1. Acute Alveolar Osteitis Dr Ashraf Abu Karaky Assistant Professor Faculty of Dentistry The University of Jordan

2. Synonyms Dry socket Dry socket Fibrinolytic alveolitis Fibrinolytic alveolitis Dry alveolagia Dry alveolagia Necrotic socket Necrotic socket Postoperative Osteitis Postoperative Osteitis

3. Definition Earliest sign of infection of the alveolar bone. Earliest sign of infection of the alveolar bone. - if not treated properly, might spread: soft tissue; Cellulites soft tissue; Cellulites bone; Osteomyelitis bone; Osteomyelitis

4. Pathogeneses Blood clot lost secondary to transformation of plasminogen to plasmin with subsequent lyses of fibrin and formation of kinins Blood clot lost secondary to transformation of plasminogen to plasmin with subsequent lyses of fibrin and formation of kinins Local trauma, estrogens and bacterial pyrogens are known to stimulate fibrinolysins. Local trauma, estrogens and bacterial pyrogens are known to stimulate fibrinolysins.

5. Incidence 3-5% of extraction cases, more after impacted third molars (up to 30% in some studies) 3-5% of extraction cases, more after impacted third molars (up to 30% in some studies) Age: 20-40 yrs when most teeth are extracted although > 40-45 age group Age: 20-40 yrs when most teeth are extracted although > 40-45 age group F>M F>M Mandible>Maxilla Mandible>Maxilla Posterior > Anterior Posterior > Anterior

6. Signs & Symptoms Severe Neuralgic Pain starts in the 1 st 24-48hrs. Severe Neuralgic Pain starts in the 1 st 24-48hrs. Bad taste and smell Bad taste and smell Socket wall is extremely tender Socket wall is extremely tender Empty socket and exposed bone or grayish/yellowish tissue. Empty socket and exposed bone or grayish/yellowish tissue. Less frequently; swelling and lymphadenopathy after 3-4 days of extraction Less frequently; swelling and lymphadenopathy after 3-4 days of extraction S & S may last from 10-40 days. S & S may last from 10-40 days.

7. Radiology

8. Etiology Unknown Multifactorial; decrease vascularity trauma trauma infection infection fibrinolysis fibrinolysis

9. Predisposing Factors Decrease vascularity Decrease vascularity Trauma Trauma Infection Infection Smoking Smoking Contraceptive pills Contraceptive pills Higher risk in patients with history of alveolar osteitis Higher risk in patients with history of alveolar osteitis

10. Decrease vascularity Decrease vascularity - massive use of LA - anatomical considerations - general conditions; systemic conditions that increase bone density - chronic infection

11. Trauma: Trauma: - Traumatic extraction - thermal trauma - excessive curettage

12. Infection Infection - sterility - Recurrent pericorinitis - foreign body - systemic

13. Management RG RG Irrigation with warm saline Irrigation with warm saline Inspection of the socket Inspection of the socket Curettage is not advised Curettage is not advised Socket is packed with obtundent and antiseptic dressing. Socket is packed with obtundent and antiseptic dressing. Pain killers Pain killers Antibiotics if needed Antibiotics if needed

14. Preventive measures Control local and systemic factors of infection Control local and systemic factors of infection L A L A Proper postoperative instructions Proper postoperative instructions Females on contraceptive pills Females on contraceptive pills Intraoperative irrigation Intraoperative irrigation Antimicrobial rinses before and after extraction Antimicrobial rinses before and after extraction Systemic antibiotics or topical antibiotics for high risk patients. Systemic antibiotics or topical antibiotics for high risk patients.

15. Periapical Surgery Chapter 17 Peterson

16. The American Association of Endodontists defines Apicectomy as: The excision of the apical portion of the tooth root and attached soft tissue during periradicular surgery. The excision of the apical portion of the tooth root and attached soft tissue during periradicular surgery.

17. History The first cases of endodontic surgery were those performed by abulcasis in the 11 th century. Root end resection with retrograde (root end) cavity preparation and filling with amalgam was documented in 1871. Some researchers claim Claude Martin as the inventor of root end resection in 1881.

18. Indications for Apicectomy Anatomic problems preventing complete debridement/obturation Anatomic problems preventing complete debridement/obturation Restorative considerations that compromise treatment Restorative considerations that compromise treatment Horizontal root fracture with apical necrosis Horizontal root fracture with apical necrosis irretrievable material preventing canal treatment or re-treatment irretrievable material preventing canal treatment or re-treatment Procedural errors during treatment Procedural errors during treatment Large periapical lesions that do not resolve with root canal treatment Large periapical lesions that do not resolve with root canal treatment Need for biopsy Need for biopsy

19. Contra-indications Unidentified cause of root canal ttt failure Unidentified cause of root canal ttt failure When conventional RCT is possible When conventional RCT is possible Anatomic structures Anatomic structures compromise of crown/root ratio compromise of crown/root ratio Medical systemic complications Medical systemic complications

20. Technique Access flap Access flap Apical curettage Apical curettage Apicectomy Apicectomy Retrograde root filling Retrograde root filling

21. Access flap Mucoperiosteal flap Full mucoperiosteal flap Full mucoperiosteal flap Semi lunar flap Semi lunar flap Submarginal flap Submarginal flap

22. Apical curettage Infected tissue Infected tissue Granulation tissue Granulation tissue Cystic tissue Cystic tissueHistopathology

23. Apicectomy Section of the root apex With anterior bevel or without? With anterior bevel or without? How much apex to remove? How much apex to remove? - As much root as possible should remain to deal with occlusal loads - Apical root should be removed (potential for lateral canals) - Extent of apical pathology - Not to expose any post within the canal

24. Retrograde Filling Provides Apical Seal Cavity preparation Types of fillings: Amalgam Amalgam Super EBA (ortho ethoxy benzoic acid) Super EBA (ortho ethoxy benzoic acid) IRM IRM MTA (mineral trioxide aggregate) MTA (mineral trioxide aggregate)

25. “ Super EBA and IRM have higher success rate than amalgam. ” J Endodontics 1990;16:391-393 “ Super EBA and IRM have higher success rate than amalgam. ” J Endodontics 1990;16:391-393 “ root end filled with MTA has a complete layer of cementum over the root end following healing and no evidence of inflammation ” J Endodontic 1995; 21: 603-608 “ root end filled with MTA has a complete layer of cementum over the root end following healing and no evidence of inflammation ” J Endodontic 1995; 21: 603-608

27. Success rate Success rate range from 34%-99% Success rate range from 34%-99% Mean 82.5% Mean 82.5% Best success rate when apicectomy is performed at the same visit with the root filling. Best success rate when apicectomy is performed at the same visit with the root filling. Repeat surgery has a lower success rate (about 35%). Repeat surgery has a lower success rate (about 35%).

28. Complications Failure Failure Trauma to adjacent roots Trauma to adjacent roots Trauma to vital structures Trauma to vital structures Inflammatory reaction to amalgam retrograde filling Inflammatory reaction to amalgam retrograde filling Apex dislodgment Apex dislodgment

29. Thank you Thank you