牙拔除術(shù)的并發(fā)癥【-】

第四節(jié)拔牙創(chuàng)的愈合愈合過程(四個(gè)階段)一、拔牙創(chuàng)出血及凝血塊形成15min保護(hù)創(chuàng)口/防止感染/促進(jìn)傷口正常愈合脫落/質(zhì)量不佳—拔牙創(chuàng)感染/疼痛愈合過程(四個(gè)階段)二、凝血塊機(jī)化牙齦組織收縮/拔牙創(chuàng)變小24h開始機(jī)化3d－20d纖維結(jié)締組織愈合過程三、骨組織修復(fù)6d開始形成新骨30d新骨充滿牙槽骨3mo完全形成骨組織愈合過程四、上皮覆蓋拔牙創(chuàng)3d牙齦上皮向血凝塊表面生長(zhǎng)4w內(nèi)上皮愈合完成愈合過程臨床上1w牙槽窩內(nèi)形成肉芽組織1－2m牙槽窩平復(fù)，有新骨形成3－6m重建過程完成，正常骨結(jié)構(gòu)第五節(jié)牙拔除術(shù)的并發(fā)癥一．牙拔除術(shù)中的并發(fā)癥㈠軟組織損傷⒈牙齦撕裂

原因：⑴分離不徹底⑵牙鉗夾住

后果：⑴術(shù)后出血

處理：⑴及時(shí)發(fā)現(xiàn)，再分離⑵撕裂后縫合㈠軟組織損傷⒉下唇損傷⒊行翻瓣手術(shù)時(shí)粘骨膜瓣被撕裂⒋軟組織刺傷⒌使用骨鉆去骨或分冠拔牙時(shí)將鄰近軟組織卷入

㈡牙槽骨折斷

原因：突然使用暴力致頰側(cè)骨板折斷。常見牙位：上頜尖牙：唇側(cè)骨板薄，牙頸部骨增厚，根阻力大

上頜第一磨牙:頰，腭根分叉大，頰側(cè)骨板薄

上頜第三磨牙:上頜結(jié)節(jié)骨疏松，與骨粘連

㈡牙槽骨折斷處理：如骨板折斷后一半以上已無(wú)骨膜附著

－－最好去除如折斷骨片大部分有骨膜膜附著可將其復(fù)合

－－使其愈合㈢口腔上頜竇交通

原因：

⑴解剖因素:根尖與上頜竇僅有一薄層或無(wú)骨相隔⑵操作因素：取斷根時(shí)用力不當(dāng)

㈢口腔上頜竇交通

后果：上頜竇感染，口腔上頜竇瘺

預(yù)防：

⑴上頜磨牙拔除困難時(shí)，用翻瓣去骨及分根法拔除。⑵疑上頜竇穿孔時(shí)，用捏鼻鼓氣法檢查。㈢口腔上頜竇交通處理：⑴小穿孔〔≤2m〕 ①常規(guī)處理②抗生素③勿用鼻腔鼓氣⑵中穿孔〔2~6mm〕①“8〞字形縫合②鼻腔噴霧可以減輕充血的藥劑⑶大穿孔〔＞6mm〕 ①轉(zhuǎn)移臨近組織關(guān)閉穿通口②術(shù)后本卷須知〔同上〕㈣下頜骨骨折

原因：下頜角部骨折下8阻生原來就存在病理性骨質(zhì)疏松狀態(tài)。㈤顳下頜關(guān)節(jié)脫位原因：操作時(shí)間長(zhǎng)，習(xí)慣性脫位防治：左手支持㈥鄰牙或?qū)︻M牙損傷

鄰牙大面積齲壞，修復(fù)體---術(shù)前解釋安放牙鉗---長(zhǎng)軸一致，鉗喙過寬牙挺---鄰牙支點(diǎn)脫位力需控制，保護(hù)㈦神經(jīng)損傷鼻腭神經(jīng)和頰神經(jīng)損傷頦神經(jīng)損傷原因：頦孔周圍的手術(shù)預(yù)后：與神經(jīng)是否切斷與關(guān)。預(yù)防：必須作翻瓣手術(shù)時(shí)，垂直切口應(yīng)盡可能位于前方。舌神經(jīng)損傷原因：遠(yuǎn)中切口偏舌側(cè)㈦神經(jīng)損傷下牙槽神經(jīng)損傷

原因：拔下頜阻生智齒時(shí)發(fā)生。

預(yù)后：導(dǎo)致下唇及頦部麻木或感覺異常有望在半年內(nèi)恢復(fù)，但也有相當(dāng)一部分不能恢復(fù)。

㈦神經(jīng)損傷下牙槽神經(jīng)損傷

預(yù)防：⒈術(shù)前X線評(píng)估⒉取斷根技術(shù)

治療：⒈予預(yù)防水腫及減壓藥⒉予促神經(jīng)恢復(fù)藥⒊理療㈧斷根或牙移位⒈斷根進(jìn)入上頜竇或下頜管⒉上頜第三磨牙斷根進(jìn)入顳下間隙位置：多在翼外板的外側(cè)、翼外肌的下方。原因：上頜結(jié)節(jié)骨質(zhì)疏松，用力不當(dāng)時(shí)，斷根或牙突破骨板和骨膜被推入顳下間隙。處理：6周后，牙可被纖維組織包繞而相對(duì)穩(wěn)定。此時(shí)再進(jìn)行手術(shù)。

㈧斷根或牙移位

⒊進(jìn)入下頜舌側(cè)骨膜下或穿破骨膜進(jìn)入舌下間隙或下頜下間隙原因：下頜骨舌側(cè)骨板越向后越薄，用力不當(dāng)。預(yù)防：避免使用向根方的壓力

處理：⑴在骨膜下，手指壓回牙槽窩內(nèi)取出⑵在骨膜下，手指固定，止血鉗鉗?、沁M(jìn)入間隙內(nèi)，6周后再?、硇g(shù)中出血⒈預(yù)防⑴病史了解①出血史②家族史③了解病員藥物使用情況“5A藥物〞④了解可能引起出血的一些全身疾病5A阿司匹林〔Aspirin〕：影響血小板，使它在小動(dòng)脈中的聚集及堵塞功能降低?？鼓齽睞nticoagulants〕：多用于有心肌梗塞或腦梗塞的病患。廣譜抗生素〔Antibiotic〕：可抑制腸道菌叢，使維生素K生成減少，進(jìn)而使依賴維生素K而產(chǎn)生的凝血因子減少。酒精〔Alcohol〕：長(zhǎng)期大量飲酒容易產(chǎn)生肝硬化，從而使依賴肝臟合成的凝血因子減少?？拱┧帯睞nticancel〕：抑制骨髓，使血小板生成減少。㈨術(shù)中出血⒈預(yù)防實(shí)驗(yàn)室檢查把握拔牙適應(yīng)征⒉術(shù)中出血的處理

壓迫結(jié)扎二．牙拔除術(shù)后并發(fā)癥㈠拔牙術(shù)后出血原發(fā)性出血類型繼發(fā)性出血

全身因素引起的原發(fā)性拔牙后出血

---應(yīng)以預(yù)防為主

處理：局部、全身會(huì)診㈠拔牙術(shù)后出血㈠拔牙術(shù)后出血

局部因素引起

①軟組織撕裂②牙槽骨內(nèi)殘留炎性肉芽組織③牙槽內(nèi)小血管破裂④牙槽骨骨折⑤血凝塊未能有效形成㈠拔牙術(shù)后出血

臨床表現(xiàn)：血凝塊高出牙槽窩表面，滲血。處理：

清除—縫合—壓迫—碘仿紗條㈠拔牙術(shù)后出血繼發(fā)性拔牙后出血

牙槽窩內(nèi)血凝塊受損造成處理：同前㈡拔牙后感染

原因：

⒈常規(guī)拔牙少見2.異物殘留：牙碎片、結(jié)石、肉芽等處理：1.徹底清創(chuàng)，去除異物，沖洗創(chuàng)口2.減少損傷，采取預(yù)防感染的措施㈢拔牙后疼痛

原因：⒈拔牙時(shí)對(duì)硬組織的損傷⒉拔牙時(shí)對(duì)軟組織的創(chuàng)傷：

處理：創(chuàng)傷較大的拔牙，如翻瓣去骨取根術(shù)或下頜阻生智齒的拔除，術(shù)后應(yīng)給予鎮(zhèn)痛劑。與干槽癥的鑒別㈣面頰部腫脹反應(yīng)

臨床特點(diǎn)：開始－12～24h；消退－3～5d組織松軟有彈性，皮膚可捏起——與炎癥鑒別

㈣面頰部腫脹反應(yīng)產(chǎn)生機(jī)理：與組織滲出液沿頰溝向前擴(kuò)散有關(guān)。影響因素：⒈個(gè)人體質(zhì)差異〔明顯有關(guān)〕；⒉瓣切口過低以及翻瓣時(shí)的創(chuàng)傷；⒊縫合過嚴(yán)。㈣面頰部腫脹反應(yīng)預(yù)防：⒈縫合不過密⒉冷敷⒊加壓包扎處理：抗生素預(yù)防感染激素?zé)岱?，理療㈤干槽癥命名：干槽癥、纖維溶解性牙槽炎。發(fā)生率：國(guó)外10～30%，國(guó)內(nèi)14.1%好發(fā)牙位：下頜智齒→下頜第一磨牙→下頜第二磨牙

～㈤干槽癥組織病理學(xué)表現(xiàn)：病理特點(diǎn)：主要表現(xiàn)為牙槽窩骨壁的炎癥或輕微的局限性骨髓炎。㈤干槽癥病因⑴感染學(xué)說⑵創(chuàng)傷學(xué)說⑶解剖因素學(xué)說⑷纖維蛋白溶解學(xué)說⑸其它因素㈤干槽癥干槽癥診斷標(biāo)準(zhǔn)：⑴拔牙2~3d后出現(xiàn)劇烈疼痛，并可向耳顳部、下頜下區(qū)放射；⑵一般鎮(zhèn)痛藥不能止痛；⑶拔牙窩空虛，或有腐敗惡臭的殘留血凝塊。㈤干槽癥

治療目的—迅速止痛關(guān)鍵—徹底清除，并隔絕外界對(duì)牙槽骨的刺激，促進(jìn)肉芽組織生長(zhǎng)。

㈤干槽癥方法步驟：⑴麻醉；⑵擦拭；⑶沖洗；⑷填碘條；⑸固定。預(yù)后：1-2周逾合

㈤干槽癥

預(yù)防：臨床實(shí)踐證明，碘仿海綿的預(yù)防效果較好。牙槽外科手術(shù)義齒修復(fù)前外科：牙槽突修整術(shù)，骨隆突修整術(shù)，牙槽突增高術(shù)牙槽突周圍組織手術(shù)：系帶矯正術(shù)，唇頰溝加深術(shù)，口腔上頜竇瘺修補(bǔ)術(shù)牙槽突修整術(shù)麻醉：局部浸潤(rùn)〔碧蘭麻〕黏骨膜切口：弧形，角形，梯形翻瓣：骨膜下去骨修整：骨鑿，咬骨鉗，渦輪機(jī)縫合：間斷，連續(xù)骨隆突修整術(shù)下頜骨骨隆突修整術(shù)腭隆突修整術(shù)處理原那么不影響義齒修復(fù)者可以不處理骨膜下翻瓣注意重要的解剖結(jié)構(gòu)系帶矯正術(shù)唇頰系帶矯正術(shù)舌系帶矯正術(shù)原那么橫切縱縫避免損傷重要解剖結(jié)構(gòu)口腔上頜竇瘺修補(bǔ)術(shù)頰側(cè)滑行瓣修補(bǔ)術(shù)：隨意瓣腭黏骨膜瓣修補(bǔ)術(shù)：軸形瓣HZ8qJ!asK%buM*dwO(fxQ-hzS0jBT2kDV4mFX6oGZ7qI!9sK%btM&dvO(fxQ-gzR0iBT2kCV3mEX5oGZ7pI#9rK$btM&cvN(exP-gzR+iAT1kCV3lEW5nGY7pI#8rJ$atL&cvN*ewP)gyR+iAS1jCU3lEW5nFY6pH#8rJ!asL%cuN*ewO)fyQ+hAS1jBU2lDW4nFY6oHZ8qJ!asL%buM*dwO)fxQ-hzS0jBU2kDV4mFX6oHZ7qI!9sK%buM&dvO(fxQ-gzR0iBT2kDV3mEX5oGZ7qI#9rK$btM&dvN(exP-gzR0iAT1kCV3mEW5nGY7pI#9rJ$atL&cvN(ewP)gyR+iAT1jCU3lEW5nFY6pH#8rJ$asL%cuN*ewP)fyQ+hAS1jCU2lDW4nFY6pHZ8qJ!asL%buM*dwO)fyQ-hzS0jBU2lDV4mFX6oHZ8qI!9sK%buM*dvO(fxQ-hzR0iBT2kDV4mEX5oGZ7qI!9rK$btM&dvO(exP-gzR0iAT1kCV3mEX5nGY7pI#9rK$atL&cvN(exP)gyR+iAT1kCU3lEW5nGY6pH#8rJ$atL%cuN*ewP)gyQ+hAS1jCU3lDW4nFY6pH#8qJ!asL%cuM*dwO)fyQ+hzS0jBU2lDW4mFX6oHZ8qJ!9sK%buM*dvO(fxQ-hzS0iBT2kDV4mFX5oGZ7qI!9sK$btM&dvO(fxP-gzR0iBT1kCV3mEX5oGY7pI#9rK$btL&cvN(exP-gyR+iAT1kCU3lEW5nGY7pH#8rJ$atL&cuN*ewP)gyR+hAS1jCU3lEW4nFY6pH#8qJ!asL%cuN*dwO)fyQ+hAS0jBU2lDW4nFX6oHZ8qJ!asK%buM*dwO(fxQ-hzS0jBT2kDV4mFX6oGZ7qI!9sK%btM&dvO(buM*dwO)fxQ-hzS0jBU2kDV4mFX6oHZ7qI!9sK%btM&dvO(fxQ-gzR0iBT2kDV3mEX5oGZ7qI#9rK$btM&cvN(exP-gzR+iAT1kCV3mEW5nGY7pI#9rJ$atL&cvN(ewP)gyR+iAS1jCU3lEW5nFY6pH#8rJ$asL%cuN*ewP)fyQ+hAS1jCU2lDW4nFY6oHZ8qJ!asL%buM*dwO)fyQ-hzS0jBU2lDV4mFX6oHZ7qI!9sK%buM&dvO(fxQ-hzR0iBT2kDV4mEX5oGZ7qI!9rK$btM&dvN(exP-gzR0iAT1kCV3mEX5nGY7pI#9rK$atL&cvN(ewP)gyR+iAT1jCU3lEW5nGY6pH#8rJ$atL%cuN*ewP)gyQ+hAS1jCU2lDW4nFY6pHZ8qJ!asL%cuM*dwO)fyQ+hzS0jBU2lDW4mFX6oHZ8qI!9sK%buM*dvO(fxQ-hzS0iBT2kDV4mFX5oGZ7qI!9rK$btM&dvO(exP-gzR0iBT1kCV3mEX5oGY7pI#9rK$btL&cvN(exP)gyR+iAT1kCU3lEW5nGY7pH#8rJ$atL&cuN*ewP)gyQ+hAS1jCU3lDW4nFY6pH#8qJ!asL%cuN*dwO)fyQ+hAS0jBU2lDW4mFX6oHZ8qJ!9sK%buM*dwO(fxQ-hzS0jBT2kDV4mFX6oGZ7qI!9sK$btM&dvO(fxP-gzR0iBT2kCV3mEX5oGZ7pI#9rK$btL&cvN(exP-gyR+iAT1kCV3lEW2kDV3mEX5oGZ7pI#9rK$btM&cvN(exP-gzR+iAT1kCV3mEW5nGY7pI#8rJ$atL&cvN*ewP)gyR+iAS1jCU3lEW5nFY6pH#8rJ$asL%cuN*ewO)fyQ+hAS1jBU2lDW4nFY6oHZ8qJ!asL%buM*dwO)fyQ-hzS0jBU2kDV4mFX6oHZ7qI!9sK%buM&dvO(fxQ-hzR0iBT2kDV3mEX5oGZ7qI#9rK$btM&dvN(exP-gzR0iAT1kCV3mEX5nGY7pI#9rJ$atL&cvN(ewP)gyR+iAT1jCU3lEW5nGY6pH#8rJ$asL%cuN*ewP)fyQ+hAS1jCU2lDW4nFY6pHZ8qJ!asL%cuM*dwO)fyQ-hzS0jBU2lDV4mFX6oHZ8qI!9sK%buM*dvO(fxQ-hzS0iBT2kDV4mEX5oGZ7qI!9rK$btM&dvO(exP-gzR0iBT1kCV3mEX5nGY7pI#9rK$atL&cvN(exP)gyR+iAT1kCU3lEW5nGY7pH#8rJ$atL%cuN*ewP)gyQ+hAS1jCU3lDW4nFY6pH#8qJ!asL%cuN*dwO)fyQ+hzS0jBU2lDW4mFX6oHZ8qJ!9sK%buM*dwO(fxQ-hzS0iBT2kDV4mFX5oGZ7qI!9sK$btM&dvO(fxP-gzR0iBT2kCV3mEX5oGY7pI#9rK$btL&cvN(exP-gyR+iAT1kCV3lEW5nGY7pH#8rJ$atL&cuN*ewP)gyR+hAS1jCU3lEW4nFY6pH#8rJ!asL%cuN*dwO)fyQ+hAS0jBU2lDW4nFX6oHZ8qJ!asK%buM*dwO)fxQ-hzS0jBT2kDV4mFX6oGZ7qI!9sK%btM&dvO(fxQ-gzR0iBT2kCV3mEX5oGZ7pI#9rK$btM&cvN(exP-gzR+iAT1kCV3mEW5nGY7pI#8rJ$atL&cvN*ewP)gyR+iAS1jCU3lEW5nFY6pH#8rGY7pI#9rJ$atL&cvN(ewP)gyR+iAT1jCU3lEW5nFY6pH#8rJ$asL%cuN*ewP)fyQ+hAS1jCU2lDW4nFY6pHZ8qJ!asL%buM*dwO)fyQ-hzS0jBU2lDV4mFX6oHZ8qI!9sK%buM&dvO(fxQ-hzR0iBT2kDV4mEX5oGZ7qI!9rK$btM&dvO(exP-gzR0iAT1kCV3mEX5nGY7pI#9rK$atL&cvN(exP)gyR+iAT1jCU3lEW5nGY6pH#8rJ$atL%cuN*ewP)gyQ+hAS1jCU3lDW4nFY6pHZ8qJ!asL%cuM*dwO)fyQ+hzS0jBU2lDW4mFX6oHZ8qJ!9sK%buM*dvO(fxQ-hzS0iBT2kDV4mFX5oGZ7qI!9sK$btM&dvO(exP-gzR0iBT1kCV3mEX5oGY7pI#9rK$btL&cvN(exP-gyR+iAT1kCU3lEW5nGY7pH#8rJ$atL&cuN*ewP)gyR+hAS1jCU3lEW4nFY6pH#8qJ!asL%cuN*dwO)fyQ+hAS0jBU2lDW4nFX6oHZ8qJ!9sK%buM*dwO(fxQ-hzS0jBT2kDV4mFX6oGZ7qI!9sK%btM&dvO(fxP-gzR0iBT2kCV3mEX5oGZ7pI#9rK$btM&cvN(exP-gyR+iAT1kCV3lEW5nGY7pI#8rJ$atL&cvN*ewP)gyR+iAS1jCU3lEW4nFY6pH#8rJ!asI#9rJ$atL&cvN*ewP)gyR+iAS1jCU3lEW5nFY6pH#8rJ$asL%cuN*ewP)fyQ+hAS1jBU2lDW4nFY6oHZ8qJ!asL%buM*dwO)fyQ-hzS0jBU2lDV4mFX6oHZ7qI!9sK%buM&dvO(fxQ-hzR0iBT2kDV4mEX5oGZ7qI#9rK$btM&dvN(exP-gzR0iAT1kCV3mEX5nGY7pI#9rK$atL&cvN(ewP)gyR+iAT1jCU3lEW5nGY6pH#8rJ$atL%cuN*ewP)gyQ+hAS1jCU2lDW4nFY6pHZ8qJ!asL%cuM*dwO)fyQ+hzS0jBU2lDV4mFX6oHZ8qI!9sK%buM*dvO(fxQ-hzS0iBT2kDV4mFX5oGZ7qI!9rK$btM&dvO(exP-gzR0iBT1kCV3mEX5oGY7pI#9rK$atL&cvN(exP)gyR+iAT1kCU3lEW5nGY7pH#8rJ$atL&cuN*ewP)gyQ+hAS1jCU3lDW4nFY6pH#8qJ!asL%cuN*dwO)fyQ+hAS0jBU2lDW4mFX6oHZ8qJ!9sK%buM*dwO(fxQ-hzS0jBT2kDV4mFX5oGZ7qI!9sK$btM&dvO(fxP-gzR0iBT2kCV3mEX5oGZ7pI#9rK$btL&cvN(exP-gyR+iAT1kCV3lEW5nGY7pI#8rJ$atL&cvN*ewP)gyR+hAS1jCU3lEW4nFY6pH#8rJ!asL%cuN*ewO)fyQ+hAS0jBU2lDW4nFX6oHZ8qJ!asK#8rJ$asL%cuN*ewO)fyQ+hAS1jBU2lDW4nFY6oHZ8qJ!asL%buM*dwO)fxQ-hzS0jBU2kDV4mFX6oHZ7qI!9sK%buM&dvO(fxQ-hzR0iBT2kDV3mEX5oGZ7qI#9rK$btM&dvN(exP-gzR0iAT1kCV3mEW5nGY7pI#9rJ$atL&cvN(ewP)gyR+iAT1jCU3lEW5nGY6pH#8rJ$asL%cuN*ewP)fyQ+hAS1jCU2lDW4nFY6pHZ8qJ!asL%cuM*dwO)fyQ-hzS0jBU2lDV4mFX6oHZ8qI!9sK%buM*dvO(fxQ-hzR0iBT2kDV4mEX5oGZ7qI!9rK$btM&dvO(exP-gzR0iBT1kCV3mEX5nGY7pI#9rK$atL&cvN(exP)gyR+iAT1kCU3lEW5nGY7pH#8rJ$atL%cuN*ewP)gyQ+hAS1jCU3lDW4nFY6pH#8qJ!asL%cuM*dwO)fyQ+hzS0jBU2lDW4mFX6oHZ8qJ!9sK%buM*dwO(fxQ-hzS0iBT2kDV4mFX5oGZ7qI!9sK$btM&dvO(fxP-gzR0iBT1kCV3mEX5oGY7pI#9rK$btI!9sK%btM&dvO(fxP-gzR0iBT2k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