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Management
Fracture of:
Crown of tooth being extracted
Alveolar bone
Leave them in certain circumstances Removal of root apex Removal of any pulp tissue, and cover fragments with ZnO and oil of clove Remove any alveolar fragment which has lost half of its periosteal attachment by gripping it with haemostatic forceps and dissecting off the soft tissues with a periosteal elevator, Mitchell trimmer or Cumine scaler
Maxillary tuberosity
Fractured tuberosity and the tooth should be free from the palatal soft tissue by blunt dissection and lifted from the wound The soft tissue flaps are then opposed
Mandible
Carious / heavily restored Tooth being extracted yields suddenly to uncontrolled force and forceps strike opposing tooth In line of withdrawal Under GA, teeth other than the one being extracted maybe damaged injurious uses of gags and props Excessive / incorrectly applied force used Pathological changes weakened the jaw Weakened by senile osteoporosis and atrophy; osteomyelitis; previous therapeutic irradiation, osteodystrophies Unerupted teeth, cysts, hyperparathyroidism, tumours Similar to causes of fracture tooth Use of elevators transmit some pressure to
with mattress suture, which evert the edges and left in situ for at least 10 days Stabilise mobile parts of bone with rigid fixation techniques for 4-6 weeks If tooth is infected / symptomatic at the time of tuberosity fracture, extraction continued by loosening the cuff of gum and removing as little bone as possible while attempting to avoid separation of the tuberosity from layer of skin immediately overlying the bone (periosteum) If tooth delivered with attached tuberosity, tissues should be closed with watertight stitches (as there may not be clinical oro-antral communication) No force should be applied to adjacent tooth during extraction Other teeth should not be used as fulcrum Careful controlled extraction technique
Dislocation of:
Adjacent tooth Elevator should not be applied to mesial surface of first permanent molar, because the smaller 2nd premolar may be dislodged
TMJ
Lower jaw supported during extraction by pressing upwards with both hands beneath angles of mandible Stand in front of patient and places thumbs intra-orally on external oblique ridges lateral to any mandibular molars and fingers extraorally under the lower border of the mandible. Downward pressure with thumbs and upward pressure with fingers Not open mouth too widely or yawn for few days Extra-oral support to joint and worn until tenderness in affected joint subsides
Displacement of root:
Into soft tissues Ineffectual attempts to grip the root when visual access is inadequate Large antrum Grasp roots only under direct vision
Into antrum
Never apply forceps to maxillary cheek tooth / root unless sufficient of its length is exposed both palatally and buccally to allow blades to be applied under direct vision Lave apical 1/3rd of the palatal root of maxillary molar if it is retained during forceps extraction unless there is a positive indication for removing it Never attempt to remove a fractured maxillary root by passing instruments up the socket Raise large mucoperiosteal flap and remove enough bone to permit elevator to be inserted above broken surface of root
Excessive Haemorrhage:
During tooth removal
Hemorrhagic diathesis Swabbing gauze packs Use sucker (P = 20psi) Hot (50oC) normal saline pack held in position for 2 minutes Vasoconstrictor in LA
On completion of extraction
Postoperatively
Rinse mouth with bland mouthwash once Firm gauze roll placed upon socket, patient asked to bite upon for few minutes Horizontal mattress suture inserted into mucoperiosteum to control haemorrhage Place firm gauze pack upon socket and bite upon Tannic acid powder Suture (interrupted horizontal mattress suture bite upon gauze for 5 minutes) Gelatin / fibrin foam tucked into socket and composition block moulded over the area Hospitalised Careful selection of forceps and good technique Careful dissection of gums which adhered to tooth with scalpel or scissors Extra care
Damage to:
The gum Lower lip Removal of lower premolar roots Acute inflammation in tissues around it Traumatic extraction of lower molar (lingual soft tissues traped in forceps / caught up with bur during removal of bone) Soft tissues crushed in forceps / between teeth and blades of mouth gag Use of elevator without proper control Crushed between handles of forceps and anterior teeth
Lingual nerve
Preoperative radiographic diagnosis Careful dissection Nerve protected by metal retractor during operation Bone removal is maximal mesially to first premolar root and distally to 2nd premolar root Metal retractor to protect adjacent soft tissues from harm
Avoidance of errors
Dry socket
Scaling Gingival inflammation treated at least one week before extraction Adm only min LA Remove teeth as atraumatic as possible
1. Irrigate with warm saline, remove all degenerating blood clot 2. Excise sharp bony spurs with rongeur forceps / smooth with wheel stone 3. Tuck loose dressing composed of ZOE and oil of cloves into the socket / whiteheads varnish on pom-pom or ribbon gauze left in situ for 2-3 weeks 4. Analgesic tablet + hot saline mouth-baths 5. Chemical cauterization of exposed bare painful bone Traumatic extraction of lower Admitted emergency to hospital molar under local anaesthesia in presence of acute gingival inflammation Lower jaw unsupported Steadies mandible by holding under angle of mandible Ask patient to hold dental prop tightly between his teeth on contralateral side during extraction
Trismus
Postop oedema Heaematoma Inflammation of soft tissues Mandibular nerve block Creation of Oro- Apices of maxillary cheek teeth closely related t antral antrum Communication Periapical infection destroy soft-tissue lining air sinus Perforation of soft-tissue lining air sinus during extraction
Hot saline mouth-baths Frequent hot saline mouth-baths Evacuate pus prescribe Ab Severe infection hospital Intraoral heat by short-wave diathermy / hot saline mouth-baths Adm Ab Specialist treatment 1. Raise mucoperiosteal flap 2. Reduce height of bony socket 3. Loosely suture flaps across defects with interrupted horizontal mattress suture 4. Covering area with quick-cure acrylic extension to an existing denture / base plate
Syncopal attacks
1. 2. 3. 4.
Lower head Maintain airway Consciousness regained glucose drink Does not recover within few minutes administer Oxygen + monitor vital signs + I.V. inj 250mg aminophylline 1. Lay flat on floor 2. Clear airway 3. Pulmonary resuscitation External cardiac massage Management similar to collapse