EKTRAKCIJA ZUBA KOD PASA I MAČAKA EXODONTIA
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- Susanna Simmons
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1 EKTRAKCIJA ZUBA KOD PASA I MAČAKA EXODONTIA Ekstrakcija (vaďenje) zuba je hirurška intervencija kojom se zub odvaja od alveole (zubne čašice) i uklanja iz nje, nakon čega sledi zbrinjavanje nastale rane. Pre nego sto se pristupi ekstrakciji zuba potrebno je odrediti način ekstrakcije i isplanirati sve korake. Potrebno je (poželjno) imati i RTG snimak, pripremiti svu neophodnu opremu i sl. Potrebno je dobro poznavati indikacije za vađenje zuba, poznavati morfologiju jednokorenih i višekorenih zuba i odabrati odgovarajuću tehniku ekstrakcije, obezbediti po potrebi adekvatnu atibiotsku zaštitu, primeniti odgovarajuću tehniku analgezije i anestezije. Glavne indikacije za vađenje zuba su: Zubi u završnoj fazi periodontalne bolesti usled čega su postali mobilni Zubi koji sprečavaju normalnu okluziju vilice i/ili podgrizaju opozitni zub Zaostali mlečni zub (nikad dva zuba na istom mestu u isto vreme) Zubi na frakturnoj liniji kod loma mandibule i maksile Zubi oštećeni patološkim procesom Endootski izmenjeni zubi (odontoklastna lezije kod mačke) Slika 1. Zaostali mlečni zub - očnjak. 1
2 Slika 2. Kosa fraktura mandibule rostralno od molara. Slika 3. Zub oštećen patološkim procesom. 2
3 Slika 4. Endootski izmenjen zub - uznapredovala odontoklastična resorptivna lezija zuba kod mačke Slika 5. Fraktura zuba sa eksponiranom pulpom. 3
4 INSTRUMENTARIJ ZA EKSTRAKCIJU ZUBA Osnovni set za ekstrakciju zuba se sastoji iz: Klešta za ekstrakciju zuba Periostalni elevator Zubni elevator Raspatorijum za kosti Set za šivenje stomatološka turbina sa setom fisurnih borera 701L, 700L, 330 za rasecanje i seta okruglih borera za zaravnjivanje alveole (½, 1 i 2). Slika 6. Set za ekstrakciju zuba. 4
5 EKSTRAKCIJA JEDNOKORENOG ZUBA PSA Tehnika kojom se vrši ekstrakcija jednokorenih zuba (sjekutića, ne i očnjaka) spada u jednostavne tehnike exodoncije (vađenja zuba). I pored toga poželjno je uraditi RTG snimak kako bi se sagledali i morfološki aspekti korena i alveole, dijagnostikovali prelomi i drugi problemi. Tehnika se sastoji iz gingivalne incizije, luksacije zuba i uklanjanja zuba sa korenom. Gingivalna incizija Potrebno je preseći epitelijalnu vezu gingive sa zubom i to u dnu gingivalnog žleba. Presecanje se vrši tako što se u gingivalni žleb uvuče nožić skalpela (No. 15 ili 11) i to pod uglom od 20 u odnosu na uzdužnu osu zuba. Inciziju je potrebno obaviti oko zuba (okolo-naokolo). Gingivalna incizija - sekutić psa Luksacija zuba Izvođenje luksacije zuba podrazumeva inciziju periodontalnog ligamenta. U prostor između zuba i alveole se kroz prethodno isečeni ginivalni rub uvede luxator ili elevator. Instrument se uvlači i pokretima oko zuba se kidaju leriodontalni ligamenti koji povezuju zub sa zubnom alveolom. Za to vreme zub možemo pomerati levo-desno i gurati apikalno kako bi instrument dobio više prostora za ulazak u prostor između zub i alveole. Nakon ovoga trebalo bi da se zub može pomerati ("klimati") u svim pravcima. Presecanje periodontalnog ligamenta luksatorom (1 min, 28 sec) Uklanajanje zuba Zub se prihvata kleštima za ekstrakciju. Nakon čvrstog prihvata zub se rotira levo-desno i gura apikalno. Sila treba da je umereno snažna i kontinuirana. Nakon toga se zub izvlači opet uz rotacione pokrete. Uklanjanje zuba (20 sec) 5
6 Obrada alveole zuba Zubna alveola se ispere fiziološkim rastvorom i po potrebi iskiretira. Alveolarne procesuse neophodno je skratiti i istupiti kako bi preko njih moglo da se zašije gingivalno tivo bez tenzije. Alveolarnu šupljinu moguće je i ispuniti osteopromotivnim materijalom koji će ubrzati popunjavanje elveolarne šupljine koštanim tkivom. Ovaj materijal sprečava ispunjavanje šupljine krvnim koagulumom i smanjuje broj fibroblasta (Consil : Vetoquinol UK). Kiretaža alveole (10 sec) Šivenje GIngivalno tkivo je potrebno zašiti tako da se zatvori ulaz u alveolu. Koriste se pojedinačni prosti šavovi a udaljenost ne bi trebala da je više od 1,5 mm. Koristi se brzoresorptivni monofilament debljine 5-0, 6-0. Prednosti šivenja su to što se sprečava upadanje hrane u alveolu i preveniranej ispdanja tromba prilikom mastikacije što prouzrokuje postoperativno krvarenje.međutim, šivenjem povećavamo mogućnost da se ispod zašivene gingive u alveoli zaostane kontaminirano tkivo (važnost obrade alveole). Ponekad je poželjno i nakon vađenjazuba odraditi RTG snimanje kako bi se uverili da je su uklonjeni svi delovi zub kao i da nismo naneli štetu susednom alveolama i zubima. 6
7 EKSTRACIJA VIŠEKORENOG ZUBA Kod ektrakcije višekorenih zuba kod psa (molari premolari) treba uzeti u obzit njihovu anatosku osobenost da su korenovi zuba divergentni. To znači da pokušaj vađenja analogan vađenju sekutića će rezultirati lomom i retencijom korena ili prelomom zubne alveole. Zbog toga se kod vađenja višekorenih zuba postupa tako da se zub podeli na onoliki broj delova koliko ima korenova pa da se svaki deo vadi posebno sa pripadajućim korenom. Formiranje flapa Pre formiranja flapa potrebno je skalpelom načiniti gingivalnu inciziju analogno inciziji kod jednokorenog zuba. Formiranje flapa se vrši kako bi smo izvršili vizuelizaciju alveolarne kosti i furkuacije. Najčešće se formira tzv. mukogingivalni flap na taj način što se sa bukalne strane desni načine dve vertikalne incizije tako da se nalaze u nivou nešto kaudalnije i nešto rostralnije odciljnog zuba ali tako da ne ugrožavaju desni susednog zuba. Ove incizije je potrebno postaviti blago divergirajuće kako bi osnova flaa bila šira a time i vaskulariacija bolje očuvana. Incizija gingivalnog žleba (18 sec) Incizije za formiranje flapa (17 sec) Formiranje flapa (34 sec) Ekspozicija furkuacije Furkuacija je mesto na zubu gde se korenovi sustiču. U normalnim uslovima mesto furkuacije se ne vidi jer je prekriveno gingivom. Nakon elevacije gingive (formiranje flapa) potrebno je još iseći turbinom sa odgovarajućim borerom i vodenim hlađenjem. Međutim, kod terminalnog stadijuma periodontalne bolesti furkuacija je već 7
8 eksponirana, pa ovi koraci nisu potrebni. Nakon eksponiranja furkuacije potrebno je iseći krunu zuba (2 ili 3 dela) tako da svakom korenu pripadne odgovarajući deo krune zuba. Sečenje se vrši pomoću stomatološke turbine sa odgovarajućim fisurnim borerom sa vodenim mlazom (701, 669,701L ili 700L) i to uvek u smeru od furkuacije prema kruni, nikako obrnuto. Ukloniti 1-2 mm labijalnog alveolarnog procesusa oko korenova. Ekspozicija furkuacije (43 sec) Objašnjenje za inciziju kod ekspozicije furkuacije (18 sec) Presecanje kaudalnog i mezobukalnog korena (1 min, 7 sec) Presecanje mezobukalnog i mezopalatalnog korena (22 sec) Luksacija zuba Da bi smo luksirali zub u principu koristimo tri vrste pokreta kako bismo presekli periodontalne ligamente. 1. Nakon presecanje krune zuba pomoću zubarske turbine u liniju reza uvući elevator kako bi smo maksimalno raširili delove zuba. Kada dotignemo maksimum (držati tako 10 sekundi) proces ponoviti više puta sve dok se korenovi ne razlabave. Voditi računa o intezitetu sile i mogućnosti pucanja korena. 2. Pomoću elevatora prići sa kaudalne ili rostralne strane priečemu susedni zub služi kao osnova za polugu prekokoje pomuću elevatora koren guramo rostralno ili kaudalno. Voditi računa da se na ovaj način ne ošteti gleđ zdravog zuba. 3. U prostor između korena i alveole se uvede luksator ili elevator. Instrument se uvlači i pokretima oko zuba se kidaju leriodontalni ligamenti koji povezuju zub sa zubnom alveolom. Za to vreme zub možemo pomerati levo-desno i gurati apikalno kako bi instrument dobio više prostora za ulazak u prostor između zub i alveole. 8
9 Objašnjenje postupka luksacije (15 sec) Razdvajanje korenova i stresiranje periodontalnog ligamenta (23 sec) Upotreba susednog zuba kao osnove za polugu elevatora (52 sec) Uklanjanje zuba - korena Svaki deo zuba se uklanja sa pripadajućim korenom tako što se pomoću klešta za ekstrakciju vrše rotacioni pokreti. Sila treba da je analogna sa pravcom pružanja korena i da je svo vreme kontinuirane. Obrada alveole zuba Alveolarne šupljine se najpre isperu fiziološkim rastvorom. Obrada -zatupljivanje alveolarnih procesusa (alveoplastika) je neophodna kako bi se meko tkivo gingiva, zašila preko alveole bez traumatizacije. Alveoplastika se izvodi turbnom na koju je postavljen okruglasti borer. Alveoplastika - obrada alveole (49 sec) Poželjno je nakon ispiranja a pre šivanja gingive alveolarne šupljine ispuniti osteoprogenitornim materijalom. Na ovaj način se stimuliše brža osifikacija alveole. Na ovaj način ispod gingive ostaje izdašnija količina koštanog tkiva pa je uloga u mesta gde je zub bio jače izražena i manja je mogućnost ispadanja hrane Šivenje GIngivalno tkivo (flap) je potrebno zašiti tako da se zatvori ulaz u alveolu. Koriste se pojedinačni prosti šavovi a udaljenost ne bi trebala da je više od 1,5 mm. Koristi se brzoresorptivni monofilament debljine 5-0, 6-0. Veoma je važno da se flap ušije bez tenzije jer u tom slučaju nastaje dehiscijencija. 9
10 Lavaža alveole i postavljanje flapa (7 sec) Šivenje flapa (43 sec) Ponekad je poželjno i nakon vađenjazuba odraditi RTG snimanje kako bi se uverili da je su uklonjeni svi delovi zub kao i da nismo naneli štetu susednom alveolama i zubima. EKSTRAKCIJA OČNJAKA PSA Uvod Očnajci (cuspidni zubi) predstavljaju naročiti izazov prilikom ekstrakcije zbog svoje veličine i zakrivljenosti. Slika 7. Muko-gingivalni flap. Očnjaci gornje vilice su odvojeni od nosne šupljine tankom koštanom pločom sa medijalne strane. Zbog toga gruba i nekontrolisana upotreba luksatora će dovesti do nastanka oro-nazalne fistule. Očnjaci donje vilice čine su odgovorni i za mehaničku 10
11 stabilnost mandibule. Zbog toga prilikom ekstrakcije moguća je čak i frakutura mandibule. Lower canines cross the floor of the oral cavity, from buccal to medial, with the apex located at the caudal mandibular symphysis. The root is, therefore, not accessible for much of its length. Over-robust elevation of the lower canines may well cause symphyseal or horizontal ramus fracture of the mandible. Očnajci gornje vlilice Maksilarni očnjaci su najveći zubi kod psa % ukupne dužine očnjaka se nalazi u zubnoj alveoli tako da se apeks očnjaka nalai zbog svoje zakrivljenosti iznad drugog premolara. Koren očnjaka se može ispalpirati solja preko gingive sve do svog apeksa. Ukoliko je očnjak već razlabavljen (zbog patološkog procesa) ekstrakciji pristupamo po principu vađenja jednokorenog zuba pri čemu vodimo računa da prilikom pokreta rotacije na rotiramo apeks prema nosnoj šupljini i tako probijemo laminu koja odvaja nosnu šupljinu od alveole. Međutim ukoliko je očnjak čvrsto usađen potrebni su sledeći koraci: 1. Palpirati koreni kanal preko gingive sve do apeksa (iznad drugog premolara). 2. Skalpelom napraviti inciziju gingive, koja se proteže od apeksa očnjaka do kaudalne granice trećeg sekutića nekih 2mm rostralno od rostralne granice očnjaka. Iseći skalpelom oko očnjaka epitelijalnu vezu (gingivalni žleb). Ovaj rez produžiti sve do dr Incise round the circumference of the canine to sever the epithelial attachments and continue this sulcar incision back caudally as far as gog molara. Ovaj rez (produžetak reza iz gungivalnog kanala) i rez iznad korena zuba su spojeni i daju oblik slova L. 11
12 Slika 8. Incizija od apeksa prema trećem sekutiću i incizija sulkusa elongirana kaudalno. 3. Počevši od mesta gde se dve incizije spajaju, pomoću periostalnog elevatora početi formirati flap (odvajanje gingive od kosti) i to tako da se eksponira čitava prominijencija maksile u kojoj je usađen očnjak. 12
13 Slika 9. Muko-gingivalni flap podignut dorzalno kako bi se videla prominijencija maksile u kojoj je usađen očnjek.full thickness mucogingival flap lifted from rostral to caudal to expose root juga of Potrebno je stomatološkom turbinom (fisurni borer 701 L) preseći i ukloniti maksilarnu prominijenciju u kojoj je usađen očnjak i to najmanje 50 od dužine korena. Slika 10. Preseći i ukloniti maksilarnu prominijenciju u kojoj se nalazi koren očnjaka. 5. Uvući luksator duž konveksne strane zuba prema apeksu presecajući pri tome periodontalni ligament. Ne uvlačiti luksator sa palatinalne strane jer će to prouzrokovati pritisak apeksa na turbinatne kosti. 13
14 Slika 10. Luksator uvučen sa konveksne strane zuba. Koristiti apikalne i rotacione poktrete. 6. Očnjak čvrsto prihvatiti ekstrakcionim kleštima i izvući bez pokreta rotacije. Pri tome pokret ruke treba da prati zakrivljenost korena, kao prilikom šivenja sa zakrivljenom iglom. Slika 11. Koren je potrebno izvući iz alveole bez rotacije i tako da se onemogući svaki pokret apeksa prema medijalno i ulaak u nosnu šupljinu. 7. Isprati alveolu fiziološkim rastvorom i proveriti eventualno prisutvo oro-anazalne fistule. Ukoliko je sve uredu izostane curenje iz rastvora iz nosa) postupak nastavljamo tako što izbrusimo oštre ivice alveole kao pripremu za postavljanje i 14
15 ušivanje već pripremljenog gingivalnog flapa. Flush the alveolus and check for any pre-existing ONF by flushing the alveolus with saline and checking for liquid flow from the ipsilateral nostril. If there is good integrity of the alveolus floor, pack with alloplastic material (e.g. Boneglass ). Slika. 13. Krajevi alveole se izbruse kako ne bi oštetile gingivalni flap. 8. Gingivalni flap se šije počevši od kaudalnog kraja sa malim razmacima 1,5 mm između šavova. Koristi se brzoresorptivni monofilament. Slika 14. Šivenje flapa. 15
16 9. Antibiotici (cefaleksin) se upotrebljavaju 6-8 dana. Potrebno je primeniti i postoperativnu analgeziju (diklofenak). Slika 15. Efikasno zarastanje 7 dana post op. Očnjaci donje vilice Koren očnjaka donje vilice je usmeren bukalno-medijalno u alveoli. Takođe koren donjeg očnjaka je deblji od krune što može stvoriti probleme prilikom izvlačenja. Takođe koren donjeg očnjaka daje značajnu potporu mehaničkoj stabilnosti mandibule pa vađenje očnjaka može (dok se alveola ne ispuni koštanom masom) značajno umanjiti snagu i dovesti do frakture mandibule. Zbog toga je postoperativno bitno davati mekanu i kašastu hranu. Potrebno je pre ekstakcije formirati dva flapa, jedan sa bukalne a drugi sa lingvalne strane. Baze ovih flapova se prostiru od drugog sekutića do drugog premolara, kako bi se obezbedioadekvatan pristup alveolarnoj šupljini. Nakon formiranja flapa potrebno je ukloniti koštanu alveolu iznad korena kako bi se eksponirao koren zuba. Prilikom formiranja bukalnog flapa potrebno je voditi računa o tome da se ne oštete strukture mentalnog foramena. Mentalni foramen se nalazi ispod prvog premolara i iz njega izlazi mentalni nerv i krvni sudovi. takđe upitno je i oštećenje 16
17 labijalnog frenuluma (prelaz nepomične gingive u pomičnu bukalnu sluzokožu). Nakon formiranja flapa i uklanjanja alveolarne kosti potrebno je još i izbrusiti alveolarne prominijencije. Luksatorom se zatim preseku periodontalni ligamenti, a zatim se zub izvlači tako da se sila kojom izvlačimo zub usmerava da prati putanju korena zuba. Ekstrakcija mandibularnog očnjaka - uvod (55 sec) Ekstrakcija mandibularnog očnjaka - alternativi pristup (12 sec) Lingvalni pristup - postavljanje incizija za ormiranje flapa (19 sec) Lingvalni pristup - formiranje i elevacija flapa (14 sec) Uklanjanje alveolarne kosti (12 sec) Inicijalna luksacija korena (8 sec) Dodatno uklanjanje alveolarne kosti (25 sec) Objašnjenje postupka uklanjanja alveolarne kosti i formiranja flapa (27 sec) Uklanjanje zuba iz alveole (9 sec) Šivenje flapa (29 sec) 17
18 MLEČNI ZUBI Indikacije za ekstrakciju Izostanak zamene mlečnog zuba u odgovarajuće vreme može dovesti do malokluzije i ortodontskih problema u kasnijem uzrastu. Izostanak zamene (ispadanja) mlečnog zuba ponekad je potrebno hirurški sanirati dosta rano (8-12 nedelja) kako bi se prevenirali pomenuti problemi. Retencija mlečnih zuba se najčešće javlja kod sekutića i očnjamka. Mlečni i stalni zub često mogu da budu istovremeno prisutni u vilici. tada je potrebno napraviti razliku između mlečnog i stalnog zuba, pa je ponekad potrebno načiniti RTG snimak. Po pravili stalnui zubi su pozicionirani lingvalno ili palatijalno u odnosu na zaostali mlečni zub. Izuzetak je stalni maksilarni očnjak koji je rostralno i stalni maksilarni premolar 4 koji je bukalno i distalno od poslednjeg mlečnog zuba. Malokluzija. Zaostali 704 i604 doveli su do lingvalne devijacije 304 i 204. Rostralni deo mandibule. vide se mlečni i stalni zubi. 18
19 Ekstrakcija mlečnih zuba Take care - Mlečni zubi se lako zalome prilikom vađenja pa zaostali koren i dalje može da utiče na stalni zub i da dovede do njegovog pomeranja i nastanka malokluzije. Koren mlečnih zuba je gotovo istog promera kao i kruna. Prilikom vađenja potrebno je napraviti rez u gingivalnom žlebu. Pri tome voditi računa da se ne ošteti alveola od stalnog zuba. Nije potrebno ali je ipak moguće zatvaranje alveole šivenjem. Uvod ZUBI KOD MAČAKA Tehnika vađenja zuba kod mačaka je umnogome identična vađenju zuba kod psa. Pa ipak izuzetci postoje onda kada je reč o ekstrakciji zuba kod mačke koji je oštećen resorptivnim lezijama (FORL Feline Odontoclastic Resorptive Lesions). Zubi pogođeni sa FORL često imaju morfološki oštećene korenove koje je teško izvaditi. Vađenje se obavlja tako što se najpre preseče kruna zuba i odvoji od korenova a zatim se svaki koren posebno tretira i uklanja. Slika 15. Uznapredovali slučaj periodontalne bolesti kod mačke koji može da bude posledica i FORL. 19
20 Slika 16. Uznapredovali slučaj FORL na bukalnoj strani zuba. KOMPLIKACIJE EKSTRAKCIJE ZUBA Uvod The operator needs to be aware of the complications associated with tooth extraction in dogs and cats. In most instances, complications need to be addressed immediately. However, some may not be immediately apparent. Haemorrhage can occur several hours post-op if the blood clot retracts or is lost by tongue probing. Oral nasal fistulae may take several weeks to become apparent and functional following maxillary canine removal. 20
21 Fig. 17. Fracture of mandible caudal to symphysis including the apex of the mandibular canine tooth. Fig. 18. Dog skull with buccal bone plates removed to demonstrate location and morphology of roots. Oro-nasal, oro-antral fistula Oro nazalna fistula podrazumeva patološku komunikaciju između nosne i usne duplje. Najčešće se ova veza ostvaruje u predelu zubne alveole očnjaka This complication can occur in any location from the upper canines, caudally. Oro-nasal refers to a communication between the oral and nasal cavity - most commonly at the site of the maxillary canine. Oro-antral refers to a communication between the oral cavity and the maxillary sinus - most common following upper premolar 4 (carnassial) extraction. They are most common where the bone plates are thinnest - either naturally or after periodontal or metabolic disease. 21
22 Correct attention at the time of extraction can limit the need for complex flap surgery later. Debride socket gently with 0.05% chlorhexidine gluconate (CHX Solution : St Jon VRx Products) and fill with alloplastic graft material if a solid floor is present. This may require a mesh type product (BioSyst ) followed by BoneGlass (Consil ). Suture tissues should be sutured without tension. Treat with suitable antibiotics. Review after four to six weeks to identify the need for flap surgery. This timeframe will allow for wound contraction. The main reasons for dehiscence of flaps are: Chronic osteitis at site from local infection Tension on sutures Suture lines unsupported and located over a void. Expect 20% contraction of soft tissue during healing. Tension on flaps is usually due to poor flap design. To prevent this, ensure that the releasing incisions are made off the target tooth, preferably at the line angle of the teeth rostrally and caudally, and that the flap is sufficiently undermined before suturing. Many ONF's stay open due to the pressure differential between the nasal and oral cavities. After six weeks, if the ONF is large enough to cause chronic rhinitis and sneezing, closure by flap surgery is indicated. Fig. 19. Large, chronic, functional oral nasal fistula. Krvarenje Iz kosti Iz mekog tkiva Uglavnom se brzo zaustavlja Tamponiranje alveolarne šupljine Haemorrhage can be from bone or soft tissue. Most sockets stop bleeding 22
23 Slika. 20. Profuzno krvarenje iz nosa nakon ekstrakcije očnjaka. Fraktura korena Uglvnom se dešavaju ako je patološki process u korenu uznapredovao ili ukoliko se ne koristi odgovarajuće tehnika ekstrakcije. Zaotali koren nekrotizira što može dovesti do problema u zarastanju alveoli. Zbog toga je potrebno osigurati pristup do korena uklanjanjem dodatne površine alveolarne kosti ili pokušati ukloniti koren prihvatom kleštima (što obično ne uspeva). Slika 21. Zaostao koren maksilarnog očnjaka mačke. 23
24 Slika 22. RTG - zaotatak korena u mandibuli nakon - pogrešna tehnika ekstrakcije. Fraktura mandibularne simfize andible symphysis fraction Ukoliko se koristi preterana slia prilikom ekstrakcije, naročito ako je ona greškom usmerena lateralno, moguć je prelom simfize pogotovo ako je reč o mlađim životinjama kod kojih simfiza još nije srasla. Jatrogene trauma Prevelika sila često kod ekstrakcije često dovodi do fracture kostiju. Oprez je još potreban kod ekstrakcije zuba u neposrednoj blizini infraorbitalnog i mentalnog otvora. Mehanička trauma u ovom delu može prouzrokovati presecanje krvnih sudova koji se onda uvuku u koštane kanale pa je krvarenje često nemoguće zaustaviti osim podvezivanjem karotide. 24
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