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OS and Pain Management 2 > Principles of uncomplicated exodontia > Flashcards

Principles of uncomplicated exodontia Flashcards

1
Q

ESSENTIALS OF EXODONTIA
(5)

A
  • Finesse
  • Dexterity and Skill
  • Controlled force
  • Firm steady pressure
  • Knowledge of what to treat and what to refer out
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2
Q

PRE-EXTRACTION PREP

A
  • Medical history
  • Physical examination
  • Radiologic evaluation
  • Informed consent
  • Surgical plan
  • Pain, anxiety control
  • Patient and surgeon preparation
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3
Q

SURGEON & PATIENT PREP
* UNIVERSAL PRECAUTIONS
(6)

A
  • Over coat/garment
  • Mask
  • Surgical gloves
  • Hair out of surgical field (cap or hair tie)
  • Eye protection
  • Patient drape
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4
Q

BASIC PREPARATION
(4)

A
  • PROFOUND anesthesia is required
  • Check for signs and symptoms
  • If patient says they are not numb…BELIEVE THEM
  • Extractions should be painless and relatively quick
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5
Q
  • If patient says they are not numb…BELIEVE THEM
    (2)
A
  • May have to distinguish pain with pressure which often is difficult for patients
  • LA results in loss of pain, temperature, and touch. But DOES NOT anesthetize
    proprioceptive fibers, thus potentially can feel intense pressure
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6
Q

COMMON INJECTIONS
MANDIBLE

A
  • Inferior alveolar nerve block
  • Gow-Gates block
  • Akinosi block (closed mouth)
  • Long buccal block
  • Mental nerve block
  • PDL injection
  • Intrapulpal injection
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7
Q

COMMON INJECTIONS
MAXILLA

A
  • Posterior superior alveolar block
  • Middle superior alveolar block
  • Anterior Superior alveolar block
  • Infraorbital Nerve block
  • intraoral and extraoral approaches
  • Greater palatine
  • Nasopalatine nerve block
  • V2 block*
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8
Q

LOCAL ANESTHESIA
* 2% Lidocaine w/ 1:100k epi →
* 3% Mepivacaine plain →

A

7 mg/kg or 3.2 mg/lb
6.6 mg/kg or 3.0 mg/lb

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9
Q
  • Epi limit for healthy adult →
  • Epi limit for cardiac patients →
A

0.2 mg (works out to 11.76 cartridges of 1:100k epi)
0.04 mg (works out to 2 cartridges of 1:100k epi)

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10
Q

OPTIONS FOR THE ANXIOUS PATIENT
* TLC most important concept
(2)

A
  • Proper explanation of procedure
  • Assurance that sharp pain will not be felt, but significant pressure will still be present
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11
Q

Basic pharmacologic option available
(3)

A
  • Pre-operative oral sedation (valium)
  • Nitrous oxide analgesia
  • Intravenous Sedation
  • Fentanyl, versed, propofol, ketamine
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12
Q

INDICATIONS FOR TOOTH REMOVAL
* SHOULD BE COMPLETED BY GENERAL DENTIST PRIOR TO ORAL
SURGERY CONSULTAITON
* OMS is a CONSULTING service
(3)

A
  • We do not determine restorability of teeth
  • All options for treatment should be discussed prior to OMS consultation
  • If patient asks what could be done other than extraction, the patient should be sent back to general
    dentist for treatment discussion
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13
Q

Extractions are non-reversible, and if there is a questions about the procedure, the patient is

A

not fully informed

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14
Q

INDICATIONS FOR TOOTH REMOVAL

A
  • Caries
  • Pulpal necrosis
  • Periodontal disease
  • Orthodontic reasons
  • Malpositioned teeth
  • Fractured teeth
  • Impacted teeth
  • Supernumerary teeth
  • Teeth associated with pathology
  • Radiation therapy
  • Teeth involved with jaw fractures
  • Financial issues
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15
Q

CONTRAINDICATIONS FOR TOOTH REMOVAL
(5)

A
  • Severe uncontrolled metabolic issues
  • Uncontrolled lymphoma/leukemia
  • Pregnancy in 1st and 3rd trimester
  • Uncontrolled Blood/Bleeding disorders
  • Uncontrolled cardiac issues
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16
Q
  • Uncontrolled lymphoma/leukemia
    (2)
A
  • Concern for infection due to
    nonfunctioning white cells
  • Bleeding concern due to nonfunctioning
    platelets
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17
Q

Uncontrolled cardiac issues
(4)

A
  • Unstable angina
  • Recent MI
  • Malignant hypertension
  • Uncontrolled dysrhythmias
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18
Q

CLINICAL EVALUATION OF TEETH FOR REMOVAL
* Access to tooth
(3)

A
  • Small mouth, limited opening
  • Posterior more difficult to visualize
  • Severe crowding
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19
Q

CLINICAL EVALUATION OF TEETH FOR REMOVAL
* Mobility of tooth
* Periodontally involved teeth –

A

greater than normal mobility
* Increased amount of bleeding due to overgrowth of granulation
tissue
* Soft tissue management is more problematic
* Root fractures unpredictable

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20
Q

Less than normal mobility
(2)

A
  • Hypercementosis at root
  • Ankylosis
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21
Q

CLINICAL EVALUATION OF TEETH FOR REMOVAL
* Condition of crown
(2)

A
  • Extensive carious lesions causing destruction
    of crown during delivery with forceps
  • Similar with excessively large restorations
  • Endodontically treated roots over time cause
    brittle root structure prone to root fracture
    during extraction attempt
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22
Q

Check condition of adjacent teeth crowns

A
  • Large restorations or crowns could be
    damaged with improper luxation or forceps
    use
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23
Q

RADIOGRAPHIC EXAMINATION OF TEETH
* Need a periapical radiograph that is properly:
(3)

A
  • EXPOSED – proper contrast
  • POSITIONED – entire tooth structure visualized
  • PROCESSED – developed and fixated
  • Less of a concern with advent of electronic radiographs
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24
Q

Department policy for impacted third molar
evaluation is an —
radiograph of good diagnostic quality

A

ORTHOPANTOMOGRAM (PANO)

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25
Relationship of associated vital structures * Maxillary molars – * Mandibular molars – * Mandibular premolars – (2)
sinus position Inferior alveolar canal position mental foramen position * Can easily be confused with a periapical abscess * Careful when creating and reflecting FTMP flap
26
Configuration of Roots (6)
* Number of roots and length * Curvature * Divergence * Shape * Associated pathology: Abscess, hypercementosis, external and internal root resorption * PDL space
27
RADIOGRAPHIC EXAMINATION OF TEETH * Condition of surrounding bone (2)
* Increased bone density vs decreased bone density * As patient’s age, bone becomes less medullary →more cortical, thus more dense
28
SURGEON & PATIENT PREP * UNIVERSAL PRECAUTIONS
* Over coat/garment * Mask * Surgical gloves * Hair out of surgical field * Cap or Hair tie * Eye protection * Patient drape
29
SURGEON & PATIENT PREP
* Sterile drape over patient * Antiseptic mouth rinses * Oral pharyngeal partition!! * No throat pack →immediate failure during comp exams * Sterilized instruments and equipment
30
CHAIR POSITION * Standing vs sitting * Choose the position that allows you:
* To feel comfortable * The maximum amount of control over the forces being sued * Good visualization and access * Free hand for ancillary tasks * Does not block the light source
31
SURGEON POSITION
* Keep feet firmly planted on the floor * Keep elbows in close to body * Keep forceps, hands, wrist, and lower arm in a straight line * Transmit the force with the more stable and powerful upper arm and shoulder and not the wrist or hands
32
FORCEPS EXTRACTION * Frequent errors: (4)
* Chair is too high * Operator blocks out light * Elbows flailing * Bending over or craning neck
33
Elbows flailing
* Increased stress on deltoids and trapezius muscles * Causes fatigue which could potentiate mistakes at the end of the workday
34
Bending over or craning neck
* Causing potential career ending neck and back problems
35
MAXILLARY EXTRACTIONS (4)
* Operator in front position * Chair recline so maxillary occlusal plane is 60º to 90º to the floor * Mouth at level of elbow * Patient’s head turned towards or away operator to degree necessary for appropriate visualization
36
MANDIBULAR EXTRACTIONS (5)
* Patient in more upright position * Mandibular occlusal plane parallel to floor * Chair will be lower than for maxillary extractions * Mouth at level of elbow * Patient’s head turned towards or away operator to degree necessary for appropriate visualization
37
REAR EXTRACTION POSITION ADVANTAGES (5)
* Underhand grip allowing operator to use more powerful biceps instead of weaker forearm * Keeps elbows tight to body * Less light obstruction * More effective support of mandible for free hand * Easier for assistant to see
38
REAR EXTRACTION POSITION DISADVANTAGES (3)
* Acceptable technique for mandible, MORE DIFFICULT for maxilla * View of field is upside down * Causes operator to rely more on “feel” than direct vision - Especially with maxilla
39
PRINCIPLES (3)
* The LEVER * The WEDGE * The WHEEL AND AXLE
40
THE LEVER * --- are used primarily as levers * ---CLASS lever system
Elevators FIRST
41
THE LEVER Mechanical advantage: (2)
* Long lever arm with short effector arm * Transforms small force and large movement to small movement and large force
42
THE WEDGE (3)
* Wedge can be used to expand, split, and displace portions of the substance that receives it * Elevators wedged into PDL space expanding bony socket as well as displacement of root toward occlusal surface * Forceps seated below crestal bone to aid in crestal bony expansion
43
THE WHEEL AND AXEL (3)
* More closely identified with use of Cryer elevators (flag elevator) * Handle serves as the axel * Tip of elevator serve as the wheel and engages and elevates the root from socket
44
DENTAL ELEVATORS (3)
* Used to LUXATE teeth, not to remove them * Minimizes root fracture * Requires fulcrum point
45
RULES FOR LUXATION (5)
* Never use adjacent tooth as fulcrum, UNLESS the tooth is also to be extracted * Never used the buccal/lingual plates at the gingival line as fulcrum * Always use finger guards to protect the patient in case elevator slips * Be certain that the forces applied by the elevator are under control * Elevator tip should exert pressure in the right direction
46
STRAIGHT GOUGE ELEVATORS * The ONLY elevators that use all 3 principles (3)
* Lever * Wedge * Wheel and Axel
47
FORCEPS * The PRIMARY instrument for
removal of teeth
48
FORCEPS' Goals: (3)
* Expansion of bony socket by movement of the tooth against alveolar socket * Separation of the PDL attachment * Removal of tooth from socket
49
FORCEPS FORCES (5)
* Apical * Buccal * Lingual * Rotational * Traction
50
FORCEPS FORCE (4)
* Apical force * The first force applied * Used on all teeth * Seat forceps beak on firm root structure
51
* Seat forceps beak on firm root structure (2)
* Expands crestal bony cortex * Displace center of rotation as apically as possible
52
Seat forceps beak on firm root structure * Expands crestal bony cortex * Displace center of rotation as apically as possible (2)
* Reduces apical root fracture * If fulcrum is too high, there is increased force placed on apical region of root →root fracture
53
FORCEPS FORCE * Buccal force
* After apical force applied * Most frequently used to expand socket * Buccal plate usually thinner than palatal or lingual plate * Possible to fracture buccal plate without expansion of socket if large buccal force and thin alveolus present
54
FORCEPS FORCE * Lingual force (2)
* Similar to buccal force, but with lingual/palatal bony expansion * Rare to get lingual plate or palatal plate fracture with this force
55
FORCEPS FORCE * Rotational force (3)
* Create internal expansion of socket * Best application is teeth with single conical roots * Least chance to fracture bony plates, roots, or tooth
56
FORCEPS FORCE * Traction force
* Limited to the final phase of the extraction process * To deliver the tooth * Should be very minimal force - If proper bony expansion and PDL disjunction achieved with previous applied force
57
PRE-EXTRACTION PREP
* Medical history * Physical examination * Radiologic evaluation * Informed consent * Surgical plan * Pain, anxiety control * Patient and surgeon preparation
58
PRE-PROCEDURE PREP
* Proper chair position * Mandibular occlusal plane parallel to floor * Maxillary occlusal plane 60º to 90º * Universal precautions * Instrument selection * Discussion with faculty
59
Closed extraction technique
* Simple extraction →elevators and forceps * Most frequently used technique for extraction * Always attempted first
60
Fundamentals for a proper extraction (3)
* Adequate visualization and access - You can’t complete what you can’t see * Unimpeded path for removal * Controlled force to luxate and remove tooth
61
PROCEDURE FOR CLOSED EXTRACTION * Steps for closed extraction
* Loosening gingival attachment * Luxation with elevator * Proper adaptation of forceps * Luxation of tooth with forceps * Removal of tooth from socket
62
ROLE OF OPPOSITE HAND
* Reflect cheek, lips, possibly tongue * Stabilize patient head * Support lower jaw * Prevent damage to TMJ * Support alveolar process * Feel cortex expanding * Stabilize neighboring dentition
63
Maxillary incisors (2)
* Primarily rotational * #13 forceps
64
* Maxillary canine (4)
* Longest tooth * Combination of all 5 forces (mild rotational) * Fracture buccal plate very common * Upper Universal #150 forceps
65
Maxillary 1st premolar
* Highest chance of all premolars to have multiple roots * Buccal force > palatal force * Want to break buccal root instead of palatal root * Avoid rotational force * #150 forceps
66
Maxillary 2nd premolar
* Thick, blunt root * Usually relatively simple extraction * #150 forceps
67
Maxillary Molars
* Can be difficult due to large divergent roots and proximity of sinus * Apical force, with slow steady buccal force with less palatal force (buccal plate thinner) * #150 vs #88 R/L vs #53 R/L
68
Maxillary 3rd molar
* One tooth that can be frequently removed with elevators only
69
Mandibular anterior teeth
* Apical →buccal & lingual (equal pressure) → rotational →labial traction * Roots and buccal bone fracture very easily * Be sure the smooth sharp areas of bone * Lower universal #151 vs #13 Ash forceps
70
Mandibular premolars
* Next to max central incisors & max 2nd premolars, lower premolars are among the easier to extract * #151 vs #13 * Apical →buccal & lingual (equal force) → rotational (short and conical roots) →buccal traction
71
Mandibular molars
* Like max first molar, can be the most difficult of all teeth to deliver * Long, strong, divergent roots * Buccal and lingual bone more dense * Roots may converge at apex (“locking” tooth into place) * #23 Cowhorn forceps vs #17
72
COWHORN FORCEPS USE
* Seat lingual beak first, then buccal beak * Can easily crush crestal lingual cortex and inadvertently severe lingual nerve * Lingual nerve is on average ~ 2.5 mm medial and inferior to lingual cortex crest * ~15% lingual nerve is oriented superior to lingual cortex crest * Push beaks apically * Pumping motion vs Rocking motions vs gentle rotational movements * Squeeze handles together as beaks come together in the bifurcation * Figure of 8 motion * Occlusal plane of tooth will elevate above remaining mandibular occlusal plane * Gradual traction to deliver
73
DECIDUOUS TEETH
* Roots are long and thin * Easy to fracture * If unable to retrieve small root segment, leave it in place and advise the parent * If deciduous molar roots grasp around permanent crown, tooth should be surgically sectioned * DO NOT CURETTE SOCKET * Do not want to damage permanent bud underneath
74
POST EXTRACTION CARE FOR SOCKET
* If periapical pathology is present, curettage is indicated * If no pathology, no need for forceful curettage * Smooth any sharp areas of bone around alveolar socket * Irrigate socket, usually with normal saline * Suture if indicated (if mucosa does not lay passively to alveolus) * Place 4x4 gauze over socket * Instruct patient to bite for 1 hour, FIRMLY * Most common cause of post-operative bleeding from not putting enough pressure over socket

OS and Pain Management 2 (10 decks)

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