Techniques for Extraction of Impacted Lower Third Molars

Techniques for Extraction of Impacted Lower Third Molars Abstract Objectives: Many series of side effects will be produced with the extraction of impacted lower third molar which including pain, swelling, inflammation, and trismus. Flap design is important to allow good visibility, reach to the impacted tooth, and for healing of the surgically created defect. This study aims at the evaluation and comparison of standard flap design with comma type of flap design used in the surgical extraction of impacted mandibular third molar and to objectively evaluate the merits and demerits of individual flap design. Study Design: In this study 200 patient with bilateral mandibular third molars impaction of age group of 18-30yrs were selected for the study, To reflect the mucoperiosteal flap On one side standard incision and on other side comma incision were used and , after which the steps are common in the removal of impacted third molars. Immediately on the post –operative days 1, 3 and 7 the post– operative parameters (pain, swelling and mouth opening were recorded. And periodontal status were recorded pre operatively, 1st month and 2nd month respectively. Results Conclusion: The pain and swelling scores were found to be significantly lower in the surgical area with comma incisions which was recorded on days 1, 3 and 7 as compared to the the area where standard incisions were made. In mouth opening There was a sufficiently great difference seen between the two incisions on 1 post-operative day, but though there was clinical difference between the two incisions on day 3 and 7 there was no statistical significance. The results of the study shows no lingual nerve paresthesia or any other morbidity, hence the new incision design should probably be made the conventional method, considering the less degree of post operative complications encountered. although it may require some practice initially. Key words: Standard Incision, Comma Incision, Mandibular Impaction, disimpaction,Visual Analog Scale Clinical Implications:-third molar impactions are common and usually associated with postoperative complications like pain, swelling, trismus and pocket formation. Incision and flap design is important in healing wound and minimizing post-operative complications. Comma incision design has shown less post-operative complication in compare to standard incision Introduction: Impaction is defined as cessation of the eruption of a tooth caused by a clinically or radio graphically detectable physical barrier in the eruption path or by ectopic position of the tooth. at least one impacted third molar will be present in 33% of the population which requires surgical removal of impacted third molar hence disimpaction is the one of the most frequently performed procedure.1 Lower third molars constitute a major bulk of teeth that are impacted in the oral cavity2. Many series of side effects will produced with the extraction of impacted lower third molar which including pain, swelling, inflammation, and trismus 3. Flap design is important to allow good visibility, reach to the impacted tooth, and for healing of the surgically created defect. Many different incisions have been used to raise the flap, like Wards Incision, modified ward’s incision, envelope, ‘S’ shaped incision [Bould Henry] etc4. Ward’s and modified ward’s incision are more commonly used and it was observed that Wards and modified Wards incision provide excellent visual and mechanical access and can be closed by means of a suture inserted between the buccal and lingual soft tissues alone5 , However when a releasing incision is made a small buccal artery is sometimes encountered and this may be mildly bothersome during the early portion of surgery, and also the suture is usually placed on a bone defect and not on healthy bone this may cause additionally pain, delayed healing are also seen.6 Nageshwar has tried a new type of incision- comma shaped incision and has compared it with the modified wards technique (Figure 1). However the number of cases in his study were very less [n=15], hence this study was undertaken to compare this new comma shaped incision with wards incision using more objective and subjective parameters with a larger sample size. Material and Methods: 200 patients between the age group of 18-30yrs, having completely impacted bilateral mandibular third molars or partially erupted third molar, with good oral hygiene, without any symptoms of pain or swelling were included for the study. Patient on any medication, pregnancy, severe Pericoronitis, soft tissue impaction, medically compromised, Missing mandibular second molars was the exclusion criteria for the study and were excluded from the study. The instruments used to compare two flap designs were Williams probe to measure pocket depth. Visual analog scale of 0 to 10 was used to estimate pain by subjectively asking the patient to rate the nocioceptive experience7. Swelling was assessed by measuring by the distance between the: Tragus notch and a reproducible soft tissue pogonion a long the skin surface. Tragus notch to angle of mouth Tragus notch to ala base Tragus notch to outer surface on lateral wall of eye Angle of mandible to outer surface of lateral wall of eye The percentage difference between the postoperative and preoperative measurements was calculated. Mouth opening was evaluated by measuring the maximum inter incisal distance. After obtaining ethical clearance from the hospital ethical committee, written consent was obtained from all the patients who satisfied the inclusion criteria. Preoperative radiographs were taken to assess the position, depth and angulation of the third molars and to exclude any local pathosis such as a cyst, tumor etc. pain, swelling, mouth opening and pocket depth were recorded Preoperatively . One side of impacted mandibular molar is surgically removed under local anesthesia Using standard flap (figure 2). pain, swelling and mouth opening were measured Postoperative on day 1, 3 and 7 respectively. The extraction on the opposite side was done with the alternate flap design-Comma incision (figure 3). The follow up and postoperative complications of patients on day 1, 3 and 7 were recorded for the parameters studied. After flap reflection standard procedural steps were followed. Flap was sutured with 30 Braided silk sutures. Post operative instructions were given and patients with a standard antibiotic regimen of Cap. Amoxicillin 500mg TDS* 5days Tab. Ibuprofen 400mg TDS* 5 days Tab. Metronidazole 400mg TDS* 5 days Bilateral The pocket depth is recorded after month. Data management and Analysis The post-operative complications for each subject for both incisions were recorded and all data was entered in Microsoft Excel. Data was analyzed using computer software, Statistical Package for Social Sciences (SPSS) version 10. Data are expressed in its frequency and percentage as well as mean and standard deviation. To elucidate the associations and comparisons between different parameters, Chi square (à ¯Ã‚ Ã‚ £2) test was used as nonparametric test. Student’s t test was used to compare mean values between two groups. For all statistical evaluations, a two-tailed probability of value, Results: Out of 200 extractions done using ward’s incision 107 were non erupted and 93 were partially erupted, Out of 200 extractions done using comma incision 111 were non erupted and 89 were partially erupted, {table 1} In extractions done with standard incision 26.67%of subjects had severe pain on day 1 where as only 13.33% of subjects had severe pain on the exaction side done by comma incision. There is a high statistically significant difference between the two type of incision on day 1 in comparing the pain. (Chi -Square=15.627, P=0.0062) similarly the pain was severe for 6.67% of the patients extracted with ward’s incision and there was no pain on other side where comma incision was used on the 7th post operative day (Chi -Square=28.799, P=0.000) {Table 2} In extractions done with standard incision 46.47%of subjects had severe swelling on day 1 whereas only 33.33% of subjects had severe swelling on the exaction side done by comma incision. But the difference seen was statistically significant difference between the two type of incision on day 1 in comparing the swelling, (Chi -Square=2.4762, P=0.2889). the swelling was sever for 20% of the patient extracted with ward’s incision and there were no patient with sever swelling on comma incision side, (Chi -Square=8.6872, P=0.0365). on 7th day there were no patient with severe swelling in both the groups but 40%of the patients experienced moderate pain in ward’s incision group where as only 13.33% had moderate swelling in comma croup. There is a statistically significant difference between the two groups on day 7 (Chi -Square=18.879, P=0.0158).{Table 3} The mouth opening on day 1 in ward’s incision side is between 29-25mm where 33.33% where as only 13.33% of the patients in comma group. There was highly statistical significant difference between the inter incisal measurements to check for mouth opening on day 1 (Chi -Square=24.658, P=0.000). but though there was clinical difference between the two incisions on day 3 and 7 there was no statistical significance.{Table 4 } There is significant statistical difference between wards and comma incision in relation to pocket depth recorded after first month and the second month in first month is (t=2.684, P=0.025), and in second month is (t=4.937, P=0.000). and even when ward’s and comma incision are compared separately over time there was statistical significance between the pocket depth in first and the second month was seen, I’e (wards incision t=5.176, P=0.000) and (comma incision t=6.812, P=0.000) in second month. {Table 5} Discussion: Third molar surgery has been associated with a variety of complications, flap design is one important factor influencing the severity of these complications . The incisions used in surgical treatments of impacted 3rd molars can be grouped in to envelop and triangular varients.all incisions irrespective of there variations, were extended from the distal aspect of second molar towards ramus. These standerd incisions have been modified by many surgeons.the incision modified by Groves and Moore started distal to the distobuccal line angle of the second molar to conserve the periodonsium8. Berwick designed a lingually based flap using an incision line that was tongue shaped and did not lie over the bony defect.9. Comma shaped incision was designed by Nageshwar to limit the post operative pain and swelling. Post operative pain of moderate to severe intensity is usually noticed after third molar surgery, the pain usually begins as the effect of local anesthesia fades off. The peak intensity of pain is noticed after about 6 hours. The pain then disappears slowly within a few days if it heals normally.10 In our study, pain was assessed by using a Visual Analogue Scale (VAS) as it takes little time to describe to the patient and it is easily understood by the patient. The results showed less pain scores on comma incision side as compared to ward’s incision side which is similar to that of the study of Nageshwar. (This may be because small mucoperiosteal flap was elevated during comma incision, the drainage in comma incision is good and this is single flap hence it will give a tight closure on occlusal surface distal to second molar.) This result is not in correlation with the results of Gool et al as they have seen that severity in pain is not related to the type of incision.11 trauma and infection are the main cause for postoperative swelling. The truma to the tissues associated with oral surgical procedures is the usual cause of early postoperative swelling. It is most marked after 19-24 hrs and then diminishes after about seven days.12 Swelling in cases with comma incision was comparatively lees than cases with standard incision was done. This study results compliments the study by Nageshwar.1 but the method of measuring swelling was not satisfactory in that study because the swelling is three dimensional hence it is measured by marking on 6 different points on the face as described earlier. Salata L.A et al and Szmyd et al reported that restricted mouth opening peaks on the day of surgery. This study is in agreement to this statement too13. The comma incision encountered less number of subjects with limited mouth opening when compared with the standard incision side which is in agreement with the study of Nageshwar’s result The inter relation between trismus and pain have been reported in many studies. It might therefore be expected that mouth opening after the removal of impacted mandibular third molars is painful and consequently reduced to its full extent. The hypothesis has been confirmed by an electromyographic study which proved that restricted mouth opening is a voluntary action to avoid pain.14 There was a statistical difference in the postoperative probing depth between the two types of incision after the first and second months. These results are contradictory with many studies, by Rosa et al, Quee et al and Schofield et al which show no differences in pocket depth related to flap designs15. But A.A. Krausz, E.E.Machtei,M.Peled suggest that increased second molar pocket may be related to osteotomy16. However others believe that the flap design and the patients age might have an effect on second molar periodontal status. When removal of impacted molars was done during developmental stage of the tooth faster regrowth of the alveolar bone crest . However as all our subjects were in the age group of 18 -30 we feel that age was not a major factor and the difference in pocket depth is related to the type of flap. Conclusion: The results of the study shows that none of the patients in the study developed lingual nerve paresthesia or any other morbidity, hence the new incision design should probably be made the conventional method, considering the less degree of post-operative complications encountered. although it may require some practice initially. Further research with newer flap designs like the comma design, which will minimize the post operative complications, should be considered in the extraction of impacted third molar surgery.

Biography of Kate Chopin :: essays research papers

Biography   Ã‚  Ã‚  Ã‚  Ã‚  Kate Chopin was one of the most influential nineteenth century American fiction writers. She was born in St. Louis, Missouri on either one of three dates: February 8, 1851, February 8, 1850, or July 12, 1850, depending on the source. She once said that she was born in 1851, but her baptismal certificate states February 8, 1850 as her birthday (Inge, 2). There is also an indiscretion regarding the spelling of her name. Her full name is Katherine O’Flaherty Chopin, but one source spells her first name with a ‘C’ (Katherine, 1). Her father, Thomas O’Flaherty, was an Irish immigrant who became a successful merchant in St. Louis. Her mother, Eliza Faris O’Flaherty, came from a wealthy aristocratic Creole family (Inge, 2). Kate Chopin was a student at the Academy of the Sacred Heart in St. Louis. Here she learned the Catholic teachings and great intellectual discipline. She graduated from this French school in 1868 (Inge, 2). On June 9t h in 1870, she married Oscar Chopin. Together the couple had six children: Jean (1871), Oscar (1873), George (1874), Frederick (1876), Felix (1878), and Lelia (1879) (Inge, 3). During the 12 years that she was married, Chopin spent 9 years in New Orleans and the following three years in Cloutierville in Natchitoches Parish (Inge, 3). She was an extremely unconventional woman for her era. Not only did she write about a forbidden subject, female sexuality, but she smoked cigarettes and would go on long walks through the streets of New Orleans by herself, both of which were not common practices during the nineteenth century (Inge, 3). Kate Chopin enjoyed the variety of cultures that surrounded her in Louisiana; she was involved in the lives of the wealthy Creoles and the poor sharecroppers. Tragedy struck her in December of 1882, when her husband became ill from swamp fever and passed away (Inge, 3). Shortly after his death, Chopin became involved with a man by the name of Albert Sampite, a married man (Anderson, 1). A lot of inspiration is thought to have come from this relationship because so many of the characters in her stories are married individuals who become sexually involved with a single partner resulting in a relationship that ethically could never survive. She left Cloutierville in 1884, partly because of her relationship with Sampite, and moved back to St. Louis to be close to her mother (Inge, 3).

Summary & Analysis of Al-Munqidh Min Ad-Dalal

Al Ghazali is an influential thinker of medieval Islam. He describes his education and his intellectual crisis, which left him so full of doubt and questions, to the extent that he he resigned from his professorship in Baghdad, and felt the need to retire from the world. However, his faith returned after years of questioning and seeking, during which he achieved direct knowledge of God in the form of the experience of the Sufis. Abu Hamid Muhammad al-Ghazali’s ‘Al-Munqidh Min Ad-Dalal’ successfully allows the reader a brief and revealing window into the life of a great intellectual.It is an autobiographical account of Ghazali’s struggle during a period of spiritual unrest in his life that begins with him as a teacher at a prestigious academic institution at the age of thirty-three, and continues through his severe journey of questioning and curiosity, and ends upon his return to his teaching career but instead being a complete God-orientated man. The book o pens with Ghazali replying to a colleague who had questioned him regarding â€Å"the aims and inmost nature of sciences and the perplexing depths of the religious systems† and the reasons for Ghazali’s actions at this stage of his life.He is a curious man who focuses on everything using his analyzing eye. This habit and custom he describes as â€Å"a God-given nature, a matter of temperament, and not of my choice or contriving. † With this attitude he starts to question the different types of knowledge around him. He systematically and thoroughly deals with each science which influences man’s spiritual and religious state of mind, covering the four main sciences of the time: theology, authoritative instruction, philosophy and mysticism. All four continue to play significant roles today. The analysis is carried out in detail, unbiased and authoritatively.He analyzes each science like a trained surgeon and then transports his results and evaluations with ac curacy and care. Included in this book is a passage which expresses the core of his spiritual journey and can be found in section four â€Å"The Ways of Mysticism† : â€Å"I learnt with certainty that it is above all the mystics who walk on the road of God; their life is the best life, their method the soundest method, their character the purest character; indeed, were the intellect of the intellectuals and the learning of the learned and the scholarship of the scholars, who are versed in the rofundities of revealed truth, bought together in the attempt to improve the life and character of the mystics, they would find no way of doing so; for to the mystics all movement and all rest, whether external or internal brings an illumination from the light of the lamp of prophetic revelation; and behind the light of prophetic revelation there is no other light on the face of the earth from which illumination may be received. † A chapter on the nature of prophecy follows this p assage, and highlights its persuasive need.He discusses the physical and rational observations, their development in humans from simple to complex, and they end where divine inspiration and revelation begin. The methodology used to explain this range of perceptions is both simple and effective and allows the reader to follow the thought pattern of the writer. A concluding chapter on Ghazali’s return to teaching successfully deals with possible denial of the theory that he claims the need for prophetic leadership. As an expert in each of the fields his replies to the various groups are from their own teachings, doctrines and own methodologies.

Effects of Anthrax essays

Effects of Anthrax essays It seems like now a day there is tragedies, attacks, and new diseases that spring up constantly. Most recently, the American nation is plagued by a deadly epidemic Anthrax. Anthrax is a topic that is all over the newspapers, magazines, and television, but common people know very little of Anthraxs causes and effects. There are many myths and stories that are spread through rumors and false information. All people and especially those near at risk areas must be informed about the truth of Anthrax. Anthrax is a disease that is formed from a deadly bacterium that originates most commonly in dead animals, but unfortunately it can also be developed and produced in highly sophisticated labotories and scientific environments of that nature. Anthrax is being widely distributed in the United States of America through postal offices and governmental work areas. Not only do all people need to know about cures and vaccinations of this disease, but also background information and knowledge of this deadly disease must be widely distributed to give all people an understanding and precaution of this lethal and easily infected illness. The lethal bacterium, Bacillus anthracis, which causes the disease Anthrax, was not discovered until 1959. Anthrax can appear in humans and animals alike. It was first discovered in mysterious dead animals. At first, scientists believed that this bacterium, Bacillus anthracis, blocked the capillaries, which furthermore resulted in death. Through many experiments and observations, scientists discovered that blocked capillaries did not cause death, but the deadly and dangerous exotoxin released by Anthrax. This toxin is extremely deadly and lethal. The cause of death from this Anthrax toxin is due to lack of oxygen, respiratory shock and failure, secondary shock, cardiac arrest, and an increase of vascular permeability. Anthrax can be contracted in three different ways. First and most dea...

Questions for a College Representative

Questions for a College Representative Are you wondering how you could start a conversation with a college representative? Here are some tips thatll help you have a productive conversation with your college representative. Lets get answers to your important questions. College Fair Topics and Questions Ideas First, its a good idea to write out a list of things that are important to you before you go. You shouldnt feel like you have strange priorities or weird questions. Maybe something off-beat is interesting to you. College representatives hear the same questions all the time, so theyll be glad to hear something new. If you wonder about LGBTQIA life on campus, the potential for racial tension, or if youre worried about spiders in the dorms, go ahead and ask about it. Start with Hello, how are you? or Hi, my name is ... for a relaxed beginning to your conversation.Try not to ask a vague question like Tell me about your college, since the representative will have no idea where to start. That can be frustrating for the college representative and the student because the conversation will have no direction.Be specific with questions by saying things like Tell me about class spirit or Can you give me examples of some campus traditions? instead. Questions phrased in such a way will give you a sense of the atmosphere and give the representative something specific to talk about.Ask for a list of majors that you could take with you. You could look over it later.Ask about the enrollment deadline and the recommendations for taking the SAT. Some colleges will need your scores earlier for admission considerations.Ask if subject scores (like SAT II Math or History) are required or recommended.Feel free to ask if the representative can waive your application fee , but know that this usually works best at private colleges. Ask if there are any scholarship secrets. There are many little-known tricks that differ from college to college, but the conversation doesnt always get around to this in a rushed environment like a college fair.You will want to know the admission requirements, of course. You may also want to ask whether admissions officers make decisions on numbers, or if they consider activities. Some colleges  go by scores and grades and follow a formula. Other colleges give greater weight to activities, experience, and interests.Ask if a student leader can contact you to give you a students perspective. If its possible, provide the representative an email address for this.Go ahead and ask about the food. Sometimes there are many choices, and other times there arent. Remember, youll have to live with it for four years.Ask how the food plan works.Find out the safety history of the campus and the surrounding town. Sometimes the campus rests in an area where theres a high crime rate just outside th e area considered the campus. A representative may not mention this. This is also something you should research on your own before you get too attached to the dream. Be safe! Ask how many of the students drop out, transfer away, or how many stay and graduate. College representatives may cringe at this one because student retention is a touchy issue at many colleges. A low retention rate may be a warning sign, though.Ask: Whats the biggest complaint from current students?Is tutoring available?If class size is important, ask about it. Keep in mind, however, that class sizes are less important when good individual tutoring is available.Find out if tutoring is free.Ask for a direct phone number for an admission counselor and a financial aid counselor to avoid getting caught up in an automated phone quagmire at some point. Smaller colleges will be happy to provide this, but larger colleges may not. Its always worth a try though.Find out if the administration listens to student concerns. This is one of the things you might want to ask a student leader.Ask if youll have to pay for parking or if youll have to walk a million miles from a parking lot to your classe s. If you are very conservative or very liberal in your thinking, ask about the political and social climate. This is one of the things that could cause a feeling of discomfort or alienation down the road, so its not a silly question.

Classical Theories of Management Essay Example | Topics and Well Written Essays - 1500 words

Classical Theories of Management - Essay Example The classical management theory comprises of three schools of thought: scientific management, bureaucratic management, and administrative management. Although some organizations apply one or more of these theories in managing their employees, most people consider them outdated and inapplicable in managing the 21st-century workplace that needs more visionary leadership styles. Frederick Taylor advanced scientific management in his quest to increase organizational productivity (Taylor, 2003). Frederick emphasized on the efficiency of production processes that could be achieved through empirical research. Availability of skilled labor became a major problem among the 19th-century industrialists (Cameron & Green, 2009). Only a few people were educated at the time, and the few available were in high demand due to the increased number of industries hiring them. Managers thought that the best way to increase the efficiency of the available labor was to draw strict lines between tasks. This decision might have been arrived at because managers believed that they were more intellectual than the workers were, and their duty was to supervise workers as they perform their work. Taylor’s emphasis on high target is desirable since business organizations desire to grow and expand. However, this principle concentrates on selecting the highest standard possible for employees. Taylor did not accurately define the highest standards; this can cause exploitation of employees especially those who are hired on hourly rates. Although Taylor encouraged managers to use the piece-rate basis of payment, some companies may stress employees to work harder than their capacity as these companies strive to achieve their target standards (Hersey, Blanchard & Johnson, 2001). This can cause stress and poor welfare among employees. Standard conditions proposed by Taylor encourage rigidity of organizations.  

Human resource management (Case study) Essay Example | Topics and Well Written Essays - 1750 words

Human resource management (Case study) - Essay Example It defines the organisation’s behaviour and how it tries to cope with its environment.† More precisely, the MBA Tutorials (2010) defines SHRM as â€Å"the linking of human resources with strategic goals and objectives in order to improve business performance and develop organizational culture that foster innovation and competitive advantage† (par. 1). The key features of SHRM were identified as: (1) some organizing strategies or schemes link individual human resource interventions so that they are ‘mutually supportive’; (2) a great amount of responsibility is transferred down the line for the management of HR; and (3) there is a precise link between overall organization strategy, organization environment, HR policies and practices† (MBA Tutorials, 2010, par. 3) In this regard, the Talent Management at Standard Chartered Bank displays features of SHRM in terms of manifesting the presence of strategies that show â€Å"emphasis on people that has seen HR issues ascend the corporate agenda, with the bank’s declared goal of measurably increasing its leadership capacity by 2011† (Case facts, 2). ... .to introduce certain global standards and tools, (and) to give managers some freedom to decide locally how best to use them† (Case facts, 3).   1.2 Comment on the relevance of this approach in the light of the recent banking crisis? The Talent Management program that is consistent with the SHRM approach is appropriately significant in the light of the recent banking crisis due to its ability to gauge performance of personnel and bank branches regardless of their assigned locations; it has the ability to generate and integrate performance of employees on a global scale. In this regard, the effect of changes in the external environment could immediately be measured in terms of repercussive effects on bank branches worldwide and on how creative managers and respective personnel are in responding to the external pressures. The Talent Management Program of Standard Chartered manifests acknowledged the important roles and functions of HRM opting to implement SHRM in adapting to di verse factors from the external environment and adjusting to the demands of the times. Its ability to assess its effectiveness evolves into encompassing areas of employee development (employee behavior, attitudes and skills), competencies, performance, as these attributes all contribute to the achievement of organizational goals. As Cabrera & Cabrera averred, â€Å"no longer are operational measures of internal efficiency sufficient. HR departments must be able to demonstrate the value of their strategic contributions† (2003, 3) which are most applicable especially during the financial crisis. 1.3 Why is it important to measure the impact of SHRM? What might be included in an evaluation strategy to measure the impact of SHRM in