P3-OS-CHAPTER 8 BOOK

Presurgical Medical Assessment

as discussed in the previous modules, it is critical for the surgeon to examine patient's medical status. Special measures may be needed to control bleeding, lessen the chance of infection, or prevent a medical emergency.

Pain and Anxiety Control

The clinician must recognize the anxiety that usually exists in patients about to undergo tooth extraction.

-Local Anesthesia

-Sedation

What are under pain and anxiety control

Profound Anesthesia

is important in removing a tooth in order for the patient not

to feel any sharp pain from the procedure. This can also help lessen and manage

patient anxiety towards the procedure.

all pain, temperature, and touch sensations.

Always remember that dense local anesthesia only results in the loss of...

proprioceptive fibers (responsible for the sensation to pressure)

Patient's ____ is not anesthetized thus, patient can still feel the pressure placed by the clinician in the act of removing the tooth.

True

True or False: The clinician must explain this to the patient so that the patient will expect that he will still feel the pressure but will not feel any pain if profound anesthesia was administered.

Bupivacaine

Longest acting Anesthetic

Weight

Computation for patient's maximum dose is related to patient's ____

Sedation

As patient anxiety increases, the need for pharmacologic assistance in dealing

such anxiety arises.

Diazepam

may be given the night before the surgery to lessen anxiety in the

following morning.

Lorazepam

can be given on the morning of the surgery

Sedation by the inhalation of nitrous oxide

are frequently used in patient with mild to moderate anxiety.

IV Route

This route of administering sedative drugs like Diazepam or Midazolam is used in patients with extreme anxiety.

1.Caries

2.Pulpal Necrosis

3.Periodontal Doseases

4.Orthodontic Reasons

5.Malposed Teeth

6.Cracked Teeth

7.Impacted Teeth

8.Supernumerary Teeth

9.Teeth Associated with Pathologic Lesions

10.Radiation Therapy

11.Teeth Involved in Jaw Fractures

12.Financial Issues

Enumerate Indications for Removal of Tooth

Severe caries

is the most common and widely accepted reason to remove a

tooth

Pulpal Necrosis

tooth experiencing irreversible pulpitis that is not amenable to endodontic treatment should be extracted.

Periodontal Disease

tooth with excessive bone loss and mobility are deemed for extraction

Orthodontic Reasons

teeth are sometimes extracted to provide sufficient space for tooth alignment. Maxillary and mandibular premolars are the most commonly extracted

teeth under this reason

Malposed Teeth

if these teeth traumatize soft tissue and cannot be repositioned by orthodontic treatment, they must be removed

Cracked Teeth

they are painful and sometimes cannot be managed by either restorative procedure or RCT

Impacted Teeth

if it cannot erupt properly due to lack of space or soft tissue impingement, it should be removed

Supernumerary Teeth

may interfere with eruption of succedaneous teeth thus extracted

Teeth Associated with Pathologic Lesions

often seen on teeth with odontogenic cysts

Radiation Therapy

compromised teeth that are in the beam of radiation should be considered for removal

Teeth Involved in Jaw Fractures

injured, infected or severely luxated teeth as a result of fracture should be removed

Financial Issues

if the patient doesn't have enough financial resources to maintain or save the tooth (e.g. restoration and/or RCT), sometimes extraction is the best and only treatment

-Systemic Contraindications

-Local Contraindications

What are the two types of contraindications for removal of teeth

1.Severe uncontrolled metabolic diseases

2.Uncontrolled leukemia and lymphoma

3.Uncontrolled cardiac disease

4.Pregnancy

5.Hemophilia

6.Patient taking a variety of medications

Enumerate the Systemic Contraindications

brittle diabetes and end-stage renal disease

Give examples of severe uncontrolled metabolic disease

Uncontrolled leukemia and lymphoma

Related to the prone to infection and excessive bleeding

first or third trimester

Pregnant patients who are in the _____ should not undergo extraction unless deemed necessary and provided that patients' doctor consents the procedure

-systemic corticosteroids, immunosuppressive agents, bisphosphonates, and cancer therapeutic agents

Give the drugs under Patient taking a variety of medications

1. History of therapeutic radiation for cancer

2. Teeth located within area of tumor

3. Severe pericoronitis

4. Acute dentoalveolar abscess

Enumerate the Local Contraindications

Osteoradionecrosis

In history of therapeutic radiation for cancer, this is the most important to keep in mind and most critical because extraction of the tooth might lead to _____, a serious complication.

-Access to Tooth

-Mobility of Tooth

-Condition of Tooth

What are the clinical evaluation of tooth for removal

Access to tooth

- If the patient has limited ability to open his mouth, surgical removal of the tooth is considered.

- Location and position of the tooth are also considered.

Mobility of Tooth

- If tooth has less-than-normal mobility because of either ankyloses or hypercementosis, surgical removal should be considered in order to avoid using excessive force to remove such tooth.

Condition of the crown

- Presence of large caries and/or large restorations on the crown of the tooth to be

extracted and the adjacent teeth should be evaluated. Oftentimes, these teeth are prone to fracture if excessive force is used to extract the tooth.

Periapical Radiograph

Radiograph that provides the most accurate and detailed information concerning

the tooth, its roots, and the surrounding bone.

Panoramic Radiograph

radiographs that are used frequently in evaluating impacted teeth.

-proper exposure,

-should show all portions of the crown,

-roots and surrounding structures be properly mounted for easy viewing of surgeon during procedure.

A good quality radiograph must have:

Every year

Radiographs must be updated...

Relationship to Vital Structures

- Approximation to the maxillary sinus, inferior alveolar nerve and mental nerve

should be thoroughly evaluated. If possible complication is expected, surgical removal should be considered.

Configuration of Roots

- The number, curvature, shape and size of the roots can be radiographically

evaluated. Excessive bend in the root and/or bulbous roots can make routine

exodontia difficult.

- Presence of root caries and root resorption should be noted because this might

lead to root fracture during extraction.

Condition of Surrounding Bone

- Bone that is more radiolucent is likely to be less dense, which makes extraction

easier. But for those bone that are radiopaque or denser, extraction is more

difficult.

- Presence of apical pathologic conditions such as periapical cysts are also noted

in the radiograph. These cysts should be properly removed during extraction.

Second Trimester

If extraction is deemed necessary for a pregnant patient, which trimester is the safest to perform such procedure?

False

Teeth within a tumor are safe to extract. True or False?

Mental Foramen

What vital structure is noted/avoided in the surgical extraction of a mandibular premolar?

It is advised that extraction must be done 7-14 days prior to the schedule for radiation therapy.

WHEN IS THE RIGHT TIME TO EXTRACT A TOOTH FOR A PATIENT WHO WILL UNDERGO RADIATION THERAPY?

Removal of the impacted tooth with severe pericoronitis is deferred until the inflammation has subsided.

Treatment (Non-surgical treatment)

-constant irrigations on the inflamed area

-antibiotics

-removal of the maxi third molar to avoid soft tissue impingement.

IF TOOTH EXTRACTION IS CONTRAINDICATED IN THE PRESENCE OF SEVERE PERICORONITIS, WHAT WILL BE THE TREATMENT?

Universal Precautions

What precautions should be strictly followed in the dental setting most especially

during a surgical procedure.

Sterile drapes

_____ are placed across patient's chest, sometimes including the face with only the mouth exposed, to prevent contamination of the surgical field.

Clorhexidine

During preparation, Patient is instructed to rinse mouth with ____ to minimize bacterial count of the oral cavity.

comfortable for the patient and surgeon

During extraction, The best position is one that is ____, and allows the surgeon to have maximal control of the force that is being delivered to the patient's tooth through the elevators and forceps.

-levers

-wedge

-wheel and axle

What are the mechanical principles involved in tooth extraction

Reclined; 60 degrees

In maxillary extraction, chair is____ so that the maxillary occlusal plane is at an angle of about ___ degrees to the floor

At or slightly below

Height of the chair should be such that the mouth of the patient is ____ the surgeon's elbow.

Turned towards surgeon

If working on the patient's right and left quadrant, patient's head should be ___

Upward

procedures on the anterior maxilla is done with patient looking ____

Upright position; parallel

In mandibular extraction, Patient is positioned in a more ____ so that when the mouth is opened wide, the mandibular occlusal plane is ____ to the floor.

Levers

Elevators are used primarily as ____. Crane pick is inserted into the purchase point of a tooth and then used to elevate the tooth.

Wedge

- The tip of the beak of the forceps are forced into the periodontal ligament space

at the bony crest to expand the bone and force the tooth out of the socket.

- With straight elevators, the smaller ones are inserted and ____ into the periodontal ligament space, which displaces the root toward the occlusion and thus out of the socket

Wheel and Axle

Usually applied in the use of the Cryer elevators.

Axle; wheel

In wheel and axle, The handle serves as the ____ and the tip of the triangular elevator acts as the ___ and engages and elevates the tooth root from the socket.

Elevators and forceps

are the primary instruments to remove a tooth

Dental Elevators

used to luxate the tooth prior to removal

(1) expansion of the bony socket by use of the wedge-shaped beaks of the forceps and the movements of the tooth itself with the forceps.

(2) removal of the tooth from the socket.

What are the two goals of Dental Forceps

1.Apical Pressure

2.Buccal Force

3.Lingual or Palatal Pressure

4.Rotational Pressure

5.Tractional Force

Give the Five major motions applied by the dental forceps:

Apical Pressure

this causes bony expansion as the beak of the forceps are wedged into the periodontal ligament space and by applying such motion the center of rotation of the tooth is displaced apically, minimizing the risk for root fracture.

Buccal Force

results in expansion of the buccal plate at the crest of the ridge.

Lingual/Palatal Pressure

aims to expand the linguocrestal bone.

Rotational Pressure

causes some internal expansion of the tooth socket and tearing of the periodontal ligaments. This is only applied on tooth with single, conical roots like the maxillary incisors and mandibular premolars. Applying this motion to the teeth not mentioned will result into root fracture.

Tractional Force

used in delivering the tooth from the socket after sufficient bony expansion is achieved. Should only be used in the final portion of the extraction process.

Strong buccal force

maxillary teeth are removed effectively by the use of a ____ since the buccal cortical plate of the maxillary alveolar plate is thinner compared to the lingual cortical plate.

Strong buccal force

Same with the mandibular incisors, canines and premolars, they are removed via ____ because of the thin buccal cortical plate.

strong, controlled lingual force

For mandibular molars, lingual cortical plate is thinner, therefore a ____ is applied to remove these teeth.

False

Rotational pressure can be applied in the extraction of bifurcated molars. True or False?

Parallel to floor

In extracting a lower first molar, the patient's mandibular occlusal plane should be?

False

The dentist must always stand up in doing teeth extraction. True or False?

- A handpiece and a bur will be used to create a purchase point/hole of about 3mm in the tooth just above the buccal bone crest.

WHAT WILL BE USED TO MAKE A PURCHASE POINT IN THE USE OF A CRANE PICK ELEVATOR?

Angled, straight elevators

These elevators effectively in the luxation of maxillary posterior teeth since the location of these teeth prevents the proper positioning a regular, straight elevator. Though they may be used with any other teeth in the oral cavity, it is best to reserve the use of these elevators for posterior teeth in the upper arch

-Closed Technique

-Open Technique

What are the two techniques for extraction

Closed Technique

-Most frequently used technique as this is conservative, it only uses the forceps

and elevators to remove the tooth; surgical flaps are not needed.

Open Technique

- This is usually applied on complicated cases of extraction wherein the surgeon

needs to create and raise a flap in order to remove a tooth successfully.

- Will be thoroughly discussed in the next modules.

Routine technique

Closed technique is also known as...

Surgical/Flap Technique

Open technique is also known as...

STEP 1: LOOSENING OF THE SOFT TISSUE ATTACHMENT FROM THE CERVICAL PORTION OF THE TOOTH.

STEP 2: LUXATION OF THE TOOTH

STEP 3: ADAPTATION OF THE FORCEPS TO THE TOOTH

STEP 4: LUXATION OF THE TOOTH USING THE FORCEPS

STEP 5: REMOVAL OF THE TOOTH FROM THE SOCKET

Give Steps/Procedure for Closed Extraction

STEP 1: LOOSENING OF THE SOFT TISSUE ATTACHMENT FROM THE CERVICAL PORTION OF THE TOOTH.

- This step allows the surgeon to check the profoundness of the anesthesia administered. A small pressure can still be felt, but no sensation of sharpness or discomfort.

- This also allows the elevator and forceps to be positioned more apically, without interference from or impingement on the soft tissue of the gingiva.

STEP 2: LUXATION OF THE TOOTH

- Uses dental elevator; usually the small, straight elevator is used first

- This step expand the alveolar bone thus loosens the tooth from the socket

- The elevator is inserted perpendicular

to the tooth in the interdental space.

STEP 3: ADAPTATION OF THE FORCEPS TO THE TOOTH

- Forceps are seated so that the tips of the beaks grasp the root underneath the

loosened soft tissue.

- Lingual beak is usually seated first followed by the buccal/labial beak.

STEP 4: LUXATION OF THE TOOTH USING THE FORCEPS

- The surgeon now applies the five different motions of forceps use discussed in

the earlier modules.

- The major portion of the force is directed towards the thinnest and weakest bone.

Slow, steady force

Use ____ to displace the tooth buccally rather than a series of rapid, small movements.

STEP 5: REMOVAL OF THE TOOTH FROM THE SOCKET

- Removal is done by using tractional force usually directed buccally.

- This step should be performed once sufficient alveolar expansion is achieved

and tooth is loose enough for removal

- Reflects the soft tissues of the cheeks, lips and tongue

- Protect other teeth from the forceps

- Stabilize the patient's head during the extraction process

- Supports the alveolar process and provides tactile information to operator

What are the roles of the surgeon's left hand

Maxillary Canines

Extraction of this tooth would often lead to fracture of the labial cortical plate.

Bifurcation at the apical 1/3 of the root (very prone to fracture)

What makes the maxillary first premolar one the most difficult teeth to extract?

Lingual beak

In adapting the forceps to the tooth, what beak should be adapted first?

Thumb and index finger

What are the two fingers used to support the alveolar process when extracting a maxillary anterior tooth?

30 minutes as this is sufficient enough for blood to create a clot

HOW LONG WILL THE PATIENT BITE ON THE MOISTENED GAUZE AFTER TOOTH EXTRACTION?