2- Exodontia - Basic principles - Sethi.pdf

BASIC PRINCIPLES OF EXODONTIA  MEDICINE EXTRACTION SURGERY PHYSICAL MECHANICS  PRINCIPLE #1 Know your pt PRESURGICAL MEDICAL ASSESSMENT  AGE, MEDICAL HISTORY AND MEDICATIONS - AGE quality of bone and systems. bone is more dense - WHAT CON...

BASIC PRINCIPLES OF EXODONTIA  MEDICINE EXTRACTION SURGERY PHYSICAL MECHANICS  PRINCIPLE #1 Know your pt PRESURGICAL MEDICAL ASSESSMENT  AGE, MEDICAL HISTORY AND MEDICATIONS - AGE quality of bone and systems. bone is more dense - WHAT CONDITIONS AND MEDICATIONS ? (BLOOD THINNERS?) also why are taking it the more medication - ANY CHANGES TO MEDICATIONS , ANY SURGERIES the more uncontrolled is - RECENT VISITS TO PHYSICIAN / ER / HOSPITAL ADMISSIONS - ANY RECENT LAB WORK - PHYSIOLOGICAL STATES THAT MAY LEAD US TO MODIFY OUR APPROACH IMPORTANT TO DETERMINE THE SEVERITY AND STABILITY OF THE MEDICAL CONDITION DO YOU NEED TO SPEAK TO PHYSICIAN ? CONCEPT OF OPTIMIZING THE PATIENT AS OPPOSED TO “GETTING A CLEARANCE” optimize better than clearance  WORK UP FOR - DIABETIC PATIENT NEEDING AN EXTRACTION ? - PATIENT HAS CHRONIC KIDNEY DISEASE ? - PATIENT WITH RECENT MYOCARDIAL INFARCTION  PRINCIPLE #2 PAIN AND ANXIETY CONTROL Local anesthesia Removal of tooth is associated with pain and anxiety Profound local anesthesia is the “key” Despite local anesthesia, discomfort from pressure placed on adjacent teeth, surrounding tissues and TMJ Inferior alveolar nerve block in mandible supplemented by buccal and /or lingual nerve block is important Infiltration anesthesia works well in maxilla Most common solution used Lidocaine 2% with 1:100000 epinephrine Others include Articaine 4% with 1:100000 epinephrine 3% Mepivicaine (no epinephrine) Bupivicaine 0.5% with 1:100000 epinephrine(long acting) Local anesthesia may be challenging in Teeth with acute symptoms / “hot tooth” (discuss options for anesthetizing “hot tooth”) Teeth in midline or where nerves cross  Principle 3 Focused oral examination Extra oral Exam Any obvious neck swelling / node enlargement / TMJ exam Evaluate mouth opening or presence of trismus Any extra oral sinus tracts / fistula / condition of overlying skin Intraoral Exam Tooth / teeth in question - mobility, pain? Large restorations / crowns or implants on adjacent teeth Any obvious pathology on clinical and radiographic exam IMAGING  INDICATIONS OF EXTRACTIONS PERIODONTAL CARIES DISEASE  INDICATIONS OF EXTRACTIONS TEETH ASSOCIATED WITH PATHOLOGY ORTHODONTIC REASONS - PREMOLARS \(MOST COMMON WRONG TEETH EXTRACTED! PATIENT IS BEING PLANNED FOR RADIOTHERAPY TO HEAD AND NECK REGION / BISPHOSPHONATE THERAPY - EXTRACT QUESTIONABLE TEETH?  What patient factors may make extractions difficult ? AGE - DENSER BONE SIGNIFICANT GAG REFLEX PATIENTS UNABLE TO COOPERATE - AGE / MEDICAL CONDITIONS  TOOTH FACTORS ENDODONTICALLY TREATED TEETH THERE IS MINIMAL PDL SPACE, THE ROOTS ARE CLOSE TO ADJACENT TEETH LONG, DIVERGENT ROOTS TOOTH IS ADJACENT TO A LARGE CROWN OR RESTORATION TEETH WITH MINIMAL CORONAL STRUCTURE SHORT CROWN-LONG ROOTS? TOOTH IS CLOSE TO VITAL STRUCTURES? IMPACTED TEETH CURVED, DILACERATED ROOTS, MORE THAN EXPECTED NUMBER OF ROOTS, HYPERCEMENTOSIS  ANESTHESIA FACTORS FAILURE TO ACHIEVE ANESTHESIA INFECTED / HOT TOOTH? LANDMARKS THAT ARE DIFFICULT TO REACH - THINK EDENTULOUS PATIENTS WHEN LOCAL ANESTHESIA MAY NOT BE THE BEST OPTION EXTRACTIONS ARE MORE DIFFICULT THAN EXPECTED MULTIPLE EXTRACTIONS ARE REQUIRED PATIENT IS EXTREMELY ANXIOUS, UNABLE TO COOPERATE, MEDICAL NECESSITY  CONTRAINDICATIONS OF EXTRACTIONS SEVERE UNCONTROLLED METABOLIC DISEASE - DIABETES END STAGE RENAL/LIVER DISEASE? PREGNANCY - POSTPONE ELECTIVE EXTRACTIONS OTHERWISE 2ND TRIMESTER IS SAFE, IF PATIENT IS IN PAIN THEN EXTRACTIONS CAN BE DONE IN ANY TRIMESTER UNCONTROLLED LEUKEMIAS , LYMPHOMAS - RISK OF INFECTION, BLEEDING  Contraindication to extractions contd.. Patients with history of radiation to maxilla / mandible Patients who have taken bisphosphonates for osteoporosis / metastatic bone disease LET’S TAKE A BREAK ! #4.PRINCIPLE- ASEPSIS, ACCESS AND VISIBILITY EXAMINING THE ORAL CAVITY, TOOTH IN QUESTION AND RETRACTING CHEEK AND TISSUES TONGUE BLADES MINNESOTA RETRACTOR SELDIN RETRACTOR  CONSENT DISCUSSION OF RISKS, COMPLICATIONS, ALTERNATIVES DOES THE PATIENT REALLY UNDERSTAND? TAKE THIS OPPORTUNITY TO DISCUSS HOW THE PROCEDURE IS EXPECTED T O GO WHAT MAKES IT DIFFICULT SET UP FOR EXODONTIA “ TYPE A QUOTE HERE. — Johnny Appleseed ”  IMPORTANT TO USE BITE BLOCK - TO SUPPORT TMJ AND USE A GAUZE PIECE INTRA ORALLY TO PREVENT DEBRIS OR TOOTH FALLING BACK INTO THE THROAT  Operator and patient position Maxillary extractions – Patient's is positioned so that the maxillary arch is below operator's shoulder and operator stands in front of the patient Mandibular extractions – Patient is positioned so that mandible is below the operator's elbow and the operator stands in front of the patient for all quadrants RAISING A FLAP HOLDING THE BLADE AND HANDLE IN PEN GRASP 15 NO. BLADE MOLT’S PERIOSTEAL ELEVATOR  RAISING A FLAP ALLOWS YOU TO HOLD THE TOOTH BEYOND THE CORONAL STRUCTURE IT ALLOWS ACCESS TO BONE SHOULD ITS REMOVAL BE NECESSARY MOST FLAPS RAISED IN ORAL SURGERY ARE FULL THICKNESS FLAPS VERTICAL RELEASING INCISION ENVELOPE FLAP - NO VERTICAL RELEASING INCISIONS BASE OF FLAP IS KEPT BROADER TO ENSURE ADEQUATE BLOOD SUPPLY NOT RAISING AN ADEQUATE FLAP IS ONE OF THE MOST COMMON MISTAKE MADE IN THE BEGINNING OF THE LEARNING PROCESS A PLANNED FLAP IS ALWAYS BETTER THAN ONE WHICH WE RAISE ONCE WE HAVE STARTED THE PROCEDURE PRINCIPLE 5 - USE OF ELEVATORS AND FORCEPS AND PHYSICS BEHIND IT ELEVATORS HELP IN LUXATION AND FORCEPS CONTINUE THE PROCESS THROUGH EXPANSION OF BONE SOCKET AND REMOVAL OF TOOTH FROM SOCKET  ELEVATORS ARE PRIMARILY USED AS LEVER, A LEVER IS MECHANISM FOR TRANSMITTING A MODEST FORCE - WITH MECHANICAL ADVANTAGES OF A LONG LEVER ARM AND A SHORT EFFECTOR ARM-INTO A SMALL MOVEMENT AGAINST GREAT RESISTANCE  ELEVATORS AND FORCEPS BOTH EMPLOY THE WEDGE PRINCIPLE AS WELL AN ELEVATOR FORCED INTO PDL SPACE CAN DISPLACE THE ROOT /TOOTH OUT OF THE SOCKET The beaks of forceps are narrow at tip and they broaden as they go up, hence the narrow beaks should be forced into Periodontal ligament space to expand the bone and force the tooth out of socket ELEVATOR AS A WEDGE ELEVATOR AS A WHEEL AND AXLE CRYERS ELEVATORS CRANE PICK ELEVATORS PRINCIPLE 6- (APPLICATION OF FORCEPS) THE TIPS OF FORCEPS BEAKS A)SHOULD BE PARALLEL TO THE LONG AXIS OF THE TOOTH B)GO DOWN AS FAR AS POSSIBLE ON THE ROOT  ROLE OF FORCEPS AND FORCES THEY APPLY TOOTH SOCKET IS EXPANDED BY INSERTION OF BEAKS IN THE PDL THE FIRST FORCE APPLIED IS APICAL PRESSURE CENTRE OF ROTATION IS DISPLACED APICALLY (ROOT TIP FRACTURE CAN BE AVOIDED)  ◆ Universal Mandibular Extraction Forceps (151) ◆ UNIVERSAL MAXILLARY ◆ EXTRACTION FORCEPS (150) ◆ ASH FORCEPS (ENGLISH STYLE) BUCCAL FORCE BUCCAL PRESSURE CAUSES EXPANSION OF BUCCAL PLATE AT CREST OF RIDGE AND ALSO CAUSES LINGUAL APICAL PRESSURE LINGUAL PRESSURE -EXPANDING LINGUAL BONE ROTATIONAL FORCES INTERNAL EXPANSION OF SOCKET TEETH WITH SINGLE CONICAL ROOTS - MAXILLARY INCISORS, MANDIBULAR PREMOLARS NOT USEFUL FOR TEETH WITH MULTIPLE ROOTS OR ROOTS THAT ARE CURVED  TRACTIONAL FORCES THESE FORCES ARE USED TO DELIVER THE TOOTH FROM THE SOCKET GENTLE FORCES ONLY IF YOU FEEL MORE FORCE IS REQUIRED, THEN SPEND SOME MORE TIME LUXATING THE TOOTH  MAXILLARY ROOT TIP FORCEPS MANDIBULAR ROOT FORCEPS COW HORN FORCEPS  CONSIDERATTIONS FOR SPECIFIC TEETH MAXILLARY CANINES - LONG ROOTS, PART OF LABIAL ALVEOLAR BONE MAY FRACTURE AND BE REMOVED WITH THE TOOTH MAXILLARY 1ST PREMOLARS - TWO ROOTS, HIGHLY LIKELY FOR ROOTS TO FRACTURE MAXILLARY 1ST MOLARS - LOOK FOR DIVERGENCE OF ROOTS, LONG PALATAL ROOT, PROXIMITY TO SINUS  MANDIBULAR INCISORS - MAY BE HARD TO ANESTHETIZE! MANDIBULAR PREMOLARS - AMONG THE EASIEST TEETH TO REMOVE MANDIBULAR MOLAR - THICK ALVEOLAR BONE, STRONG LONG DIVERGENT ROOTS WATCH OUT FOR ISOLATED MOLARS IN ELDERLY PATIENTS - NOTORIOUSLY DIFFICULT TO EXTRACT  PRINCIPLE 7 – POST OP CARE debris left behind, always do IRRIGATION – WHY it CURETTAGE ?- WHEN TO DO IT BONE SMOOTHENING SUTURING not all sockets, yes for granulation tissues like apical cyst  POST EXTRACTION CARE RONGEOURS BONE FILE CURETTE SUTURING CHECK FOR HEMOSTASIS, PAIN CONTROL POST OP INSTRUCTIONS, WHAT TO EXPECT MEDICATIONS FOLLOW UP IF NEEDED  REFERENCE TEXT 1.CONTEMPORARY ORAL AND MAXILLOFACIAL SURGERY. HUPP, ELLIS, TUCKER. 6TH ED CHAPTER 7