis oculi		Medial aspect of superciliary arch

Mouth

Muscle		Location		Origin
Levator labii superioris	Upper lip		Zygoma and maxilla just above infraorbital foramen
Levator labii superioris alaque nasi	Upper lip and side of nose		Maxilla, frontal process
Levator anguli oris	Corner of mouth		Canine fossa of maxilla
Zygomaticus major	Cheek and corner of mouth		Temporal process of zygoma
Zygomaticus minor	Cheek and corner of mouth		Maxillary process of zygoma
Risorius	Cheek		Masseteric fascia
Depressor labii inferioris	Lower lip		Oblique line of mandible
Depressor anguli oris	Corner of mouth		Oblique line of mandible
Mentalis	Chin		Incisive fossa of mandible
Orbicularis oris	Circumscribes the mouth		Muscles in the vicinity, maxilla, nasal septum, mandible
Buccinator	Cheek		Pterygomandibular raphe, alveola arches of mandible and maxilla

Neck

Muscle		Location		Origin
Platysma	Neck and chin		Pectoral and deltoid fascia

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Rarefaction (Definition and Examples)

Definition: A decreased density of bone such as a decrease in weight per unit of volume

Examples of Systemic diseases causing generalized jaw rarefaction

1- Rickets/Osteomalacia
2- Sickle Cell Anemia
3- Cushing syndrome
4- Hypophosphatasia
5- Hypophosphatemia
6- Massive osteolysis (vanishing bone disease)
7- Osteoporosis

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Enucleation of Oral Cysts

- Description:

- Enucleation is the process by which the total removal of a cystic lesion is achieved.

- By definition, it means a shelling-out of the entire cystic lesion without rupture.

- A cyst lends itself to the technique of enucleation because of the layer of fibrous connective tissue between the epithelial component (which lines the interior aspect of the cyst) and the bony wall of the cystic cavity.

- This layer allows a cleavage plane for stripping the cyst from the bony cavity and makes enucleation similar to stripping periosteum from bone.

- Enucleation of cysts should be performed with care, in an attempt to remove the cyst in one piece without fragmentation, which reduces the chances of recurrence by increasing the likelihood of total removal.

- In practice, maintenance of the cystic architecture is not always possible, and rupture of the cystic contents may occur during manipulation.

- The Periapical (i.e., Radicular) cyst is the most common of all cystic lesions of the jaws.

- After removing the Cyst, the bony cavity fills with a blood clot, which then organizes over time.

- Radiographic evidence of bone fill will take 6 to 12 months after removing the cyst.

- Jaws that have been expanded by cysts slowly remodel to a more normal contour.

- If the primary closure should break down and the wound dehiscence occurs,
1- Recall visits for irrigation every 3-4 days.
2- Strip gauze lightly impregnated with an antibiotic ointment should be gently packed into the cavity.
3- in 3-4 days, then cavity will start to be filled with granulation tissue.

- Indications:
1- Enucleation is the treatment of choice for removal of cysts of the jaws and should be used with any cyst of the jaw that can be safely removed without unduly sacrificing adjacent structures.
2- Small Cysts
3- Away from Important Anatomical Structures.
4- Not at the bone margins (may lead to jaw fracture)
5- Not associated with teeth, roots or important structures.

- Advantages:
1- The main advantage to enucleation is that pathologic examination of the entire cyst can be undertaken.
2- Another advantage is that the initial excisional biopsy (i.e., enucleation) has also appropriately treated the lesion.
3- The patient does not have to care for a marsupial cavity with constant irrigations.
4- Once the mucoperiosteal access flap has healed, the patient is no longer bothered by the cystic cavity.

- Disadvantages:
If any of the conditions outlined under the section on indications for marsupialization exist, enucleation may be disadvantageous. For example,
1- Normal tissue may be jeopardized,
2- Fracture of the jaw could occur,
3- Ddevitalization of teeth could result, or associated impacted teeth that the clinician may wish to save could be removed.

- Technique: (Small Cysts)
1- Remove all possible irritants before starting with enucleation procedure (ex: subgingival and supragingival scaling and stains).
2- Administration of Local Anesthetic Solution, Lignocaine 2% with adrenaline 1:200,000 is used.
3- Nerve Block associated with an infiltration is preffered.
4- Flap design is picked accoring to the possition of the lesion (ex: crevicular incision with a 2 vertical releasing incisions to give a good access and visibility to the lesion).
5- Use Mucoperiosteal Elevator to raise the flap. (care not to tear tissues)
6- Use burs to remove all thin, resorbed, infected and soften bone. (care not to remove excessive bone or damage to adjacent roots and anatomical structures)
7- Remove the entire cyst carefully. (care not to tear or punch the cyst lining).
8- A Piece of rolled gauze is hold by a hemostat and inserted between the cavity and the lining.
9- The Cavity is then rinsed with Saline and Betadine.
10- The bony edges of the defect should be smoothed with a bone file before closure.
11- Reposition the flap, and suture it then with the proper suture type and suturing technique. (Vertical Mattress interrupted is preffered using a Black Braided Silk Suture type).

- The use of antibiotics is unnecessary unless the cyst is large or the patient's health condition warrants it.

- If, on the other hand, the tooth is restorable, endodontic treatment followed by periodic radiographic follow-up will allow assessment of the amount of bone fill.

- When extracting teeth with periapical radiolucencies, enucleation via the tooth socket can be readily accomplished using curettes when the cyst is small. (Caution is used in teeth whose apices are close to important anatomic structures, such as the inferior alveolar neurovascular bundle or the maxillary sinus, because the bone apical to the lesion may be very thin or nonexistent).

- Technique: (Large Cysts)
1- A mucoperiosteal flap may be reflected and access to the cyst obtained through the labial plate of bone, which leaves the alveolar crest intact to ensure adequate bone height after healing.
2- Open an osseous window, and begin to enucleate the cyst.
3- A thin-bladed curette is a very suitable instrument for cleaving the connective tissue layer of the cystic wall from the bony cavity.
4- The largest curette that accommodates the size of the cyst should be used.
5- The concave surface should always be kept facing the bony cavity—the edge of the convex surface performs the stripping of the cyst.
6- try to keep in cyst margins intact to facilitate its removal.
7- The cyst separates more readily from the bony cavity when the intracystic pressure is maintained.
8- Nerves and Vessels might be embedded or pushed to one side of the large cyst, thus, should be carefully handled.
9- Inspected the bony cavity for remnants of tissue.
10- Irrigating and drying the cavity with gauze will aid in visualizing the entire bony cavity.
11- Residual tissue is removed with curettes.
12- The bony edges of the defect should be smoothed with a bone file before closure.

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Gingival Hyperplasia

- Enlargement of gums or gingiva is called gingival hyperplasia in the dental terms.

- This occurs due to abnormal multiplication of gingival tissues due to various factors. 

- When an individual is diseased with gingival hyperplasia then the gums become swollen and enlarged. 

- If you are suffering from gingivitis there will be bleeding in the gums as well as tenderness. 

- The teeth get covered with the gums if the infection is too intense. 

- The patient is examined by a dentist and then the patient is sent for further examination if any further complications are seen.

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Causes:

There are several causes of gingival hyperplasia:

- Inflammatory and granulomatous disorders "like Hand-Schuller-Christian syndrome"

- Auto-immune disorders "like plasma cell gingivitis which is associated with allergic and collagenous nature"

- Neoplastic disorders "like acute leukemia and monocytic leukemia"

- Metabolic and storage disorders "like aspartylglycosaminuria, genetic disorders like Cross syndrome"

- Toxicity of drugs.

- Excess of deposition of drugs given to a patient. It is also called as Drug-Induced Gingival Overgrowth (DIGO).

- Immunosuppressant like Cyclosporin, anticonvulsants like valproate, phenytoin, phenobarbital, primidone and calcium channel blockers like nifedipine, verapamil and amlodipine.

Note: Cyclosporin and phenytoin toxicity are the important toxicities caused in a patient especially in case of dental plaque where these drugs get deposited on the tooth.

Causes of Gingival Enlargement is divided into five groups:
- Inflammatory Enlargement
- Enlargement due to systemic /genetic diseases
- Neoplastic enlargement
- False enlargement
- Drug induced enlargement
- Gingival Hyperplasia differential diagnosis

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Diagnosis:

- Mainly done by differential diagnosis.

- IFN-gamma-stimulated gene expression which is important to determine the presence of gingival hyperplasia in the body.

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Treatment:

The treatment of gingival hyperplasia is based on the type and cause of the gingival hyperplasia.

- Improving oral hygiene is the most important factor which will determine the cure rate of the disease.

- Maintain oral hygiene regularly to prevent any further spread of infection.

- Gingivectomy, a surgical procedure to remove the excess of gingival tissue is carried out to manage the condition.

- The drugs which cause toxicities and affect the gingival tissues can be replaced with alternative drug therapies. For instance, in case of immunosupression, cyclosporine can be replaced by tacrolimus which is has less affect in gingival hyperplasia. Nefedipine can be replaced by isradipine as it does not increase the conditions of gingival hyperplasia.

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Dental preparations before Head and Neck Radiotherapy

- The status of the dentition has a significant effect on post-treatment quality of life among patients with head and neck cancer that will undergo radiation.

- A dentition in poor repair will increase the risk of post-radiation complications, particularly dentoalveolar infections that could lead to osteoradionecrosis.

- All patients who will be treated with RT for oral/head and neck cancer should undergo a comprehensive dental evaluation prior to treatment.

- Carious teeth, teeth with deep restorations or in poor periodontal health, along with partial bony impacted third molars should be extracted prior to RT if in an area that is expected to receive a dose of at least 50 Gy.

- Teeth that are out of the radiation treatment field, but have a hopeless prognosis or is symptomatic should also be extracted.

- Extraction of healthy teeth does not appear to prevent the development of osteoradionecrosis.

- All indicated extractions should be completed prior to RT and primary closure over the extraction sites is preferred if possible.

- An adequate alveoloplasty should be performed to eliminated the possibility of bone edges ulcerating the mucosa as well as to make the mandible/maxilla ready for dentures.

- Ideally, all extractions should be completed approximately two weeks before the commencement of RT to permit proper healing.

- If the extracted teeth are outside of the treatment areas, however, radiation may be started sooner.

- The oral surgeon should attempt to do all the extractions within the portals of radiation at one sitting so as not to delay the cancer treatment.

- Postponing needed extractions of teeth that will be within the treatment area until after radiation is associated with an increased risk of non-healing and osteoradionecrosis.

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Branches of Maxillary nerve

Branches of Maxillary nerve

1. Middle meningeal nerve
2. Twiges to the sphenopalatine ganglion
3. Posterior superior alveolar nerve
4. Zygomatic nerve
5. Infra-Orbital Nerve
---- 5.A. Middle superior alveolar nerve
---- 5.B. Anterior superior alveolar nerve
---- 5.C. Terminal branches
--------- 5.C.1. Inferior palpebral nerve
--------- 5.C.2. External nasal nerve
--------- 5.C.3. Superior labial nerve

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3. Posterior Superior Alveolar Nerve
supplies
1- The Pulp
2- The Investing structures
3- The buccal mucoperiosteum of Upper Molars except MB root of 1st molar.

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4. The Zygomatic Nerve
Divides into two branches:
1- Zygomatico-Tempopral
2- Zygomatico-Facial

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5. The Infra-Orbital Nerve
Divides into:
1- The Middle Superior Alveolar Nerve
2- The Anterior Superior Alveolar Nerve
3- Terminal branches (Inferior Palpebral nerve - External Nasal Nerve - Superior Labial Nerve)

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5.A. Middle Superior Alveolar Nerve
Supplies
1- Pulp
2- Investing structures
3- buccal mucoperiosteum of Premolars & MB root of 1st molar

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5.B. Anterior superior alveolar nerve
Supplies
1- Pulp
2- Investing structures
3- labial mucoperiosteum of anterior teeth

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- Sphenopalatine Ganglion
Braches into:
1- Orbital nerve
2- Nasal nerve
3- Palatine nerve
4- Pharyngeal nerve

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- The greater (anterior) palatine nerve
Supplies palatal mucoperiosteum of maxillary molars & premolars

- The lesser ( posterior ) palatine nerve
supplies uvula, soft palate & posterior part of the hard palate

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- Nasal Branches
1- Long sphenopalatine nerve (nasopalatine nerve) - supplies palatal mucoperiosteum of maxillary anterior teeth
2- Short sphenopalatine nerve

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Read More About

- Innervations of the Mandibular teeth

- Branches of Mandibular nerve
- Innervations of the Maxillary teeth

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Innervations of the Maxillary teeth

Buccal Aspect: (pulp, investing structures and the buccal mucoperiosteum)

1- Posterior superior alveolar nerve supplies the maxillary third, second and the first molars except the mesiobuccal root of the first molar
2- Middle superior alveolar nerve supplies mesiobuccal root of the first molar, and the maxillary premolars
3- Anterior superior alveolar nerve supplies the anterior teeth

Palatal Aspect

1- The greater (anterior) palatine nerve It supplies the palatal mucoperiosteum opposite to the maxillary molars, premolars and canine.
2- The nasopalatine nerve It supplies the palatal mucoperiosteum opposite to the anterior region (including the canine)

Note: The accessory innervation of the Maxillary teeth is The upper anterior teeth cross innervation (Anterior Superior Alveolar Nerve crosses the midline from one side to another)

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Read More About

- Innervations of the Mandibular teeth

- Branches of Mandibular nerve

- Branches of Maxillary nerve

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Innervations of the Mandibular teeth

Inferior Alveolar nerve
It supplies the pulp and the investing structures of the Mandibular molars, Premolars and Anterior teeth

Lingual nerve
It supplies the lingual mucoperiosteum of all the lower teeth, anterior two thirds of the tongue and the floor of the mouth.

The long Buccal nerve
It supplies the buccal mucoperiosteum opposite to the lower molars.

Note: The accessory innervation of the Mandibular teeth is
1- The lower anterior teeth cross innervation (Incisive Nerve crosses the midline from one side to another).
2- The lower premolar may receive additional nerve supply from the cutaneous coli nerve (branch from the cervical plexus of nerves) for their labial mucoperiostieum.
3- The lower molars may receive additional nerve supply from the nerve to mylohyoid for the pulp and investing structures.

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Read More About

- Branches of Mandibular nerve

- Branches of Maxillary nerve
- Innervations of the Maxillary teeth

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Branches of Mandibular nerve

Innervations of the Mandibular Nerve

1. Main Trunk
2. Nervous Spimosum
3. Nerve to medial pterygoid
4. Anterior Division
---- 4.A. N. to Temporalis msc.
---- 4.B. N. to Massetter msc.
---- 4.C. N. to Lateral Pterygoid msc.
---- 4.D. Long Buccal N.
5. Posterior Division
---- 5.A. Auriculo-temporal N.
---- 5.B. Lingual Nerve
---- 5.C. Inferior Alveolar N.

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Sensory braches of Mandibular nerve
1. Nervous spinosum nerve (trunk)
2. Long buccal nerve ( Ant. division)
3. Auriculo-Temporal nerve
---- 3.A- Parotid branch
---- 3.B- Articular branch
---- 3.C- Auricular branch
---- 3.D- Temporal branch
---- 3.E- Terminal branch
4. Lingual nerve ( post. division)
5. Inferior alveolar nerve (Incisive nerve - Mental nerve)
---- 5.A- Mylohyoid nerve
---- 5.B- Mental nerve
---- 5-C Incisive nerve

Motor braches of Mandibular nerve
1. Nerve to medial pterygoid muscle
2. Nerve to tensor palatini muscle
3. Nerve to tensor tympani muscle
4. Nerve to lateral pterygoid muscle
5. Nerve to masseter muscle
6. Nerve to temporalis muscle
7. Nerve to mylohyoid muscle
8. Nerve to anterior belly of digastric muscle

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Long Buccal Nerve:
Supplies
1- M.M. of the cheek Except the posterosuperior area which receive sensory fibers from posterior superior alveolar nerve
2- Skin of the cheek
3- M.M. of the lower buccal vestibule
4- Buccal mucoperiosteum of the lower molars

The Lingual Nerve:
Supplies
1- M.M. of the ant. 2/3 of the tongue
2- M.M. of the floor of the mouth
3- M.M. of the lateral lingual vestibule
4- Lingual mucoperiosteum of the all lower teeth

Mylohyoid nerve:
Supplies:
1- Motor Fibers supplies the (Mylohyoid muscle - Anterior belly of digastric muscles)
2- Sensory fibers supply the (Skin of the anterior & inferior surfaces of the mental protuberance)

Mental nerve: supplies the (Skin of the chin - Skin of the lower lip - M.M. of the lower lip)

Incisive nerve: Supplies (pulp & investing structures of the lower anterior teeth)

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Read More About

- Innervations of the Mandibular teeth

- Branches of Maxillary nerve
- Innervations of the Maxillary teeth

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