L3 - Complex Exodontia (8/20) Flashcards
describe flap base and whyh
base of flap must be BROADER than the free margin
- has to preserve the blood supply
size of flap
must be adequate size
*flap extends TWO TEETH ANTERIOR AND ONE TOOTH POSTERIOR to the surgical area
or vise versa
why need the size
- adequate visualization
- adequate access of instrumentatin
- large enough to retract without tension
type of flap
full thickness – mucoperiosteal
make incision where - general
over an intact bone
describe flap base
BROADER than the free gingival margin
go over canine eminence?
NEVER
how far away from bony defect
must be at least 6-8 mm away from a bony defect
do not want margin too close tot he bone we will be removing
desctibe the vertical releasing incisions *
should NOT cross the bony eminence
types of mucoperiosteal flaps
- envelop
- tytpical - three-cornered
- four-cornered
- type of flap used to cover a large hole
indications for SURGICAL extractions
- long list
- surgeon perceives a possible need for excessive force to extract a tooth
- when closed technique has failed
- patient with heavy dense bone
- short clinical crowns secondary to bruxism
- hypercementosis
- widely divergent
- close proximity to sinus
- teeth with extensive caries
- severe attrition
check what before surgical extraction is an option **
LOOK AT X-RAYS
-
when will you know a tooth will need surgical extraction?
after taking the time to examine the X-rays
is it okay to come over the bone with the forceps?
YES
first force on a tooth?
APICAL
REMOVE BUCCAL CORTICAL PLATE?
you can
- NEED a finger rest
purchase point?
with bur – to get a point to grab onto
when have multi-rooted tooth?
general
you can take one root out at a time if you want
elevator in to separate the tooth and remove them
take the crown off?
*before you open up what must you do
look at x-rays and look at mouth and know your approach before hand
oroantral communications prevention
surgical removal
this is a sinus perforation
oroantral communications diagnosis
- examine tooth
- visualization
- nose-blowing
treatment of oroantral communications if less than 2mm
dont have to do anything about it really
- try to ensure a good blood clot
tx for oroantral communications if b/w 2-6 mm
pack the socket, and do a figure 8 suture
antibiotics, decongenstants, and sinus precautions like no smoking, nose blowing, sneezing, sucking out of a straw
tx for oroantral communications if b/w 2-6 mm
pack the socket, and do a figure 8 suture
antibiotics, decongenstants (dont use for awhile), and sinus precautions like no smoking, nose blowing, sneezing, sucking out of a straw
tx for oroantral communications if greater than 7
consider flap closure
- buccal or palatal finger
most common injury to adjacent tooth
fracture of existing restoration
common injuries to adjacent teeth
fracture of existing restoration
fracture of an adjacent carious tooth
luxating an adjacent tooth
- using elevator as a scoop instead of using it the other way
extracting the wrong teeth
how to prevent taking out the wrong tooth
THE TIME OUT METHOD
most common complications with tooth being extracted
root fracture - most common
root / tooth displacement
complications with tooth being extracted
- into max sinus
- into infratemporal space – maxillary third molar
- into the sublingual space
- into the submandibular space
- down the pharynx
- aspirated
where can maxillary molar be displaced to
the maxillary third molar
nerves that can be affected
- mental
- lingual
- long buccal
- nasopalaatine
5 IAN
bite blocks for?
to alleiviate any post op discomfort in the TMJ
patients on coumadin INR?
CAN perform an extraction on a patient with an INR of 3.0 or less
(if 2.8 – single tooth go for it if very invasive then i would be tentative)
microfibular collagen uses
avitene
microfibular collagen uses
avitene
describe dry socket
- pain 3-4 days post op
- bad taste
- headaches
- bad headache
- pain radiated to patients ear
pain radiating to ear singifies
dry socket
details about the vertical releasing incisions
- should NOT cross a bony eminence (like canine eminence)
- should NOT end at the facial aspect of the tooth
- should cross the free gingival margin at the line angle of the tooth (avoid cutting the papilla away)
adequate radiogrpahs include?
- root apexes
- morphology
adjacent structure like
- sinus
- IAN
Three conditions must be met for a tooth / root fragment to be left in the alveolar process
- The root fragment must be small <4-5 mm
- The root must be deeply embedded
- The tooth involved must NOT be infected
No radiolucency present
in order For a surgeon to leave a previously described root fragment in place
The risk of removal must be greater than the benefit
Three examples of when the risk of removal would be greater than the benefit
- Large amounts of bone must be removed
- The root tip is close to vital structures
There is a high liklihood the root tip may be displaced
- The root tip is close to vital structures
If a root tip is left in place what must occur
- Patient must be informed
- radiographic documentation is obtained
- the decision to leave the root tip must be well documented in pt. chart
- the patient should be placed on a periodic recall schedule
- the patient should be instructed to contact you if they develop any symptoms
multiple extractions sequencing and why
maxillary before mandibular
- aneshetic considerations
- wound contamination (debris)
posterior before anterior
- the 1st molar and canine teeth are removed last
teeth that are removed last
1st molar and canine
main components / tools to control bleeding
- gauze packs
- patient told to expect oozing for 12-24 hours
AVOID
- smoking
- spitting
- sucking through straw
- strenuous exercise
pt. told to expect oozing for?
12 -24 hours
most pain can be managed with
mild analgesics
peak pain usually occurs when?
12 hrs. post-operative
pain rarely persist longer than 2 days
diet in post-op
high calori liquid diet
soft diet
adequate hydration
cool foods
when can patient rinse
post -op day 2
brushing on day of surgery
AWAY from the extraction site
max edema/ swelling will occur?
24-48 hours post-op
how to control edema
- elevate head
- ice packs (20 on 20 off) for the 1st 24 hours
- 3rd post-op day heat may e applied
when can you apply heat
3rd day
for infection control consider…
consider antibiotics
trismus details
patients MUST be told that this may occur
- most commonly caused by multiple injections
heat packs may be helpful
ecchymosis
onset?
bruising / not dangerous
- usually seen in older patients
- onset usually in 2-4 day post-op
- can last 7-10 days
radiographically needs to show what on roots
apex
morphology
*adjacent structures need to see sinus and IAN
Cardinal rules of surgery
- adequate visualization
- light, retraction, and suction - unimpeded pathway for removal
- controlled force (finesse, NOT force)
- aseptic technique
- atraumatic handling of tissues
- adequate hemostasis
adequate visualization
light
retraction
suction
Post-op instruction headlines
- activity
- diet
- pain control
- wound care
soft tissue injuries include
- tearing of flaps (most common)
- puncture injury
- abrasions
tearing of flaps
most common soft tissue injury – most common injury is to the mucoperiosteal flap
due to
- poor design
- excessive retraction force
reasons for puncture injury
inadequate finger rest
reasons for abrasions
- re-tractors can cause
rotary instruments
main injuries to osseous structures
- bone fracture
- management of fractures
- tuberosity fractures
main cause of bone fracture during extraction?
most common areas?
excessive force – common in the maxillary canine and maxillary molar area
- fracture of the maxillary tuberosity
excessive force use common in?
the maxillary canine region and maxillary molar area
prevention of bone fracture
age
poor morphology
thickness of buccocortical plate
if bone is removed with tooth? if bone remains attached?
if it is removed completely with the tooth– do not attempt to replace it – no blood supply
if bone is still attacahed to periosteum- there is a high probability that the bone will heal
management of tuberosity fractures
splint tooth and return 6-8 weeks for surgical extraction
remove crown and wait for healing (6-8 weeks)
tx for dry socket
- irrigation
- placement of a medicated dressing
- change dressing every day or every other day for 3-6 days
common etiology causing oro-antral communications
- removal of maxillary molars and pre-molars
risk factors for oro-antral communications
- divergent roots
2. no bone separating roots from sinus
sequelae of oroantral communications (what can follow)
- fistula formation
2. sinusitis
best method for diagnosing oro-antral communications
nose-blowing test (best method)
Control of pain
- Mild analgesics usually work well T/F
True
most common post -op pain meds used
tylenol
tylenol with codeine
NSAIDs
Vicodin
Percocet
give first dose of meds when?
before the anesthetic wares off
armentarium to control bleeding post - op
- pressure
- collagen plug
- microfibular collagen (Avitene)
- gelfoam
- collagen tape
- surgical
- topical thrombin
- bone wax
wound dehiscence aka
exposure of bone
main signs of dry socket
- pain radiating to ear
- bad smell
- bad taste
- exposure of bone
- PAIN STARTS 3-4 DAYS POST OP***
bite blocks especially important with?
taking out mandibular teeth and limited the medial movement of the jaw
- place on contra-lateral side
medications that can increase risk of post-op prolonged bleeding
he 5 A’s
- ASA / aspirin
- anticoagulants
- antibiotics
- anti-cancer drugs
- alcohol
put tooth back in to control bleeding
yes - can be used as a means to stop bleeding
dry socket is complication of
delayed healing and infection
