PERIAPICAL DISEASE

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.

PERIAPICAL DISEASEClassified as:

– Acute Apical Periodonitis

– Acute Apical Abscess

– Chronic Apical Periodontitis(Diffuse, Suppurative Apical Periodontitis with

sinus tract, Apical cyst)

– Condensing Osteitis

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.

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)

• 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

Case 1, fig.1a21-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.1bMeasurement of the tooth canal length

Case 1,fig.1cFinal endodontic

treatment Foredent and gutapercha

Case 1,fig.1d5 months after the

endodontic treatment without any surgical procedure,intraoral x-

ray shows chronic apical periodontitis,

partial restitution of the periapical region

Case 2,fig.2aOrthopantogram image,unsuccessful endodontic treatment d.N.22,

Cystis radicularis D.N.22

Case 2,fig.2bIntraoral image D.22-Cystis radicularis processus alveolaris maxillae reg.frontalis purulenta

Case 2,fig.2c3months after the

therapy-Cystectomio sec.PARTSCH II. et

resectio apicis dentis N.22

Retrograde root canal endodontic therapy with

amalgam

Egalisatio,suturae

Fig.BGranuloma periapicalis

and infection transmission paths

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

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

Periodontitis chronica circumscripta d.14

Periodontitis chronica circumscripta d.41

PULPITIS PATHWAYS

PATHOGENESIS OF PULPAL INFLAMMATION

SPREAD TO ADJACENT STRUCTURES

SPREAD TO ADJACENT STRUCTURES

SPREAD TO ADJACENT STRUCTURES

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)

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.

PULP ABSCESS

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.

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

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

CAVERNOUS SINUS

Severe Ludwig's Angina

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.

Causes of Impacted Teeth

• Role of civilization

• Local causes of Impaction

• Systemic causes of impaction

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;

Lack of space in the dental arch

for eruption

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

Impacted teeth

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.

Classification of impacted mandibular third molars

Radiographic visualization of impacted teeth

The removal of impacted mandibular third molars

Scheme of Periconitis

Scheme of Periostitis ( upper jaw )

Scheme of Periostitis ( lower jaw )

Acute Periostitis left upper jaw

Acute Periostitis left lover jaw

Acute Periostitis of hard pallate

Surgical treatment of periostitis

Treatment of abscess of hard pallatine

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.

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)

Class3

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

- 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)

B - Relative depth of the third B - Relative depth of the third molar inmolar in bonebone::

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

C - the position of the long axis of the impacted C - the position of the long axis of the impacted tooth in relation to the long axis of the 2nd molar tooth in relation to the long axis of the 2nd molar

(winter's classification):(winter's classification):

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

1- gaining access to impacted tooth:

Envelope Incision and reflection

When more accessibility is needed , a releasing incision is made.

Envelope Flap Incision and Reflection

Triangular Flap Incision and Reflection

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

2- bone removal

This is done for :- A- exposure of impaction

B- reduction of resistance

C- making a point for application of the elevator

Bone Removal With a Fissure Surgical Bur

3- tooth delivery1- 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 tootha- 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 curvedc- 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

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

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 removedb- remnant of tooth structure or fragments of bone

debris is gently removedc- 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.

closure of the wound:

• 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:1. a pressure pack is held in place for 1hour2. post operative instruction given to pt:3. cold packs on outside of face 20 min/h 5 time daily4. proper antibiotic therapy5. mouth wash6. soft diet7. patient return back for check up after two days 8. suture removal after 5 days

post operative complication:

1. pain.2. infection3. heamoraghe4. anesthesia or parenthesis of the lingual or inferior

alveolar nerve5. trismus,limitation of jaw movement6. osteomylitis7. pain at tmj8. pain on swallowing due to edema of pharynx and

hematoma formation.

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