exodontia) general)principles))...
TRANSCRIPT
Exodontia
General Principles and Complications
Dr Andrew Ow BDS, MDS(OMS), FRACDS, MOSRCS (Edin), AdvDip (OMS), FAMS
Discipline of Oral and Maxillofacial Surgery National University of Singapore
‘Ideal’ tooth extraction
Painless
Minimal or no damage to surrounding 1ssues
En1re tooth removed
Uneven6ul healing
No prosthe1c problems
Indications
Extensive destruc1on by caries
Unsuccessful root canal therapy
Advanced periodontal disease
Intrabony pathologies (e.g. cyst, tumours)
Trauma1c damage
Orthodon1c indica1on
Prosthodon1c indica1on
Forthcoming radiotherapy/immunosuppressive/bisphonate therapy
Clinical steps Pre-‐opera1ve assessment
Medical, dental and social history
Clinical and radiographic examina1on
Assess need for an1bio1c cover, steroid cover, an1-‐coagulant therapy modifica1on
Check and confirm with pa1ent tooth to be extracted (1me out)
Local anasthesia
Extrac1on of tooth/teeth
Check comple1on of roots/crown
Hemostasis achieved ?
Post-‐op instruc1ons
Records
Pre-‐operative assessment
Medical history Systemic diseases e.g. Bleeding disorders, DM,
immunosuppression, cardiac condi1ons, liver cirrhosis etc
Medica1ons e.g. an1-‐coagulants, an1-‐platelet, steroid therapy, bisphosphonates, contracep1ves
History of radiotherapy, chemotherapy
COMMUICATE WITH PATIENT’S PHYSICIAN IF UNSURE!!
Pre-‐operative assessment
Dental history Previous extrac1ons Difficult extrac1ons Complica1ons e.g. dry socket
Reac1ons to local anasthesia
Pre-‐operative assessment
Social history Smoker?
Pack years?
Clinical examination
Extra and intra-‐oral
Hard and soU 1ssue examina1on
Oral hygiene
Tooth to be extracted Heavily restored Grossly carious Mobility
Rotated, inclined Overlying soU 1ssue
Radiographic examination
Compulsory to have a pre-‐extrac1on radiograph
WHY? Root morphology e.g. hypercementosis, curved,
bulbous Crowned, heavily restored teeth Proximity to vital anatomical structures Impacted teeth Peri-‐apical pathology Accompanying condi1ons e.g. hemangioma, ostei1s
deformans
Extraction of teeth
Instruments
Posi1oning of pa1ent and operator
Technique
Instruments
Forceps
Elevators Couplands Cryers Warwick james Root pick Luxators
2 basic methods
Intra-‐alveolar or ‘Forceps’ extrac1on
Trans-‐alveolar extrac1on
Mechanical principles
Expansion of the bony socket (***)
• Socket dila1on
• Small fractures of buccal plate and inter-‐radicular septa
• Loose bone must be removed
Mechanical principles…Elevators The use of a lever and fulcrum to force tooth or root out of
socket
The inser1on of a wedge or wedges between tooth-‐root and the bony wall
Post-‐op instructions
Bite on the gauze for 30mins; change if necessary
NO rinsing out for 24 hrs
NO high intensity ac1vi1es for 2-‐3 days
SoU diet
Sleep with head slightly inclined
Pain control
Medications
Analgesics e.g. panadol, panadeine, ibuprofen, ponstan
An1-‐bio1cs ?
CHX mouthwash ?
Records Important to detail procedure
Procedure today:
Xn 34 under LA
Clinical findings: 34 grossly carious, possible surgical exo OR curved root
2 carpules scandonest given (IDN and buccal nerve block), 2%, 1:100,000 adrenalin)
Forceps Xn 34
34 extracted completely
+/-‐ apical granuloma cureied
Pressure gauze placed
Hemostasis achieved
Post-‐opera1ve instruc1ons given (POIG)
Panadol 1g QDS prn x 3 days
Chlorhexidine M/W 10ml TDS x 5 days
Review 1/52
Complications -‐ During
1. Failure to:
Obtain adequate anasthesia
Remove the tooth with forceps / elevators
2. Fracture: Crown, root, bone, tuberosity, opposing tooth, mandible
3. TMJ disloca1on
4. Displacement of root
Mx Sinus, lingual soU 1ssues, infra-‐temporal fossa, aspira1on
5. Excessive hemorrhage
Complications -‐ During
6. Wrong tooth
7. Damage to:
SoU 1ssue (lips, cheek),
NERVES: IDN, lingual nerve
Adjacent teeth
Maxillary sinus (oroantral communica1on) etc
Complications -‐ After
1. Post-‐opera1ve pain: Damage to hard and soU 1ssue ‘Dry socket’ or alveolar osteiDs Acute osteomyeli1s Trauma1c arthri1s of the TMJ
2. Post-‐opera1ve swelling: Odema Hematoma forma1on Infec1on Trismus OAC
Oro-‐antral communication
Occurs with maxillary molars and some1mes premolars
Proximity of roots to maxillary sinus
Pneuma1sa1on of sinus
Clinical signs: Actual visualisa1on of sinus Part of sinus floor aiached to molar root Water entering the nose from the mouth Mis1ng of the mirror on occluding the nasal passage Acute sinusi1s (post-‐opera1vely) -‐ > pus discharge, bad
smell, pain and erythema over sinus, Chronic sinusi1s
DON’T GO PROBING INTO THE SOCKET TO CHECK!!!! MEMBRANE LINING MAY STILL BE INTACT…
Treatment
Small perfora1ons (<2mm)
Moderate perfora1ons (2-‐6mm) can be allowed to heal on its own with local measures (surgicel + suturing) and an1obio1cs
Treatment
Large perfora1ons (>6mm) need to be surgically closed immediately Buccal advancement flap
Buccal fat pad
Palatal island flap
Post-‐opera1ve instruc1ons NO nose blowing, sneezing, straw drinking etc for
10days
Nasal decongestants An1-‐bio1cs (Augmen1n) for 2 weeks
STO 10 days or more
Alveolar osteitis
‘Dry socket’ – incidence 5-‐20%
Increasingly severe pain 3-‐7 days aUer extrac1on
Absence of blood clot from socket
Bony walls are denuded and highly sensi1ve to even gentle probing
Exact pathophysiology unknown
? Increased fibrinoly1c ac1vity within the alveolus and clot
Risk factors (???) Higher microbial counts
Surgical difficulty
Flap design and extent
Reac1vated herpes simplex virus
Inadequate intraopera1ve lavage
Increased age
Female gender (hormone induced fibrinolysis?)
Oral contracep1ves
Tobacco use
Clinical signs
++ pain 3-‐5 days post-‐extrac1on
Bad smell
Empty socket
Necro1c walls
Very sensi1ve to probing
Treatment
Not an infec1on!
Local measures: Placement of medicaments e.g. alvogyl, BIPP
Surgical interven1on
Review every 2 days
Root in antrum 1. Confirm with radiographic imaging -‐2 x-‐rays perpendicular to each other -‐CT scan
2. If root small 2-‐3mm, aiempt retrieval through socket with irriga1on
3. If unsuccessful, decide to leave or perform addi1onal surgery
4. Closure of OAC required as described
5. If root large, it should be removed via a Calwell-‐Luc approach in anterior wall of sinus. Please refer to an Oral and maxillofacial surgeon.
Uncontrolled bleeding….
Preven1on Medical history e.g. HTN, liver cirrhosis, cardiac problems, Drug history e.g. 5As – Aspirin, An1-‐coagulants, An1bio1cs, Alcohol,
An1-‐cancer drugs Blood tests e.g. INR
During the extrac1on Minimal trauma to soU 1ssues Sharp bony spicules should be smoothened All granula1on 1ssue removed (except near vital structures) Wound inspected for any bleeding vessels (pressure or liga1on) Bone inspected for bleeding Local hemosta1c agents with suturing if necessary Hemostasis should be checked again before pt leaves and gauze
replaced with a new one (for 30mins)
Hemostatic agents
Gelfoam
Surgicel
Collagen plug
Transexamic acid
Secondary bleeding Pa1ent posi1on
Adequate ligh1ng and suc1on
Local anesthe1c
Suc1on clot away
Inspect the socket and soU 1ssues
* Bleeding can come from 3 areas
Bony socket SoU 1ssue (gingivae) Neurovascular bundle (IAN), vessels
If not an arterial bleed, local hemosta1c measures can be used
Thank you