MAXILLOFACIAL SURGERY ANESTHESIA. EXODONTIA. FORCEPS
EXTRACTION.
ACTUALITY
Painlessness of operations in oral and maxillofacial surgery is the same basic demand, as
well as painlessness of surgical interventions in other areas. Development of surgery of this area
is obliged much more to successes of a local anesthesia. Nevertheless it is not always possible to
do without the general anesthesia at operations in an oral cavity. The necessity of carrying out
long and volumetric interventions demands carrying out general anesthesia and thorough
preoperative preparation. Therefore the dentist should know well the basic properties of
narcotics, indications and contraindications to their application, to study technique of a narcosis
and treatment of known complications.
Analgesia is the elimination of painful sensations during of carrying out surgical or
diagnostic manipulations.
Anesthesia is the eliminations of all sensations (including pain) during of carrying out
surgical or diagnostic manipulations.
Anesthesia is distinguish:
1.
The general (narcosis):
1.
Inhalation
а) mask
б) Endotracheal (through a nose)
2.
Non-inhalation
а) intramuscule
б) intravenous
в) rectal
г) epidural
II.
Local.
It is known, that the opportunity of painless operating had huge value for development of
surgery due to opening of narcotic properties of an Aether and Chloroformium. For the first time
narcosis was provided by dentists: Horace Wells (nitrous oxide) and William Morton (Aether).
Occurrence of a local anesthesia is connected to opening of anesthetizing actions of Cocainum
in 1879 by Anrep which since 1884 have started to use in clinic.
The local anesthesia is continuously improved. New anesthetics are synthesized and new
methods of their introduction in an organism are developed. In dental practice methods of
intraligament and intrapulp injections of these preparations are developed alongside with
superficial, infiltrative and a conductive anaesthesia. For carrying out of such an anesthesia small
volumes of local anesthetics are entered. In this connection they should have high anesthetizing
activity.
According to N.E.Vvedensky's classical representations, local anesthetics influence a
functional condition of the sensitive nervous terminations and conductors, changing their
excitability and conduction. A susceptibility of neurones to action of local anesthetics is not the
same.
To these preparations are most sensitive non-myenilized and thin myenilized nervous fibers.
The more thick a nervous trunk, the less it sensitive to an anesthesia. In a result these agents
cause transient loss of sensation of a pain, a cold, heat and at last turn of pressure. Myenilized
fibers are going to sceletal muscles, tangoreceptors and proprioreceptors and tolerate against
action of local anesthetics. It explains the sensation of pressure upon tissues during operation
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even at well carried out local anesthesia,
For a superficial anaesthesia are used anesthetics, well penetrating in tissues and influencing
on the sensitive nervous terminations. Through uninjured integuments these preparations do not
pass, therefore the surface anesthesia is used for a wound surfaces and mucosa. With this
purpose it is possible to apply Dicainum, Pyromecainum, Anaesthesinum, Lidocainum.
Cocainum now in dental practice is not used in connection with a high toxicity and an
opportunity of development of medicinal dependence to it.
For infiltrative and a conductive anesthesia Novocainum, Trimecainum, Lidocainum,
Mepivacainum, Prilocainum, Bupivacainum, Articainum are used. As a matter of fact in the
general surgery practice for carrying out of an infiltrative anesthesia are required great volumes
of solutions. For this purpose they are used in small (0,25-0,5 %) concentration.
In dental practice great volumes of anesthetics are not applied. Therefore their concentration
can be increased up to 1-4 %.
For carrying out intraligament anesthesia small volumes (0,2-0,3 ml) of anesthetic are
required. But the most active preparations are used, i.e. Lidocainum, Mepivacainum,
Articainum.
Any agent for the local anesthesia has the features of action which are taken into account by
the doctor at their use.
The general anesthesia (narcosis) a condition of the convertible inhibition of CNS is
achieved by pharmacological agents, influence of physical or mental factors. It assumes
suppression of perception of pain stimulations, achievement of neurovegetative blockade and a
muscular relaxation, deenergizing of consciousness, maintenance of an adequate gas exchange
and a circulation, a regulation of metabolic processes.
To the general anesthesia belongs
1.
A narcosis
2.
NLA
3.
Ataralgesia
4.
The central analgesia
5.
An audioanaesthesia and hypnosis
6.
An electronarcosis
7.
Acupuncture, electrical puncture
Neuroleptanalgesia (NLA) is loss of pain sensitivity, which is achieved due to rational
cooperation of deep analgesia and neurolepsia by the introduction of analgesic and neuroleptic
drugs.
Ataralgesia – sort of NLA, when ataraxia and analgesia are achieved by the introduction of
tranquilizers and analgesics.
Central analgesia – elimination of pain sensations due to introduction of great doses of
analgetics.
Audioanestesia is based on stimulation of auditory analyzer by the certain frequency
signal, which causes inhibition in other parts of brain cortex.
Neuroanatomy of the maxillofacial area
Since the trigeminal nerve is a mixed nerve, it has four nuclei of which two sensory and
one motor nuclei are in the metencephalon, while the sensory (proprioceptive nucleus) is in the
mesencephalon . The processes of cells contained in the motor nucleus (nucleus motorius)
emerge from the pons on the line separating the pons from the middle cerebellar peduncle and
connecting the place of emergence of the trigeminal and facial nerves (linea trigeminofacialis),
forming the motor root of the nerve, radix motoria Next to it the sensory root, radix sensaria,
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enters the brain matter. Both roots comprise the trunk of the trigeminal nerve which on
emergence from the brain penetrates under the dura mater of the middle cranial fossa and is
distributed onto the superior surface of the pyramid of the temporal bone at its apex where the
trigeminal impression (impressio trigemini) is located. Here the dura mater separates to form a
small cavity for it, cavum trigemi-rtale. In this cavity the sensory root has a large semilunar (or
Gasser's) ganglion, ganglion trigeminale (s. semilunare Gasseri). The central processes of the
cells of this ganglion comprise the sensory root and run to the sensory nuclei: superior sensory
nucleus (nucleus sensorius principalis n. trigemini), spinal nucleus (nucleus tractus spinalis n.
trigemini) and mesencephalic nucleus (nucleus tractus mesencephalicis n. trigemini), while the
peripheral processes are part of the three main branches (divisions) of the trigeminal nerve
emerging from the convex edge of the ganglion.
The Second Branch of the Trigeminal Nerve
The maxillary nerve (n. maxillaris) emerges from the cranial cavity through the foramen
rotundum into the pterygopalatine fossa; here it is directly continuous with the infra-orbital nerve
in injraorbitalis) which passes through the inferior orbital fissure into the orbital sulcus and canal
on the inferior orbital wall and then emerges through the infraorbital foramen onto the face
where it ramifies into a bundle of branches. These branches join partly with the branches of the
facial nerve and innervate the skin of the lower eyelid, the lateral surface of the nose and the
upper lip. The following branches arise from the maxillary nerve and its continuaion is the infraorbital nerve.
1. - ganglion trigeminale;
2. - n. maxillaris;
3. - foramen rotundum;
4. - n. infraorbitalis;
5. - rr. alveolares superiores posteriores;
6. - r. alveolaris superior medius;
7. - rr. alveolares superiores anteriores;
8. - n. zygomaticus;
9. - r. zygomaticotemporale;
10.- r. zygomaticofacial;
11.- rr. ganglionares ad ganglion pterygopalatinum.
1. The zygomatic nerve (n. zygomaticus) goes to the skin of the cheek and the anterior part of the
temporal region. It anatomizes with the lacrimal nerve (from the first branch of the trigeminal
nerve).
The superior dental nerves (nn. alveolares superiores/ form a plexus in the thickness of the
maxilla - the superior dental plexus (plexus dentalis superior) from which superior dental
branches arise to the upper teeth and the superior gingival branches to the gums.
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2. The ganglionic branches (nn. pterygopalatine, several (two-three) short branches connecting
the maxillary nerve with the pterygopalatine ganglion.
The sphenopalatine ganglion (ganglion pterygopalatinum) is located in the pterygopalatine fossa
medially and down from the maxillary nerve. In this ganglion, which relates to the vegetative
nervous system, the para-sympathetic fibres are interrupted; they run from the vegetative nucleus
of the sensory root of the facial nerve (n. intermedius) to the lacrimal gland and to the mucous
glands of the nose and palate as part of the nerve itself and further as the greater superficial
petrosal nerve (a branch of the facial nerve).
The sphenopalatine ganglion gives off the following (secretory) branches.
(1) Nasal branches (rami nasales posteriores) pass through the sphenopalatine foramen to the
mucosal glands of the nose; the largest of these, the long sphenopalatine nerve (n. nasopalatine)
passes through the incisive canal to the mucous glands of the hard palate; (2) the palatine nerves
(nn. palatini) descend along the greater palatine canal and, after passing through the greater and
lesser palatine foramina, innervate the mucosal glands of the hard and soft palates.
In addition to the secretory fibres the nerves arising from the sphenopalatine ganglion contain
also sensory nerves (from the second branch of the trigeminal nerve) and sympathetic fibres.
Thus, the fibres of the sensory root (the parasympathetic part of the facial nerve) which pass
along the greater superficial petrosal nerve, through the sphenopalatine ganglion, innervate the
glands of the nasal cavity and palate and the lacrimal gland. The last pathway runs from the
sphenopalatine ganglion through the ganglionic branches of the maxillary nerve (nn.
pterygopalatini) into the zygomatic nerve, and from it through an anastomosis into the lacrimal
nerve.
3rd division of 5th cranial nerve. Mandibular nerve. 7th cranial nerve. Facial nerve.
Intermedius nerve.
The third branch of the trigeminal nerve
n. mandibularis
1 - ganglion trigeminale; 2-n. mandibularis;
3 - r. meningeus;
4- n. auriculotemporalis; 5-n. buccalis;
6- n. lingualis;
7 - n. alveolaris inferior;
8 - plexus dentalis inferior;
9- n. masseter;
10- nn. temporales profundi;
11 - n. pterygoideus lateralis;
12 - n. pterygoideus medialis
The mandibular nerve (n. mandibularis)
contains, in addition to the sensory root, the whole motor root of the trigeminal nerve. The motor
root arises from the motor nucleus and passes to the muscles originating from the maxillary arch.
As a result the mandibular nerve innervates the muscles attached to the mandible, the skin
covering it and other derivatives of the maxillary arch. On emerging from the cranium through
the foramen ovale, it divides into two groups of branches.
A.
Muscle branches.
To the muscles of the same name; nerve to the masseter (n. massetericus), deep temporal nerves
(nn. temporales profundi), nerves to the medial and lateral pterygoid muscles (nn. pterygoidei
medialis and lateralis), nerve to the tensor tympani muscle (n. tensoris tympani), nerve to the
tensor palatine muscle (n. tensoris veli palatini), mylohyoid nerve (n. mylohyoideus); the latter
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arises from the inferior dental nerve (n. alveolaris inferior), a branch of the mandibular nerve and
also innervates the anterior belly of the digastric muscle.
B. Sensory branches.
The buccal nerve (n. buccalis) goes to the mucosa of the cheek.
The lingual nerve (n. lingualis) descends along the medial side of the m. pterygoideus medialis
and lies under the mucous membrane of the floor of the oral cavity. After giving off the
sublingual nerve to the mucosa of the floor of the mouth it innervates the mucosa of the anterior
two thirds of the back of the tongue. At the place where the lingual nerve passes between both
pterygoid muscles, it is joined by a small thin branch of the facial nerve, chorda tympani, which
emerges from the squamotympanic fissure. It contains parasympathetic secretory fibres that arise
from the superior salivary nucleus of the sensory root of the facial nerve and pass to the
hypoglossal and submaxillary salivary glands. It also contains gustatory fibres from the first two
thirds of the tongue. The fibres of the lingual nerve itselfdistributed in the tongue are conductors
of general sensitivity (sense of touch, pain, and temperature).
The inferior dental nerve (n. alveolaris inferior), together with the artery of the same name,
passes through the foramen mandibulae into the mandibular canal where after forming the
inferior dental plexus it gives off branches to all the lower teeth. At the front end of mandibular
canal the inferior dental nerve gives off a thick branch, the mental nerve (n. mentalis), which
emerges through the foramen mentale and spreads in the skin of the chin and the lower lip. The
inferior dental nerve is a sensory nerve with a small addition of motor fibres which leave it at the
foramen mandibulae as part of the mylohyoid nerve (see above).
The auriculotemporal nerve (n. auriculotemporal) penetrates into the upper part of the parotid
gland and, turning upward, passes to the temporal region accompanying the superficial temporal
artery. Along the way the nerve gives off secretory branches to the parotid and salivary glands
(whose origin is discussed below) and sensory branches to the temporomandibular articulation,
to the skin of the anterior part of the concha of the auricle and the external acoustic meatus. The
terminal branches of the auriculotemporal nerve supply the skin of the temple.
In the region of the third branch of the trigeminal nerve there are two ganglia belonging to the
vegetative system by means of which the salivary glands are innervated. One of them, the otic
ganglion (ganglion oticum), is a small round body located under the foramen ovale on the medial
side of the mandibular nerve. It receives parasympathetic secretory fibres in the composition of
the lesser superficial petrosal nerve which is a continuation of the tympanic nerve originating
from the glossopharyngeal nerve. These fibres are interrupted in the ganglion and pass to the
parotid gland by means of the auriculotemporal nerve, with which the otic ganglion is joined.
Another small ganglion, the submandibular ganglion (ganglion sub-mandibulare), is located at
the anterior edge of the m. pterygoideus medialis, above the submandibular salivary gland, under
the lingual nerve. The ganglion is connected with the lingual nerve by branches. By means of
these branches the fibres of chorda tympani pass to the ganglion where they terminatetheir
continuation become the fibres arising from the submandibular ganglion, which innervate the
submaxillary and sublingual salivary glands
THE FACIAL (7th) NERVE
The facial nerve (n. facialis, s. intermedio-facialis) is a mixed nerve. As a nerve of the second
visceral arch it innervates the muscles developing from it, namely, all the facial-expression and
part of the sublingual muscles. It also contains the efferent (motor) fibres emerging from its
motor nucleus that pass to these muscles, and the afferent (pro-prioceptive) fibres arising from
their receptors. It includes gustatory (afferent) and secretory (efferent) fibres belonging to the n.
;ntermedius.
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The way of facial nerve in facial canal
1- ganglion geniculi;
2- foramen stylomastoideum;
3- n. petrosus major;
4- ganglion pterygopalatinum;
5- chorda tympani;
6- n. lingualis;
7- n. stapedius; 8-m. digastricus; 9 - m. stylohyoideus.
Indications to a narcosis
In maxillofacial area it’s indicated for carrying out
long-term and traumatic surgical interventions are
combined with risk of the airways obstruction.
Indications to a narcosis on an outpatient basis
General
- allergic reactions on local anesthetics
- low effect or impossibility of local anesthesia
- the patient is mentally unbalanced
- mental deficiency
- traumatic interventions
- surgical interventions at children
Specific
- premorbid background
- anesthetic
Contraindications
- acute disease of parenchymatous organs
- cardiovascular collapse
- acute cardiac infarction and postinfarction period (up to 6 month)
- severe bronchial asthma
- alcoholic or drug inebriation
- epinephros’ disease
- long-term intake of homones
- anemia
- acute respiratory disease
- pneumonia
- clinically apparent thyrotoxicosis
- pancreatic diabetes (diabetes mellitus)
- epilepsy
- full stomach
Narcosis’ stages
1.
Initial narcosis
2.
Agitation
3.
Surgical phase
4.
Terminal phase
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Premedication – preoperative and preanesthetic preparation of the patient.
Premedication’s tasks
1.
The normalization of the general condition of the patient.
2.
The creation of mental and emotional rest before operation.
3.
Increasing local and general anesthesia action and its duration.
4.
The prevention of undesirable reflex influences during operation
5.
Reducing number of complications.
To the local anesthesia belongs
1. Non injection
а) Chemical
б) Physical
2. Injection
a) Synergistic
b) Non-synergistic
Methods of local anesthesia are:
- topical
- infiltration
- regional block
- nerve block
Methods of local infiltration are:
- subperiostal
- apical
- intraosseous
- layer-by-layer
- intraligament
Methods of nerve block (conduction anesthesia)
At maxilla
- tuberal
- infraorbital
- nasopalatine nerve block
- palatine nerve block
At mandible
- mandibular
- torusal
- Mental
Methods of the central anesthesia
1. At the round foramen
- subzygomaticopterigoid
- suprazygomaticopterigoid
- tuberal
- infraorbital
- pterygopalatine
2. At the oval foramen
- subzygomaticopterigoid
- suprazygomaticopterigoid
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- mandibular
Infraorbital anesthesia
Mandibular anesthesia
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Tuberal anesthesia
Complications arising at a local anaesthesia:
The general
1.
An intoxication
2.
A syncope
3.
A collapse
4.
An anaphylactic shock
Local
1.
Damages of vessels
2.
Damages of nerves
3.
An ischemia of a skin
4.
Breakage of a syringe needle
5.
Damage of soft tissues
6.
A necrosis of tissues
7.
A dermatitis
What are the preparations are used for classic NLA?
A. Thiopental sodium and Suprastine
B. Aminazinum and Droperidol
C. Omnoponum and Aminazinum
D. Diazepam and Pipolphen
E. Fentanyl and Droperidol
Indications and contraindications to deciduous teeth extraction
It is to be considered, that deciduous teeth would be kept up to permanent dentition. Deciduous
teeth should be removed with completely resorbed roots and if its crown is posed in a gingiva
superficially, and permanent dentition are legibly shown. Deciduous tooth that can cause
development of a septic state are a subject to extraction. It is also necessary to remove those
temporary teeth with inflammatory focuses that can affect germs of permanent teeth.
When temporary tooth remains in a jaw at a level of impacted tooth, there is no need to remove
it, as within several years it can carry out function of the permanent. In case of a birth of the
child with the emerged inferior incisors, they would be extracted, as they can cause nursing.
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It is not necessary to extract deciduous teeth in the early term as in a future permanent can
emerge outside of a dental arch from the vestibular or palatal (lingual) side.
Premature extraction of deciduous big molars can result a growth disorder of jaws, and various
deformations. It is recommended to preserve the top temporary canines as they play the
important role in formation of the upper jaw and an occlusion. Also, it is necessary to concern
the inferior temporary incisors, that are considerably influencing the development of a mandible.
Indications and contraindications to permanent teeth extraction.
Indications to an exodontia can be general and local. From the general indications it is
necessary to specify on sepsis and chronical odontogenous intoxication developed as a result of
diffusion of infection from the inflammatory locus.
First of all it concerns teeth with gangrenous pulp disintegration and roots of dens that can
trigger the development of some diseases (infectional myocarditis, endocarditis, reumatism,
arthritis, myositis, pyelonephritis, etc.). Septic state, as a rule, is accompanied with characteristic
hematological disorders (anemia, lymphocytosis, leukopenia, etc.).
Local indications can be absolute and relative. The absolute indication to a dental extraction is
the teeth with a purulent inflammatory process in a periodontium that can not be treated
therapeutically and there is a danger of formation an acute osteomyelitis of jaw, an abscess or a
phlegmons, a purulent genyantritis, a lymphadenitis, etc. Thus simultaneous dissecting a
subperiostal abscess is quite often indicated. Tactics of the doctor should be enough awake if
tooth does not represent function value.
The majority of authors adhere to this rule, however I.G.Lukomsky (1933) and
I.M.Starobinsky (1950) during many years were putting it under a doubt. These authors
considered more probability of activization and diffusion of the inflammation by the tooth
extraction without simultaneous dissection of the abscess at the acute osteomyelitis because
through the small cavity of the removed tooth, in their opinion, complete evacuation of pus does
not occur.
All other indications to exodontia are relative:
- impossibility of conservative therapy because of significant destruction of a dental crown or
obstructions of root canals;
- a perforation of the tooth or its root by the instrument;
- impossibility of decayed dens usage for a prosthetic repair;
- extraction of the teeth caused inflammatory process in genyantrum;
- presence of dens in a late stage parodontitis, in the last stage of alveolar edge resorption;
- supercomplete dens with maleruption and prosthetic difficulties, if they injure a mucosa, invoke
painful sensations and also break function of the mastication;
- impact teeth at odontalgia and pathosis presence (bone destruction, a cyst, etc.) around them;
- an unsuccessfulness of conservative medical actions concerning a periodontitis of multirooted
teeth;
- intensifying of inflammatory processes in a periodontium and development of incipient states
of an acute osteomyelitis;
- maleruption of the inferior third molar posed in slanting or a transverse direction;
- neoplasms of an alveolar process (the extraction is effected simultaneously with a resection of
the changed tissues - an ameloblastoma, malignant tumours, and so during an enucleation of the
cyst);
- aesthetic indications when orthopedic correction of atypically posed dens is impossible;
- premolars at orthodontic shift of frontal teeth;
- decayed teeth or those, placed in a line of the jaws (mandible) fracture;
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- orthopedic indications (the teeth are moved on an axis or aside or interfere to manufacturing of
a functional dental prosthesis);
- an extraction with ectomy of epulis, other tumors and an alveolectomy;
- the teeth are involved in inflammatory process, at specific diseases (a lues, an actinomycosis, a
tuberculosis).
Contraindications to permanent teeth extraction are always relative, unless the exodontia
should be carried out on the vital motives. Contraindications are divided to general and local.
The general contraindications:
- contagions, as they result weakening of the organism and reduce immunological activity (flu,
tonsillitis, diphtheria, etc.);
- systemic blood diseases: leukemia, agranulocytosis, pernicious anemia, etc., (it is necessary to
direct patients to a hematological hospital where it will be carried out a preoperative
preparation);
- an angiostaxis and hematolysis, Werlhof’s disease (there is necessary a preoperative
preparation of the patient) ;
- pregnancy up to III and after VII month;
- a Barlow's disease and other avitaminoses;
- an icterus;
- a diabetic coma;
- a nutritional dystrophy, a cachexia of a various genesis;
- a menses (2-3 days prior to and after the same term after it;
- cardiovascular diseases (myocardial infarction, especially if it is accompanied by a state of
collapse, heart attack and a cardiac asthma, an uncompensated heart disease, a hypertonic crisis,
an acute aneurysm of the heart ventricle, subacute bacterial endocarditis with thrombosis
liability, chronic coronary failure, paroxysmal arrhythmia, etc.);
- organic and functional lesions of the nervous system (apoplectic attack, meningitis,
encephalitis, epilepsy, psychosises, a hysteria, etc.);
- a stroke in an acute stage, a craniocerebral trauma, tumours of a brain, etc.;
- mental diseases in a stage of an exacerbation (a schizophrenia, manic-depressive insanity);
- acute diseases of parenchymatous organs.
Presence of the general somatopathies handicapping an exodontia, cannot be contraindication
for a long time. After an additional examination and a conforming clinical preparation at
indications on the vital motives a dental extraction can carry out with keeping a maximum
caution.
The special attention should be given to psychological and medicamental preoperative
preparations.
Local contraindications:
- acute radiation syndrome at stage I-III;
- necrotize ulcerative gingivitis and stomatitis;
- a locating of dens in region of a malignant or vascular tumour;
- presence of single dens which are necessary for bracing prostheses, even at their some
mobility.
Stages of typical tooth extraction.
1. Applying of the dental forceps
2. Advancing of the dental forceps
3. Closing up of the dental forceps
4. Luxating and rotating of the tooth (root)
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5. Traction
6. Control of the alveola.
Instruments to perform a typical tooth extraction.
Dental forceps.
At maxilla: A - straight;
B - S-shaped for bicuspids;
C - S-shaped for molars (left and right) ;
D - bayonet-shaped;
E - for the wisdoms.
At mandible: A - beak-shaped, nonconverging;
B - beak-shaped, converging;
C - beak-shaped with spikes; D - curved on
flat, for wisdoms.
A
B
C
D
E
Root elevators: A - straight;
B - angled (left and right) ;
С - bayonet-shaped;
D - Lecluse elevator.
А
B (L)
B (R)
D
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Tooth extraction can be typical and atypical (surgical exodontia)
Typical extraction
Atypical extraction
Atypical tooth extraction - method of exodontia
which is performed with chisel and bur. It’s indicated
when tooth or root extraction cannot be performed with
dental forceps or elevators only. This method most
frequently is used to extract third lower molar. The
surgical approach and direction of the incision depends
on tooth or root position. Access to the tooth is
achieved by forming and raising a mucoperiosteal flap.
Then using bur and chisel remove portions of the bone
that covers the tooth. Exposed tooth can be removed.
Sharp bone edges should be smoothed, the flap is
closed up and stiched.
Stages of surgical (atypical) extraction of the teeth
1. Raising a flap
2. Removal of bone
3. Tooth division
4. Removal of tooth / tooth fragments
5. Primary closure
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All complications that can occur during an operation of a dental extraction are general and
local. There are local complications occur during the operation, and the complications which
have been occur after it.
The complications, that are occur during an exodontia:
- fracture of an extracted tooth or its root;
- fracture, a dislocation and extraction of the nearby tooth;
- fracture of a mandible;
- fracture of an alveolar process;
- fracture of a maxillar tuber;
- a dislocation of a mandible;
- damage of soft tissues;
- pushing the dens or its root into soft tissues;
- perforation of a bottom of a genyantrum;
- choking the removed root or tooth;
- breakage of the instrument.
The complications, that are occur after an exodontia:
- bleeding;
- Sharp osteal edges of the socket.
- An alveolitis.
The alveolitis can proceed in two forms. The first is an alveolar osteitis. It is characterized by
the socket sequestration during the 2-3 weeks of disease, and there is a necessity of an operative
measure.
The second is a «dry socket» which lasts within 1 week and does not require any operative
activity. Rather alveolites educe in a result of traumatic dental extraction.
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