EXTRACTIONS Flashcards
Contraindications of exo
Split into systemic, local, physiology, pharmacology
Systemic:
a) uncontrolled cardiac disease
b) blood disorders (severe anemia, leukemia, haemophilia)
c) liver disease (Vit k deficiency or clotting factor deficiency)
d) uncontrolled DM
e) high grade fever
Local factors
a) malignancy to avoid seeding of tumour cells of extraction around tumour site
b) history of radiotherapy - risk of ORN, consider RCT as alternative
c) severe pericoronitis around 3rd molar
d) acute dentoalveolar abscess (if patient has trismus and compromised access)
Physiological factors
a) pregnancy 1st and 3rd trimester
b) very old patient
Pharmacology
a) allergy to LA
b) patients on steroids
alternatives to LA
SEDATION via
- diazepam
- inhalation of nitrous oxide
- IV anxiolytic drugs like diazepam and midazolam
5 motions of forcep
1) apical pressure to expand bony socket and displace centre of rotation apically
2) buccal force - expand buccal crestal bone
3) lingual force - expand lingual crestal bone
4) rotational force - cause internal expansion of tooth socket, useful for tooth with conical root
5) tractional force - applied last, gently deliver tooth from socket after adequate bony expansion is achieved
indications for the use of elevators
1) luxate and remove teeth which cannot be engaged by beaks of forceps eg impactions, extensively decayed tooth etc
2) reflect mucoperiosteal membrane
3) remove roots, fractured or carious
4) loosn teeth prior to application of forceps
5) split teeth which have had grooves cut in them
6) remove intra radicular bone
4 precautions when using elevators
1) never use adjacent tooth as fulcrum
2) always use finger guard to protect patient’s tissues
3) forces applied through instruments should be controlled, if not will cause fracture of mandible, maxilla or alveolar process
4) deliver force in correct direction
list 7 post op complications of exodontia
1 post op pain
- bc of damage to hard and soft tissue
- might be becuase of dry socket
- acute osteomyelitis
- traumatic arthritis of TMJ
2 post op swelling
- oedema (part of inflammatory reaction to surgical interference
- hematoma formation
- infection
3 trismus
- may be due to post op edema/ swelling
- hematoma
- damage to TMJ
- trauma to medial pterygoid muscle when giving IDN
4 paresthesia (nerve injury)
5 delayed healing
- wound dehiscence
- infection
- prolonged bleeding due to clotting defect
- OAF
6 post op bleeding
7 post op infection
- intrinsic poor immunity
- lack of asepsis
what to do if difficulty in achieiving anesthesia
1 increase amount
2 consider usign alternative techniques like blocks, intra ligamental or intra pulpal
3 use alternative anesthetic eg articane which has better diffusion into bone and soft tissue compared to other LAs
what is a common cause of excessive hemorrhage
more commonly due to local factors (infection, trauma, local vascular lesions) rather than systemic factors
to reduce infection/ inflammation, should do
- SAP 1 week pre op
- instruct px to maintian good OH
- CHX mouthrinse may be used
tx for fracture of max tuberosity
- if tooth is symptomatic, must remove tooth but remove as little bone along with it as possible
- if not symptomatic, can rigid fixation with arch bar or acrylic plate for 4-6 weeks then after that time, raise flap and remove bone around tooth to take the tooth out
Mx of large OAP
> 6mm
Need to be surgically and immediately, flap advancement done to provide primary closure and cover sinus opening
1) buccal advancement flap (usually the op of choice)
2) buccal fat pad
3) palatal flap
- this one needs to be raised with periosteum to include palatine artery which must be preserved. and is more uncomfortable for patient
Post op instructions
- no nose blowing/ sneezing/ straws for 10 days
- nasal decongestants
- Augmentin antibiotics for 2 weeks
- STO 10 days or more
Mx of small OAP
less than <2mm
1) establish blood clot and preserve it in place
- gauze pack placed for 1-2 hours
- no need for soft tissue flap elevation
- primary closure can be easily accomplished with adequate healing
2) nasal precautions for 10-14d
- open mouth when sneezing
- avoid nose blowing
- don’t suck on straw or any situations that may produce pressure changes in the sinus and hence dislodge the clot
Prescribe meds
- antibiotics to prevent infection
- antihistamines and systemic decongestants eg oxymetazolline for 7-10d to shrink mucous membrane and maintain ostium patency for normal sinus drainage
Follow up
- within 48-72 hour intervals
- patient instructed to return if OAC becomes evident eg leakage of fluid through nose or symptoms of maxillary sinusitis
Mx of moderate OAP
2-6mm
General principle is that we let it heal on its own with LOCAL MEASURES
same measures as small perfs
1) establish blood clot and preserve it in place
2) nasal precautions
3) prescribe AB and decongestants
PLUS
1) suturing of the mucous membrane to reposition soft tissue
2) surgicel (small piece) to help stabilise the clot
3) STO 10 days later
What is the Tx if OAF were to form delayed?
Aim is to eliminate any acute/chronic infection within sinus
Meds prescribed
- antibiotics
- decongestants
- antihistamines
Keeping space clean
- need frequent irrigation of fistula and sinus tract + use of antibiotics and decongestants
- construct temporary appliance to cover fistula and prevent food and other contaminants from getting into sinus
- buccal or palatal flap advancement
If persistent
- might need to remove diseased tissues using Caldwell Luc procedure
- adjacent teeth to be evaluate for possible involvement
- in the case of chronic fistulas, fistulous tract will be lined with epithelium which must be excised/elevated from bony walls before inverting into sinus cavity
S/S of acute sinusitis
- pain together with the feeling of weight in the cheek on affected side, especially on bending down
- discharge from maxillary
- cheek over infected sinus is red
- tenderness on pressure in canine fossa
- pus may be seen and smelled in nostril
- transillumination and radiographs show opacity, if pus is present
