華西口腔課件外科牙齒拔除術(shù)

華西口腔課件外科牙齒拔除術(shù)Extractionisasurgery

Theextractionofteeth,howeveraccomplished,isasurgicaloperationinvolvingbonyandsofttissuesoftheoralcavity,accesstowhichisrestrictedbythelipsandcheeks,andfurthercomplicatedbythemovementofthetongueandmandible.2020/11/322020/11/33

Itisessentialthatthisphaseoforalsurgerybegiventhesamecarefulstudyandapplicationofsoundsurgicalprinciplesasisgiventosurgeryinanyotherpartofthehumanbody.2020/11/34IndicationsfortheextractionofteethThefollowingareindicationsfortheextractionofteeth.(a)teeththatarefociofinfections;(b)teethwithnonvitalpulps,oracuteorchronicpulpitiswhenrootcanaltherapyisnotindicated;2020/11/35

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(c)incasesofsevereperiodontoclasiainwhichexcessivebonysupportoftheteethisdestroyed;2020/11/37Indicationsfortheextractionofteeth(d)teethnottreatablebyapicoectomy;(e)teethmechanicallyinterferingwiththeplacementofrestorativeappliances;(f)teethnotrestorablebyoperativedentistry;2020/11/38

(g)impactedteeth;(h)supernumeraryteeth;(i)retaineddeciduousteethwhenasuccedaneoustoothispresent,andinnormalpositiontoerupt;2020/11/39Indicationsfortheextractionofteeth(j)teethwithfracturedcrown;(k)malposedteethnotamenabletoorthodontictreatment;(l)roots;(m)teeththataretraumatizingsofttissues,ifothertreatmentwillnotpreventthistrauma.2020/11/310Contraindications:systemicdiseases11.Uncontrolleddiabetesmellitus2.Cardiacdisease,suchascoronaryarterydisease.hypertension,andcardiacdecompensation,e.g.postinfarctionwithin6months3.Blooddyscrasiassuchasanemias,hemorrhagicdiseasese.g.hemophilia,andtheleukemias.4.Debilitatingdiseasesofanykindmakingpatientspoorrisksforfurthertraumaticinsults.5.Addison'sdiseaseoranysteroiddeficiency,suchasthepatientwhohasbeentreatedforanydiseasewithsteroidtherapymaynothavesufficientadrenalcortexsecretiontowithstandthestressofanextractionwithouttakingadditionalsteroids.

2020/11/311Contraindications:systemicdiseases26.Feverofunexplainedoriginisrarelycuredandoftenisworsenedbyextraction,e.g.subacutebacterialendocarditiswouldbecomplicatedconsiderablybyanextraction.7.Nephritis8.Pregnancy:extractionisbettertobedoneinthesecondtrimester.Menstruation:electiveexodontiaisnotdoneduringtheperiodbecauseoflessnervousstabilityandgreatertendencytowardhemorrhageofalltissues.9.Senility:greatercareinovercomingapoorphysiologicresponsetosurgeryandaprolongednegativenitrogenbalance.10.Psychosesandneuroses2020/11/312Localcontraindications1.Acuteinfectionwithanuncontrolledcellulitis,toxemiauntiladequatebloodlevelofaspecificantibiotichadbroughtsystemicfactorsundercontrolandtheinfectionhadbecomelocalized,thepuswasdrained,andtheinfectionhadsubsidedtoachronicstate.2.Acutepericoronitis3.Acuteinfectiousstomatitis4.Malignantdisease5.Irradiatedjawsmaydevelopanacuteradio-osteomyelitisafterextraction2020/11/313specialinstrumentsfortheextractionThespecialinstrumentsfortheextractionofteethandrootsareforceps,elevators.Inspecialcases,wherebonehastoberemoved,otherinstrumentsrequiredsuchaschiselsandmallet,burs,etc..2020/11/314

Averylargevarietyofforcepsandelevatorshavebeendevised.Afewwell-selectedinstrumentswillsufficeallhutveryextraordinarycases.2020/11/315StraightelevatorPhysicalcharacteristics1.Large,bulboushandle.2.Workingendresemblesasharp,narrow,elongatedspoon.3.Straightshank,paralleltotheworkingend.Use1.Toseparateandloosenthetoothinitsalveolus.2.Toremovelargetoothfragments.ApplicationPositionedbetweenthetoothanditsalveolus.2020/11/316Maxillaryposteriorforceps

UniversalmaxillaryforcepsPhysicalcharacteristics1.Plierslikeappearance.Beakshavesmoothedgesthatallowthemtofitaroundthebifurcatedareasofallmaxillarymolarteeth.apointonthebuccalbeakthatallowsthemtofitintothebuccalbifurcationarea.UseToextractmaxillaryposteriorteethfromtheiralveoli.2020/11/317Maxillarypremolarforceps/universalforcepsPhysicalcharacteristics1.Plierslikeappearance.2.Instrumentswithbayonet-shapedbeaksareUniversal.UseToremovepremolarteethfromtheiralveoliinthemaxillaryarch.2020/11/318MandibularposteriorforcepsPhysicalcharacteristics1.Plierslikeappearance.2.Universaldesignandthereforefunctionalineitherquadrantofthearch.3.Oftenreferredtoasacowhornforceps.UseToremovemandibularposteriorteethfromtheiralveolisockets.2020/11/319MandibularincisorandpremolarextractionforcepsPhysicalcharacteristicsl.Plierslikeappearance.2.Beaksdesignedtoremoveallmandibularteeth,butmostoftenusedonincisorsandpremolars.UseToextractmandibularincisorandpremolarteeth.PedodonticextractionforcepsPhysicalcharacteristics1.Designidenticaltoforcepsmanufacturedforuseonpermanentteeth.2.Smallerinsizethanstandardforceps.UseToremoveprimaryteethfromtheoralcavity.2020/11/320Bonechisel/surgicalMalletPhysicalcharacteristics

Chisel1.Lengthandwidthoftheshaftvary.2.Cuttingendavailableinsingle-bevelanddouble-beveldesigns.

Mallet1.Hammershaped.2.Headavailableinleadornylon.UseTotrimorreshapebonetosectionteeth.2020/11/321INSTRUMENTSTERILIZATION

Aprofessionengagedindeliveringhealthcaremustbeconcernedwithinfection.Itisimperativethatsterilizationofdentalinstrumentsbearoutineprocedureineverydentaloffice.Variousmethodsofdisinfectionandsterilizationcanbeemployedtoreducetheprobabilityofinfectionandcrosscontamination.Itismandatorythatthedentalteamunderstandandproperlyusethesemethods.2020/11/322SterilizationSterilizationistheactofdestroyingallformsoflife.Themostacceptedmethodsindentistryandmedicineforachievingtruesterilizationareextendedperiodsofhighheatandsteamheat.2020/11/323Disinfection

Disinfectiononlyinhibitsthegrowthofdisease-causingmicroorganismsandisnotnearlyaseffectiveassterilization.Onlydentalinstrumentsthatcannotwithstandthehightemperatureofheatsterilizationshouldbeplacedinadisinfectantsolution.Someofthechemicalsavailableforuseasdisinfectantsarebenzalkoniumchloride,hexachlorophene,andrubbingalcohol.Amorepopulartermforchemicaldisinfectionis"coldsterilization.”Theinstrumentsareplacedinanopendisinfectantbathfortherequiredlengthoftime.2020/11/324IMPACTEDTEETHAtoothisspokenofasbeingimpactedwhenitseruptionispartiallyorwhollyobstructedbyboneorsomeotherteeth.2020/11/325ImpactedTeeth

ClassificationofMandibularImpactedTeeth

Theclassificationofmandibularimpactedteethmaybestatedsimplyas(l)mesioangular,(2)horizontal,(3)vertical,and(4)distoangular.Inaddition,thetoothmaybedisplacedtothebuccalortothelingual.Furthermoreitmaybelocatedatahighocclusallevel(neartheridgesurface)oralowocclusallevel.2020/11/3262020/11/327EtiologyManypathologicconditionsbringaboutretardederuption,displacementandimpactionofteeth.Thegrowthofthejawsandthemovementoftheteethareinaforwarddirection;consequently,anythingwhichinterfereswiththisforwardmovementorgrowthwillcauseimpactionoftheteeth.Acuteinfectiousfeversofchildhood,suchasscarletfeverandmeasles,mayinterferewiththeforwardmovementbyproducingadepositofdensebone.2020/11/328EtiologyLocalincreaseinthedensityofthebonemayalsobebroughtaboutbyinflammationoftheperidentalmembrane,extendingintothealveolarprocess.Severetraumatismtothejawsmaycauseadepositoflimesaltsinthecancellatedbonetissueandthusbringaboutimpaction.Ankylosisofthemandibularjointinchildhood,resultinginarrestofgrowthofthejaws,mayleaveinsufficientspacefortheeruptionofallteeth.Tooearlyextractionofdeciduousteethmaycausearresteddevelopmentofthejawsandmalpositionsofthepermanentteeth,thisleadinginturntoimpactionofuneruptedteeth.2020/11/329DisturbancescausedbyimpactedteethImpactedteethmaybepresentwithoutgivingrisetoanysymptomswhatever.Otherscausemanycomplicationssuchassomeoflocalandgeneraleffects.2020/11/330(I)LocaleffectsAnimpactedthirdmolarmaypressagainstthecrownofthesecondmolarandcausedecayofthetooth,oritselfbecomestheseatofcariesaroundthepointofcontact.Itmayalsocausepressureabsorptionoftherootofthesecondmolar.Exposureanddevitalizationofthepulpfromthesecausesmaygiverisetoneuralgia.Neuralgiamaybecausedinanotherwaybypressureoftheimpactedtoothontheinferiordentalnerveoritsbranches.2020/11/331(I)Localeffects-cont.Sometimes,especiallyinthecaseofthelowerthirdmolar,pericoronalinfection,pericoronalabscess,cellulitisandosteomyelitisaresetup,oftenaccompaniedbytrismus.Inanypatientsufferingfromacutecellulitisinthebackpartofthemouthandinabilitytoopenthemouth,animpactedlowerthirdmolarshouldbesuspected.2020/11/332(Il)GeneraleffectsImpactedteethmaybethecauseofobscureheadaches.Casesofmoreseriousnervousorevenmentaldisturbancehavebeenattimestracedtothiscause.Insuchconditionsasepilepsy,choreaanddementiaprecox,impactedteethmayatleastbeacontributingfactor.Inthesecasestheremaybenolocalsignsoftrouble.2020/11/333DiagnosisIfthetoothispartiallyerupted,thediagnosisisatonceapparentoninspection,butinothercasesthediagnosisdependsonabsenceofthetoothfromthedentureandtheX-rayfindings.TheX-rayismostvaluablenotonlyindetectingthepresenceofimpactedanduneruptedteeth,butalsoinaccuratelylocalizingthemanddeterminingtheshapeandpositionofthecrownandroots,andrelationtoadjoiningteeth.2020/11/334TreatmentIftreatmentisindicated,itconsistsasageneralruleinremovalbyoperationoftheimpactedtooth2020/11/335PrincipleofRemovalofMandibularImpactedTeethTheunderlyingprincipleintheremovalofmandibularimpactedteethisasectioningtechnique.Boneisremovedtoexposethecrown.Thetoothissplitwithafreshsharpchiselsothatagoodportionofthecrownisseparatedfromthetooth.Whenthisportionisremoved,spaceisobtainedsothattheremainderofthetoothcanbeelevatedintothedefect.Beforethistechniquewasdeveloped,spaceforelevationwasobtainedbymoreextensiveboneremovalandconsequentlymoretrauma.2020/11/3362020/11/337Complicationsofextractionofteeth(1)Looseningofadjacentteethiscausedbyinappropriateuseofforcepsandelevators.(2)Fractureofadjacentteethandrestorationsoccasionallyoccursduringaroutineextractionprocedure.Thismostcommonlyoccurswiththeinappropriateuseofelevators.Teethcanbefracturedifthetoothbeingextractedsuddenlyyieldstouncontrolledforceandtheforcepsstriketheopposingteeth.2020/11/338Complications(3)Fractureofthebuccalorlabialplatemayoccur.Thesurgeonwhofrequentlyfracturesthebuccalorlabialplatemustanalysehistechniques,sincethisisconsidered"heavyhanded"surgeryinthelightofmoreappropriaterefinedtechniques.(4)Teethorrootsintothemaxillarysinusispossibleeitherduringforcepsextractionorrootretrieval.Itisquiteeasytodisplacerootsofuppermolarteethintothemaxillarysinus.2020/11/339Injurytotheinferioralveolarnerve(5)Injurytotheinferioralveolarnervemayoccurwhentheinferioralveolarnerveiscloselyassociatedwithrootsandsometimeswiththecrownofthemandibularthirdmolar.Operationsinthisregioncaneasilydamagethenerve.Perhapstheeasiestwayofdamagingthenerveisduringsectioningofahorizontallyimpactedthirdmolarlyingdirectlyabovethemandibularcanal.Thiscomplicationcanbepreventedbysurgeon'sprecautionandrefinedtechniques.2020/11/340Postoperativehemorrhage'sleadingcauses(6)Postoperativehemorrhage'sleadingcausesare:①patient'smanipulationofthewound.②foreignbodyinthesocket,suchasboneortoothfragments.③sharpbonemarginsandfracturedsocketwalls.④excessivegranulationtissuenotremovedattimeofsurgery.⑤hypertension.⑥clottingdeficiencyorvasculardisorder.2020/11/341Postoperativepain(7)Postoperativepainwhichthepatientexperiencesafterthesecondandthirdpostoperativedaysshouldbecarefullyexamined,sincethisisnotanormalpostoperativecourse.Itiscausedbydrysocketorsharpbonespine.2020/11/342Drysocket'sclinicalappearance(8)Drysocket'sclinicalappearanceiswellknown.Twoorthreedaysafterremovalofthetooth,thebloodclotdisintegrates.Thealveolusisempty,withcompletelyorpartiallydenuded,verysensitiveblancsurfaces,coveredbyagrey-yellowlayerofdetritusandnecrotictissue.Thesurro