EXODONTIA & IMPACTION

yeah hi winners uh this is dr srikanth from team mds conquer now i'll be talking about uh the first and foremost important topic in your oral surgery okay that is your exudancia and in detail about impaction okay so i'll be focusing more on the contents of the topics where the neet and inactivity is focusing and i'll i'll provide you as much references as possible and i'll include as much diagram based stuff as possible in this session so coming to the contents like i don't want to discuss all the basic stuff of like definition and everything well you're well familiar with and the most important area where the questions are being thrown is the contraindications of extraction so if you go to the contra indications of extraction it is basically of two types that is absolute contraindications and relative contraindications so absolute contraindications are the conditions where you should never attempt or you should never do any sort of extraction at any cost whereas relative contraindications are the conditions where you can think of by doing some precautions you take some precautions and you can proceed with the treatment of extraction so what's one such absolute contraindication is hemangioma or hematoma so any sort of hemangioma or hematoma if if you are suspecting in the in the patient at that particular area where you are planning to go ahead with the extraction you should avoid it because there will be loss of heavy blood and it may lead to syncope and shock next one of course uncontrolled bleeding in the case of like your haemophilias where the bleeding cannot be controlled okay so such conditions are absolute contraindications or your av malformations like your av stimulus uh in such conditions it is absolutely contraindicated so coming to the related contraindications the things that you have to make a notice uh it is in the case of your acute cellulitis or in the case of anag or in the case of uncontrolled diabetes or in the case of hypertension in the case of bleeding disorders in the case of cardiovascular disorders in the case of liver diseases and in the case of long term steroid therapies and patient who is undergoing radiation therapy all these are related contraindications so make make a note they can ask you a question like which of the following is absolute contraindication which of the following is relative contraindication among the four is a regularly asked question for you so the next goes is of course the fabric topic for most of you that is transalvar extraction so other name for trans salad or extraction is it's also called as open extraction or it is called as surgical extraction okay so coming to this open extraction and surgical extraction where is normal extraction done where is open extraction or surgical extraction is done and i hope like most of you are familiar with your normal extraction uh in your under graduation level so we need to learn like what are the conditions where you have to go for this trans cellular or this open extraction the first important condition is whenever the tooth is showing lots of resistance to extraction you try it but you are not in a position to extract that in such condition it is go for it's better to go for a trans-salad or extraction next is uh endodontically treated teeth so we can discuss about that what are the changes that occurs in endodontically treated tits so endodontically treated there will be loss of nine percentage of moist in it so okay regularly teeth has moist in it okay so whenever it is whenever the pulp is removed during the endodontic procedure your moist will be lost that's nine percentage of moist is again a very very important question for you in hindu point of view so whenever the moist is lost the teeth is going to become brittle and it is more prone for fracture so whenever you are extracting and enlarge you should be very careful because the teeth is very brittle and second thing it's better to go for an open extraction the second one the next is whenever you have malformations like uh like dilaceration or like a germination or fusion which is like which is different from your regular structure of it because every two uh the movements of extraction were made in such a way that is related to the anatomy of fatigue okay so whenever you have abnormality in the anatomy or deviation in your anatomy during your developmental stage that is during your morphogenesis okay so morphological difference occurs in the morphogenesis during the growth period so such teeth uh are are very i mean like you should be very uh caution about extracting such tree that has die laceration germination fusion and everything and the next course is the sclerosis of bone okay the sclerosis of underlining bone in such conditions it's better to go for open extraction and the teeth with pathologies which includes like periapical cysts or periapical granulomas or the cyst or the teeth which are associated with the tumors all these things you need to be very very careful and you need to be very caution during the extraction and it's better to go for open extraction or trans cellular or the surgical extraction so these are all the indications of uh the extraction and of course when you have an ankylosis okay when you have ankylosis so this is a radiograph where you can see so what is abnormal in the radiograph they can question you okay you can see the teeth was not up to the occlusion level okay this is occlusion level but the teeth was not brought up occlusion level by seeing your periodontal ligament space loss of periodontal ligament space you can clearly see that ankylos is the very peculiar feature of ankylosis on radiographies there is no pdl space i i hope like most of you are familiar with the pdl space okay so you can see all these this this is pdl space okay so whereas in the ankles teeth you don't have you don't have that particular pdl okay so there is a direct bond between the teeth and the bone that is called as ankylosis so during ankylos is also it is better to go for the open extraction and next important they can ask you what is the mode of treatment or what is the pathology that you can see in this arrow weight okay you can see this is hypercementosis okay this is you can see this is this is basically the outline but you have excess cementosis this is called as hyper cementosis so even in hypercementosis case it is better to go for open extraction okay or translator extraction they can ask a pathology related diagram also they can simply give you the diagram by keeping an arrow they can ask you the diagnosis or they can ask you the treatment plan of the case uh the next comes is okay so before we go over trans cellular extraction it is mandatory that you have to take radiographs and these radiographs are going to help you out in coming with few conclusions okay so that is called as pre-extraction radiographic analysis or p extraction radiographic evaluation so what are the things that you have to see in the pre-extraction radiograph the first and foremost important thing is its relationship means the tooth to be extracted its relationship to the vital structures so how it is related to the vital structures because when you are extracting the teeth it may cause damage to the adjacent vital structure such peculiar adjacent vital structure in the case of your maxillarity when you are extracting the maxillary teeth is maxillary sinus so how far it is from maxillary sinus whereas when you are extracting mandibular molars or mandible or posterior teeth inferior alloy canal how how far it is is it very close or not this is a question that is given in the neet 20 20. this question was given in the neat 2020. uh how how like what are the modifications that occurs in the root on an iopa of mandible or third molar when it is very close or when it is overlapped with the inferior arolar canal or inferior arrow now or a bundle this is a question that is given in the recent neet 2020 and the next one is when you're talking about the mandibular premolars okay you need to talk about the mental foramen or the mental now because it is closely approximating and it is present between the two mandibler premolars and uh how far the adjacent tool structures okay but the main consent when you are extracting is these three vital structures that is the maxillary sinus which is close to the maxillary first molar inferior velar canal which is close to the mandible earth mandible or third molars and mandibular molars and mental foramen which is close to the mandibular premolars okay so these are the main concent of the vital structures that you have to make a note and you have to see the configuration of the you have to see the configuration of the root also in the pre radiographic analysis how the roots are one is you need to talk about the number of roots which is useful for both your endo as well as your surgery the second one is about the size of the roots third one is there any curvature is there any divergence is there any convergence whether roots are thin tapered any abnormality in the root structure like your torodontism you have some abnormalities which we will be discussing in oral path and if there is any hypersymmetrisis for example this case is hypercementosis case if there is any ankylosis or if it is root canally treated so all these analysis should be done from radiographic evaluation before you proceed to the extraction that is basically more often a trans cellular extraction whatever extraction is a simple extraction or a complicated or a translator extraction is mandatory that you have to do some radiographic evaluation analysis before you proceed to the next step in the oral surgery department the next comes is of course like i have discussed about the hypersymmetries and this is how the overlapping okay this these are the mandibular molars okay all these are mandibular molars and their relationship to the inferior allular canal now or cannot so whenever this roots are merging on this okay you will see some deviation in the anatomy of the canal okay so that is what the question that is given in the neat 22 which is a repeat of neet two zero one two the same question with a different uh uh concept was given in uh neat two zero one two and the same question was repeated in the neat twenty twenty okay so there are different types of different types of anatomies like whenever it measures whenever it is very close whenever it is overlaps whenever like sometimes in the case of your molars mandible or molars you will you will see the apical notch something called as epical notch means a notch which is present at the epical one-third of the mandibular roots okay you can see some epical not some deviation in the in the configuration of the root outline that is called as epical notch so whenever you have an apical notch it is better to go for split technique of extraction means for example if you see this i'm quite bad at diagrams you can see this you can consider this as a mandible or third molar and you can see some some some disturbance something like this some notch like this at one point so you can you can predict on the radiograph that the inferior alloy or no canal is going through this so what you have to do if you if you blindly extract the teeth what is going to happen your inferior alveolar now or the nerve is going to come out okay such conditions i may feel you have encountered in your ug life okay may you or your friend may extract one teeth and the patient is complaining of numbness after two or three days and it doesn't goes okay that can be something like that okay so what you have to do in such cases you have to go for an open technique you have to split the teeth so you have to remove this part and you have to remove this part separately so that so they can ask you like they can give a radiograph where you can see apical notch or they can given the description part a patient of this says and get the department upon radiographic examination you have seen an apical notch on the root configuration and now what is the mode of treatment that you are planning for this is going to be a split technique you are going to split the teeth and you are going to remove the teeth in different multiple pieces okay that's what the treatment plan is the next comes okay this is this is a very better thing like you can see this apical notch clearly in this 3d print view see you can see this this is the notch so here it is clearly seen that your channel now bundle is going into the roots in between the roots so when you are extracting this state there are high chances that this bundle is going to get damaged so this technique what you have to do is you have to split and you have to you have to split and you have to operate okay so that is what you have to learn the next comes i was talking about this forum and that is mental forum and mental foramen you can see this is present between very important points that you have to make you know mental foramen is present between the first s and second premolar mandibler and it is very close to because they can ask you this also very close to second premolar when compared to the first premolar you can see this sometimes due to the variation in the angulation you can see mental foramen as a periapical radiation in this case you can see as a periapical radiation so in such case what you have to do you have to apply the slop technique so once you apply the slop technique if it is moving away from the peripheral area then you can consider it as a mental foramen okay so mental foramen is present between the first and second premolar and mental foramen is very close to second premolar when compared to the first premolar mental foramen sometimes may get confused with a periapical cyst or a periapical lesion in such cases you have to apply slob rule to rule out of it i think you're clear until now so we are done with the radiographic analysis also with some diagram based on some case related stuff also so now you are planning for a like most of your questions will move on multiple extractions or they may be on like a complete mouth extraction full mouth extraction so what is the like when you're planning for a full mouth extraction uh what sequence you should follow is a very very important area and the area of cushions okay so first of all you have to extract the maxillary teeth and the mandibular teeth has to be extracted followed by the maxillary so maxilla is first followed by the mandible okay they're gonna ask you why why maxilla is first important thing is when you extract mandible first okay the sockets will be open and if you are planning to extract the maxilla the debris or the tooth fragments or any sort of trauma can occur to the mandibular socket so it's better to extract the maxillary so that is due to the gravity that's that's just due to the gravity so it's better to extract the maxilla first followed by the mandible that is a that is one reason and second good explanation is if you see the bones of maxilla and mandible maxilla and mandible your maxillary bones okay your maxillary bones are porous bones the porous bones when compared to the mandibular bone okay more cancellous bone is present in the maxilla so whenever you give la to both maxilla as well as mandible at the same time maxillary teeth will anesthetize fast maxillarities will get anesthetized fast anesthesia spreads fast in maxilla when compared to the mandible okay so that is one more reason but the primary reason is the debris and the fragments may fall into the mandibular sockets so the first tree that you have to extract the maxillary posterior most teeth that is maxillary third molar if the molar is present except except first molar okay so first you have to extract third second then leave the first molar then go for your premolars okay premolars then extract the first molar okay so that that's what the sequence that you have to maintain okay so how you have to do first you have to go for the maxillary posterior teeth except the first molar followed by the mandibular anterior teeth except the canon why because the root surface area of the maxillary first molar and the root surface area of the canine this this will learn in both the prosthetics as well as in the ortho that the root surface area of the maxillary first molar is highest among the more among the posterity and the canon is highest among the anterior tip so it is very difficult to extract them so relaxation will be a problem so it is better to extract the adjacent teeth first then go for the extraction of the teeth that is either the first molar or either the canal followed by the first molar followed by the canine followed by the same sequence for the mandibular teeth molar and the canon the last t that is extracted is again a commonly asked question that is the mandibler current is the last teeth to be extracted the first teeth to be extracted is a question for you the first teeth is the posterior most man maxillarity is the first teeth to be extracted and the mandibular cannon is the last teeth to be extracted so you learn some reasons why this is extracted first that is extracted last okay so we're going to the next level i mean the very important aspect is about the theories of impacted teeth okay there are two theories the first theory says that it's almost the same it's all about talking about the size okay the first series says that the okay as the as the evolution occurs okay the mandibular size decreases and there is no space for the adaption of the molars and the second theory is more often like genetic based theory okay what genetic base theory occurs okay they talk about the two parents okay you you i mean the child obtained smaller jar from one parent and larger teeth from another parent so because of which there is no space so both these are they gives the same information no space as there is no space for the eruption of the mandibular or maxillary third molars they get impacted so these are the theories of impacted teeth so the next goes is causes causes of impaction okay so because like nowadays your questions are moving on the application based okay reading returning and just trying to expel in the examination is a is a pattern of approach what we have learned in the ug level because uh you may not be exposed to the cases and number of cases or even if you are being exposed to the cases you don't have that analysis power of thinking like for example this teeth is impacted why it is impacted we never think uh as an as an intern or an as in a student from undergraduation level in your opd what you do is you see when the teeth is not open out you just simply says okay that is impacted we don't analyze why it is impacted why what is the reason it is impacted so such application based questions will be asked in the examination so it is a it is a starting process where you need to think a play what you learn reading and application okay so application part is very very less in dentistry we rudely go like for example if it is a pulpal infection i do root canal treatment done what root canal treatment okay take working length okay fill the obturation feel it finish lines no we we never think that why why we have to do this what is what is the exact diagnosis for this what type of finish line is given in the crown why this finish line has to be given so we don't analyze all these things someone comes we do someone comes they they tell something and we just follow this is what dentistry is in most of the scenarios at undergraduate level and i can i can add the same note for even the post graduates someone comes they ask you to do this you do it why the outcome is it's a small thing like a tooth structure is a small thing and you have a braid that is 32 plus 20 that is 52 teeth you have okay so no one is going to ask you pulp is something very small very very small okay the same thing cannot be applied to the human body if you have some issue in the heart ah go give this do this no it's not possible because the patient will die even if a tooth is damaged the patient may not die so this is what the negligency that occurs in dentistry in india but once you go out of out of the scope and uh go go to the other countries dentistry is very very clear documentation okay and you have an evidence-based dentist and all these are there so it's time that uh uh i mean like good good format of exams okay your need or inacti okay mostly your need ins it is not still updated to integrated approach i what i feel by seeing the questions or the question graph is still there just focusing on asking the diamond dimensions diameters which is uh meaningless at one point of you according to me okay but your need luckily has become an integrated approach okay so most of your abroad examinations for example once you're done with your masters if you're planning to move ahead to other countries most of the inter country trans examinations are now become integrated means they're going to give a clinical scenario and they're going to ask you the reason they're going to ask you the treatment plan they're asking they're going to tell you the treatment plan and they're going to ask you why only this treatment has to be done so i request personally okay we need to update dentistry at least from our point of view not in the fabric of examination but to make yourself a better dentist for the future so let's try to analyze everything just try to find out the secrets behind everything okay so these are the causes of impact and the they're divided into two types one is local causes and second one is generalized or systemic causes so coming to the local causes uh the first one is obstruction for eruption so something is coming and obstructing so that the impacted is not going to come out that is the irregularity in the position or the presence of edges and teeth no space the existing teeth was tilted no space the second one is the density of overlying and the supporting bone the density of supporting bone is not too far or not too too at the point for the impacted teeth to come out and this is what an application based question which is given in pga okay now we don't have this pga examination now everything is shifted in icd lack of space in the dental arch okay they have given the super numeratory in the in the description so whenever you have a supernumeratory teeth the extra teeth okay there are high chances that the adjacent teeth may get impacted uninterrupted adapted delayed eruption or unarrested or impacted and of course we have discussed this ankylosis of either primary teeth or permanent teeth okay they they get impacted they don't come out okay our return deciduous teeth or non-reserved uh deciduously they still stay so that the primary so the permanent teeth which is present below the deciduous is not going to come out your angular bone is very strong it's not able to resolve so that there is no space for eruption of the permanence or sometimes it can be ectopic position of the tooth burn okay it's not in the arch it is erupted in somewhere out of arch or somewhere in any part of the human body okay so such also they don't come out when they don't come out they are called as impacted so dilation or or maybe trauma no proper eruption pattern or associated with existent soft tissue or or bony lesions it's very difficult so all these are the things that you have to make a note these are the local causes means causes at a single point at a particular point at a particular tooth a single tip the next comes is the systemic causes you need to learn about few syndromes and everything where you can see more retained teeth or unadaptative that is sometimes it is hereditary sometimes it is post natal okay that may be due to the abnormalities like rickets anemias tuberculosis congenital syphilis okay or due to malnutrition or any of these systemic causes can lead to the impact at it and of course endocrine glands are going to control lots of things uh in the human body including the oral cavity that is the endocrine disorders of thyroid parathyroid pituitary like hypo and all these things uh they have some effect on the osteoclastic activity uh which is the primary culprit okay where once the resorption occurs then there is a chance for the eruption of the permanent okay so i mean these endocrine things may be indirectly related to the osteoclastic activity some hereditary things that you have to make and what about these are the syndromes which we will learn at the best of these syndromes in your oral medicine and oral path that is down syndrome your your osteopetrosis ketocranial dysplasia cleft palate very important cleft palate and all these again are some of the systemic causes for occurrence of the impacted tics i hope you are very very clear all these points are important they can convert that into clinical scenario they can tell you patient is having cleft palate and they can ask you like an option related to the impaction the next is about the classifications okay so very very important classifications okay so i hope you should be very very familiar with all these contents okay so i mean you're familiar because these are very very important first is winter's classification the second one is classification which helps in telling the relationship of the ramus with that of the mandibular third molar the third one is depth classification how far how depth it is we'll learn about this but make sure you practice this keep try to record this in your brain this diagram this is because this diagram is going to explain everything what is required so first is depth classification so what happens in depth okay the depth is just a comparison of your ocular surface of second molar to the occlusal surface of third molar okay so when the occlusal surface of the second molar and third molar are at same level or at same level or when the third molar is above the level of second molar then it is level a the second comes is b when the ocular surface of the second molar or i mean the third molar is below the occlusal surface of the second molar but above the cervical part this is the cervical part above the cervical part then it is called as level b and the third one the occlusal surface of the third molar is below the occluded surface of second molar and below the cervical line of the second molar then it is called as level c which is difficult level c is difficult which is easy this is easy the next classification next classification is rama's relationship you can see this is a ramus you have space when the space is available it is class one when the space is not available half of the part is half of the third molar is out and half the third molar is in the bone then it is clustered entire third molar is in the bone then it is class which is difficult this is difficult which is easy this is easy next the question on difficult index 2017 knee 2018 nate that is a question on difficulties this question can be prepared with a clinical scenario by giving a radiograph and asking you to analyze it one second thing or by giving the description for example a patient entered the department upon the radiographic iop examination it is concluded that your mandibular third molar is at depth b and it is in relation to ram relationship is class 2 and it's a misangular impacted teeth what is the difficult index such questions can be asked either by description or the description you have to interpret from the radiograph they can give a radiograph by seeing the radiograph rammus and comparing with the occlusal surface of the second molar to the third molar and by seeing the orientation of the third molar you have to come to the conclusion of the difficult index okay the important thing so this is a difficult index which is taken from nilima malik fourth edition so coming to the types okay that is miso angular horizontal vertical distributor so this is lower third molars so the most easiest is misangler it has one score followed by horizontal two score followed by vertical three square followed by this two angular is four square so the most difficult extraction in the mandibular third molar is disto angular the most easiest extraction in the mandible or third molar is misa angular and it's going to be reverse in the maxillary third molars so the same question is asked in the maxillary third molars so maxillary third molars the easiest is going to be distributed the difficulty is going to be the misa angular okay so these are the important things that you have to make about and further important thing is the most common impacted teeth is a regular last question so most common impacted teeth is mandibular third molar the most common type of impaction is mesoangular the most common tooth impacted is mandibular third molar the most common type of infection is miso angular the most easiest type of impaction in mandible or third molars is again miso angular the most difficult is this triangular and it's going to be reverse if they're asking for the maxillary third molar i hope you're very very clear and i hope it is very simple common sense for an undergraduate who is done with the bds to identify the angulations by seeing the iop which is misa angular which is distributed okay which is vertical which is horizontal everything can be easily done okay done next one we have already learned depths a b c a is the easiest and c is the difficult scorings are one two three we have learned the classes that is the rammus relationship or the space availability class one class two class three one is easy three is difficult one two three so basing up on these three values that is the type of impaction that is the depth of impacted teeth that is the space available for impacted teeth you combine all these values okay you add them on adding if the value ranges from seven to ten this is very difficult if it ranges from five to seven it is moderately difficult if it ranges from three to four it is minimal difficult so they can ask a question okay upon radiographic examination it was concluded that the patient is having a disto angular teeth which is at level b and which is at class 2 in relation to that of the ramus so what is the answer distro angular the score is 4 class 2 is 2 and i mean level 2 is 2 class 2 is 2 so it is 8 so if it is 8 it falls under very difficult okay so such questions either by giving a radiograph or an iopa or an opg or by giving the description they are going to ask you and then you have to count all these three parameters add one to other and then you have to compare with this index and you have to tell the index simply they can ask you what is the difficulty score second thing i can ask you what is the difficulty level these are the three levels or they can ask you simply the difficulty score the difficulty score for the question what i have given is eight for the difficulty level is very difficult i hope you are very very clear and familiar with this okay so i'm moving to the next part okay i hope most of you are familiar w a r what are these called as war lines or winter lines right so very very important so what are these water lines how to draw these water lines okay and i mean these are drawn on the radiograph right on the radiograph and the radiograph of war line should be taken must taken by parliament angle technique we'll learn about this paralleling angle bisecting angle what are the advantages what are the uses in our radiology but make a note at this point of radiology whenever you draw the water lines whenever the water lines water lines are given by scientists the scientist also has taken with paralleling angle technique so you have to draw these lines on a paralleling angle technique these are war lines that is white line this is a white line red line okay and this is an amber line okay so these are the three lines which are called as water lines so we'll try to learn each and every line related to water length because war lines at one point are going to be very easy at one point the question paper or the paper setter can make the things very very tricky so let's read each and every line and we'll try to understand what is given in our nilima malik done we'll move yeah so we will discuss what are these war lines in detail so coming to the white line okay the first one is white line so as we have already seen in the radiograph i mean in the radiograph or the animation photograph in the last slide that it corresponds to the occlusal line what a closure line a line that is drawn touching the occlusal surface of the first and second molar and extended posteriorly over the third monitor so it's going to give the occlusal difference between the second molar first molar to third mole okay so that is that is something like what we have learned in the classification that is the depth position so it indicates the difference in the occlusion level of the second and third so it's very very easy white line okay the point to be added is occlusion okay that is about white so most of we get confused between this amber line and the red line okay so we will try to read each and everything so amber line represents the bone level amber line represents the bone level how it is done a line that is drawn from the crust of the interdental septum between the molars and extended posteriorly digitally to the third molar and the ascending ramus and this line dilutes the bone covering the impacted teeth and the portion of tooth not covered by the bone so it's going to give the amount of tea that is covered by the bone and the amount of the teeth that is uncovered by the bone that is the ambulance the last one is red light okay what what is red line is drawn perpendicularly from the amber line to the imaginary point of application of elevator so when you are planning for an extraction that is impacted in extraction you are going to keep an elevator so you are going to draw a line or a perpendicular from the amber line to the imaginary point where you are going to keep the elevator that line is called as a red line and red line gives an information about the amount of bone that have to be removed before elevation because you have to remove that bone that the the line from amber line to the perpendicular where the elevator has to be opened so you have to apply the elevator at that point you should not have any bone right so all the bone has to be removed so what is the red line purpose red line is going to give an information that how much amount of bone to be removed before you apply the elevator okay so these are the important things that you have to make a white line is going to give the occlusion difference amber line is going to give the amount of bone covered by the impacted teeth and amount of bone uncovered by the impacted death redline is going to give a clear cut idea about the amount of bone that you have to remove before you apply the elevator okay so this is important the last lines are important because this was once given in the one of the entrance examination okay so if the length of the red line is more than five millimeters then the extraction is difficult so red line is amount of bone removed amount of bone to be removed when the amount of bone to be removed is more than five millimeters and the right leg is more than five millimeters it is called as a difficult extraction every additional millimeter increasing in the bone removal will increase the difficulty by three times means whenever it is if if the difficulty index for five millimeters is x if it is increased by one millimeter that is six millimeters it is going to be three x if is increased by seven millimeters the difficulty is going to be three times more difficult okay so it's going to be three times more difficult every time when there is an increase in the one millimeter and mega knot when it is nine millimeters and it is nine millimeters okay it will be present below the level of apexis of the second model so if it is nine millimeters bone has to be removed your third molar is present below the roots of the second molar okay so these lines points are very very very important so there is one more resistant okay so very important you have a question on this in your regular mcq book studies the w stands for windows classification your h stands for height of mandible your a stands for angulation of third molar your r stands for root form and development your f stands for follicle and your e stand for exit that is nothing but path of accept okay so do make a note they can ask you the full form they can ask you what is are they gonna ask you something like that so do make a note about this and coming to until now we have discussed about the max mandible or third molar so it is maxillary third molar so the classifications of angulation and the depth classification has same as mandela third molar but there is one more thing to be added when you are talking about the maxilla that is maxillary so whenever the sinus is approach up approximating okay that is one is sinus is approximating sinus is not approximating if there is no bone or a thin bone between the roots and the maxillary sinus that is called as sinus up approximately and if there is no sinus approximating ah like that then you will have a bone of two millimeters or more than okay so this is this is an extra thing that you have to make around when you are talking about the maximal thermometers so next ah of course we have discussed about the pre radiographic analysis but we learn few things about the radiograph second right related to your impact so regular radiograph what what we use in the case of your iobs is iop so what is iopa intraoral periapical reader okay why the reason why i have kept this is very simple this is not called as iopl you have taken when it is not called as i four people because i o pa is intraoral periapical there is no periapex here right so this this according to the norms is not considered as iop and it is of no use okay so this is iopa where you can uh learn so much about the anatomy of the roots and the bones and everything right so there's so many so many advantages so when i'm talking about the radiographs i mean most of you know about the radiograph that is intraoral radiograph the choice is iopa whether it's a maxillary or a metabolite for example if you are planning to extract the mandibular teeth okay the choice of radiograph is going to be the opg or the lateral oblique and when you're planning to extract the maxillary teeth the choice of radiograph is opg or the pa view or the water stream okay so they can ask you what are the external radiographs that are advised for uh the mandibular teeth extraction or the mandibular molars extraction of the maximary molar subtractions do make a note about this there is something called as right angle technique okay right angle technique is exposure in two different angles which are 90 degrees to each other so this is an iopa and this is an occlusion radiograph and these two are exposure is 90 degrees because ioba is going to give you one line of alignment it's going to give you the mesodictal environment whereas approachable radiograph is going to give you buckle equal alignment by which you can identify the exact position of the okay so that is called as a right angle technique this is a part of your object localization there is something called as object localization in your radiology so one technique of object localization is right angle technique two exposures right angle to each other the next one is of course most of you are familiar with that is called as slop technique what is slop same side lingual opposite set buckle so this is a slop technique okay so this diagram based uh slop technique is is a very familiar and most common type of technique or type of question in your radiology okay so what is this this is a regular direct exposure you have the lesion here or you have the interest of focus here and this is the mesial side this is the distal side this is the mesial side of the table is the distal side of it right so this is your area of focus that is the second primal area okay so what happens the rays has been shifted to mesial z previously have given direct now it has been shifted to the mesial cell similarly your object of interest is here it has been shifted to the mesial side it has been shifted to the measure so when you shift to the mesial side the object of interest is also shifted to the mutual side that is same setting as it is shifted on the same side it is present on the linger for example if you have shifted to the medial side and the object of interest has moved to the digital side angle that is present on the opposite side is going to be bug so now this case is this this point is present on the lingual side because it is shifted to the same side okay this is one more technique of slop i just want to add a node because as a talking of this law again we may repeat this in your radiology this is used in endodontics this technique is called as wall trans technique and the deviation of angulation is 20 degrees so when you have two canals in a root which are overlapped you cannot see on the radiograph so what you are going to do you are going to change the angulation by 20 by which you can see the canals is most commonly used in indoor this is a type of slop technique but the angulation is very specific it is 20 that is used in the endodontics to see the extra all clear the next goes are few radiographic questions which are asked in the examination i hope you are very familiar clearly seen the laceration clearly seen like dancing deep did isolated t okay so dilacerated teeth sometimes on radiograph appears like this because this dilapidation is a miso miso mesodigital dialysis means it is bended from here to here miso distal which can be seen on a radiograph this type of d dilaceration is a buccal lingual so your bucco lingual dilacerations can be seen as a scorpion day or can be seen as a target lesion or a bone solution on an ivf see this buccal lingually dilated okay so they can ask you a diagram based question over this area this is a scorpion teeth or a dialysis the angulation or in which direction is buckled this is again called as a [ __ ] which is seen on iop lingually impacted lingually [Music] impacted mandibular third molar will appears like a bull's eye you can see a bull like right so they can give you a radiograph they're gonna ask you like this it's a lingually impacted mandibular third molar atoms okay there are few uh techniques that we have to make a note when we are talking about this this is called as lateral definition this question was given in 2018 neat examination question is very very simple okay so please do make a note of the scientist name for academic purpose and the paper center is too rude okay they can ask you the scientist when the paper center is extraordinary root they can ask you this technique was first invented in gucci all these are stupid questions which are out of globe okay so i don't advise the student to remember the years not all years but few years are important okay so just try to move on like it's learning the subject uh is one of the parameter of course we need to end up with a good rank also that is also important but uh pleased to make it out of the scientist and the type of incision that is used here is a modified as shape of incision we can see a modified s type of incision that is made from the retromolar fossa i mean retromolar force are crossing the external oblique reach of the first molar you can see the external obliques ah and it is extended up to the first model clearly and what you have to do is the buccal you can see this this is a buccal cortical plate is this is is you have you have given some definitions definitions is preparing a window preparing an opening okay prepare an opening and this is a mode of like a treatment when you have an abscesses uh in your dental structures also okay which is a part of your endo learning endo okay this is the mode of treatment like you're going to keep holes and relieve the pressure so that the pulse or abscess will drain and so your your definitions will be done on our third molar and the parts buds are used to prepare the vertical cuts anteriorly and positively you can see that vertical cuts okay anteriorly and posteriorly and followed by the suturing technique okay i hope you this is the mode of technique for extracting the mandibular third motor of course again this is a diagram based question and it's a very complicated thing that's a lingual split technique so lingual split techniques okay so what is this lingual speech first of all the important things that you have to make you know the lingual split technique was first described by sir williams kesley fry and of course very important point it is popularized by t word and this is a mode of technique which is useful for lingual impacted it lingually impacted mandibular third molar lingual impacted mandibular third one so the steps they can ask you as a sequence based question in your inic and to understand to have a better concept it is better to learn the steps okay i have clearly given the steps the eight steps of this technique so initially uh it's very simple like for every extractivity you have to give a local anesthesia and followed by you have to go for either what's technique what's technique of incision or modified words technique of incision okay again your words technique and modified walls technique insertion are your most commonly asked diagram based questions in your examination so once you're done with the incision then the next step is you need to create the vertical stops so how these vertical stops i mean like this is a technique again which is done with malik and chisel okay so the patients are very very phobic okay by seeing that mallet and chisel so this is a technique which is done by marathon scissors the first step is creating the vertical stops so where these vertical stops are created they are created digital to that of the second monitor so if you consider this as a as a third monitor draw a simple diagram let's make it is very simple so you create a vertical vertical stops this is third so this position will be occupied by second so you create a vertical stops uh post i mean like distant to that of the second mother that's the first step so once you're done with that you what you're going to do you're going to convert a horizontal cut you're going to convert a horizontal cut you're going to convert a horizontal cut so once you convert a horizontal cut then you are going to extend like this this is by keeping some definitions so this area is going to become weak so that's the buccal area it's going to become weak so you what you're going to do you're going to remove the buckle plate so first you're going to vertical stop second you're going to give a horizontal stop third you're going to keep some holes and you're going to cut the buckle plate okay so by which you can get access to that other disto lingual bone and where you as as the area is very very thin you can fracture the distal lingual plate okay that is the lingual particle plate you can fracture it so when you fracture this lingual particle plate you will have a wedge type of access to that of the roots where you can keep the elevator luxate the teeth and remove the teeth okay and you can reposition the flap and keep it switching very simple techniques are vertical stops are given first distal to the second molar followed by vertical stop a horizontal stop is given keep holes remove the buckle plate now that you get access to the lingual lingual plate okay break the lingual plate so you get access completely you get an edge type of axis keep the elevator remove it keep the flaps back suture it topic is over right so they can ask you the steps they can ask you the indications is useful for lingual impacted mandeville third molar given by popularized by and the materials which are used what are the materials using male attention are the things which are used so they can ask you what are the advantages of this technique and disadvantages of this technique so coming to the advantages of this technique it's very very familiar question okay so it's a it's a uh it's a it's a it's one of the fastest mode of removing the teeth i'd want us and the second one is there is less chances for causing damage to that of the inferior angular channel or the bundle of nerves which are present closely to the third molar and third one uh it reduces the risk of the blood clot formation because mandelbrot third molars are the most common teeth gives rise to tri sockets so dry socket formation can be reduced and it decreases the damages to that of the adjacent periodontal ligaments of mandibular second molar okay and it it it decreases the risk of healing problems all these are the advantages when i'm talking about this split technique the next course the disadvantages okay i just want to mention uh disadvantages the reset one answer the risk of damaging the lingual nerve is very high because it is lingually impacted and you are going to break the lingual cortical plate so risk of damaging the lingual nerve is very high whereas risk of preventing damage to the inferior nerve is a good aspect whereas risk of damaging the lingual nerve is is a bad aspect and it also increases the risk of the post-operative infection and the patient is discovered because you use a chisel mallet patient will feel discomfort and this is regularly not a technique of choice in the case of individuals because the bone is elastic bone so elastic bone handling with chisel and mallet is a bad option so one important aspect that i want to talk about the complications like complications and everything you can go for your regular mode of preparation either with your basic mcq books or your textbook based reading most of you are well familiar with this there's more of common sense so most of your questions will move on one of the peculiar thing that is called as dry socket okay so what is this dry socket so dry socket is a one of the complication that you can see after the extraction okay so they can ask you dry socket is most commonly seen with which tape so dry socket is most commonly seen with mandibular third molars how much incidence 20 is the overall incidence of all the teeth for dry socket is two percentages and for a mandibular teeth it is twenty percentage this question was given in the aims examination okay so aura incidence of dry socket is two percentage whereas particularly the mandibular third mother where dry socket is most common is twenty percent so two percent is twenty percentage or an important area so when dry socket what are the ethiology of occurrence of dry socket so whenever you extract a mandibular third molar in a very dramatic way without taking any precautions there are high chances that the dry socket can occur so what is the first one traumatic extraction the second one is lack of proper irrigation no no irrigation no irrigation high chances of dry soil the third one is you have to make a note about all contraceptives it's a very very common thing okay when you're planning for extraction you should take all the medical information so oral contraceps what they do is they increase the fibrolytic activity so the fibonacci actually whenever your fibromyalgia activity increases your blood clot is going to split it's going to break and it's going to release the tricep so the patients or the women who are under oral contraceps increasing the fibroidic activity losing the breakdown of the blood clot which is formed in the socket leads to dry socket and the next one is hormonal changes so during the menstrual cycle all these hormonal changes again indirectly increase the fibrolytic activity the next one is the most common thing that we encounter in the clinical scenario is smoking most common in the males smoke and the dry socket complement or maybe any foreign body or any sort of thing which is left over by extraction all these things are the primary theologies for the occurrence of the dry soil so what are the clinical features that you can see in the dry socket you have to make out so dry socket is regularly seen after three to four days three to four days delayed it's a delayed problem we've seen after three to four days the patient complaints of pain the patient complaints of abnormal order in the mouth that is taste or difference in the taste perception also other important thing that you have to make about when i'm talking about three to four days is there is something called as delayed expansion in your amalgam the patient comes with a broken teeth after uh like after amalgam filling or patient complaints of severe pain after three to five days that is basically due to the delayed expansion that is due to the gene content zinc will show this delayed expansion by reacting with water and releasing the hydrogen gas this hydrogen gas is going to cause the delayed expansion and similarly you have same time duration that is hypersensitive so the that is dry soft three to four days or three to five days after the extraction the patient comes back with the pain and change in the overall perception and halidosis that is called as uh dry socket and uh i mean like uh the next important thing that you ought to make or sometimes the patient may complain something favor some systemic uh signs like fever lymphadenopathy and xyz and the first thing what you need to do is you need to take a radiograph of the socket and confirm that none of the root or none of the foreign bodies left over first you need to take it okay so the next important aspects of this are you need to make a note about the these theories of dry socket hope you are very familiar with the theories of dry socket one theory is brings theory it says about the fibrinolytic system the fibrinolytic activity is also called as fibrinolytic theory and the organism that is primarily responsible according to this theory according to this theory is t identical the second one the second one is a different theory that is called as bacterial theory and the bacteria responsible according to this theory are acne mycosis and streptococcus mutants so do make a note about the bacteria denticola is again a regularly asked question so these are the theories of dry socket the next comes is the treatment so already discussed the first thing that you have to do is take a radiograph and rule out of the leftover root fragment or leftover foreign body then you have to go for irrigation good irrigation with the chloride excellent that is zero point one two percent make it out zero point one two percentage of fluorescent is used as irrigation here in dry socket and it is the same percentage that is used in the mouthwash whereas if you are talking about the irrigation in endodontics chloride oxidation chloride accident as an irrigation endodontics the answer is two percentages two percent is chloroxylation is used in irrigation of endodontics and zero point one two percent is production is used in the irrigation of dry socket okay so apart from this the other important thing that we regularly do in our departments when you see this dry socket case is good irrigation followed by jaguar paste okay or you can use metronidazole antibiotic paste or uh ida ida form which is soaked because you're going to keep it along with the paste and recently few textbooks clearly says that you can use something called as phba para hydroxy benzenoic acid can also be used instead of your joey or materials test so how this paste is used they can ask you questions on this first this page has to be changed for every 24 hours then then you have to change for every alternative day then you have to change for every three to f four days for two weeks right first it is 24 hours then you can try it for every alternate today then three to four days you have to change it forever for about two weeks so these are the treatment things that you have to do when you're when you have seen a case of dry sockets so they can give you a simple clinical scenario okay a patient went for an extraction uh of mandibular third molar and reported back with a severe pain and a mall order and upon this you have seen this you can see this clinical feature ah and they can give you a history of smoking or a woman of using under the medication overall contraceptives so what is the possible diagnosis and what is the treatment plan can be a case limit question okay so okay so major content of exodus is done and few other things we'll be discussing on our daily activity on the group okay so it's very important for each and every one of you as you go into the preparation phase at every point at every day at every exam at every level you have to question yourself am i doing good yes yes i'm doing good so at every point of your preparation whether it's a daily examination whether it's a topic specific exam whether it's a class or a topic or a subject you have to review yourself at every point that how far you are and how far you are up to so if you do this this is going to create a cumulative effect on the end product so that is going to be on the final exam all the best signing off dr srikanth from team mds conquer