Ministry of Health of Ukraine Higher State educational institution of Ukraine "Ukrainian Medical Stomatological Academy"

Transcription

1 Ministry of Health of Ukraine Higher State educational institution of Ukraine "Ukrainian Medical Stomatological Academy" Approved the meeting of department Pediatric surgical stomatology with propaedeutics of surgical stomatology " " 20 r. protocol number Chair, DMS., profesor Tkachenko P.I. GUIDELINES for students' independent work during training to practice Educational discipline Pediatric surgical stomatology Module number 1 Inflammation in maxillofacial region in children. Anatomical and physiological features of tissues in maxillofacial area in children. Content module number 1 Anesthesia by surgery in maxillofacial region in ambulatory and hospital. Removal of deciduous and permanent teeth in children of all ages. Extraction of tooth in children (exodontia). Features of extraction of deciduous and Topic of classes permanent teeth on upper and lower jaw depending of patient age. General and local complications during and after removal of tooth, their prevention and treatment. Course 4 Faculty stomatological Poltava-2016

2 1. Relevance of the topic. Exodontia is widespread procedure in surgical practice. It is necessary to learn the technique of exodontia of temporal and permanent teeth in children, to know indications and contra-indications. Complications of exodontia poses hazard to life of patient, because their prophylaxis and treatment need special attention. Extraction of deciduous teeth has distinguishing features which necessary to know. 2. Specific objectives: 1.To learn terms and types of resorption of tooth root of temporal teeth; their anatomic signs and distinguishing feature; to learn construction of forceps, elevators and other instrument which are used for performing of extraction. 2.To know the preoperative examination of patient, stages of operation, and features of extraction of temporal and permanent teeth in different age periods. 3. To determine indications and contra-indications to exodontia in definite patient; possible complications and their treatment; to prescribe preoperative preparation of patient with associated diseases; to perform appropriate local anesthesia and exodontia in patient 3. Base knowledge, abilities, skills necessary for studying of a theme (interdisciplinary integration). Discipline Know Know how Anatomy Anatomical features of structure of bones in maxillofacial region in children (upper and lower jaws). Topographical Anatomy Topography of the natural apertures of bones and location of vessels and nervous trunks in different age periods in children. Therapeutic Pedodontia Terms of physiological resorption of tooth root in children and secondary dentition. Propedeutics of Surgical Stomatology Clinical Pharmacology Surgical instrument for extraction of teeth and injection techniques of local anesthesia Anesthetics which are used for the local anesthesia in maxillofacial region. to define first movement of dental dislocation during extraction of different groups of teeth in children to represent schematically the innervation and blood supply of upper and lower jaws to represent schematically the types of physiological resorption of tooth root in children. to determine consistency of stages of extraction and their features in children to write the recipes of anesthetics. 4. Tasks for independent work in preparation for classes A list of key terms, parameters, characteristics that must learn the student in preparation for the lesson: Term Definition Simple or The removal of an erupted tooth, with normal root structure, routine tooth reasonably sound remaining crown structure, and usual arch position. extraction Removal of such a tooth should not require tissue incision, or suturing (stitches)

3 Surgical tooth extraction Root Removal Removal of an erupted tooth, whose root structure is dilacerated (curved), fragile, or unusually shaped or if there is not quite enough crown material to obtain a suitable purchase (grasping area on the tooth). Removal of an erupted tooth which has so decayed or otherwise broken down that only the roots of the tooth remain 4.2. Theoretical problems for the classes: 1. Statistics and reasons of complications during exodontia. 2. Preoperative preparation of patient with associated diseases Practical work (tasks) are performed in classes: 1. Preoperative examination of patient. 2. To define type of resorption of tooth roots. 3. To perform local anesthesia for exodontia 4. To choose necessary forceps for exodontia. 5. To choose method of exodontia in children of different ages. 6. To prevent and treat commons and local complications. 7. To seize technique of extraction of temporal and permanent teeth. Theme contents: In children, odontogenic infections may involve more than 1 tooth and usually are due to carious lesions, periodontal problems, or a history of trauma. Untreated odontogenic infections can lead to pain, abscess, and cellulitis. As a consequence of this, children are prone to dehydration especially if they are not eating well due to pain and malaise. Prompt treatment of the source of infection is important in order to control pain and prevent the spread of infection. With infections of the upper portion of the face, patients usually complain of facial pain, fever, and inability to eat or drink. Care must be taken to rule out sinusitis, as symptoms may mimic an odontogenic infection. Occasionally in upper face infections, it may be difficult to find the true cause. Infections of the lower face usually involve pain, swelling, and trismus. They frequently are associated with teeth, skin, local lymph nodes, and salivary glands.swelling of the lower face more commonly has been associated with dental infection.most odontogenic infections can be managed with pulp therapy, extraction, or incision and drainage. Infections of odontogenic origin with systemic manifestations (eg, elevated temperature of 102º to 104ºF, facial cellulitis, difficulty in breathing or swallowing, fatigue, nausea) require antibiotic therapy. Severe but rare complications of odontogenic infections include cavernous sinus thrombosis and Ludwig s angina. These conditions can be life threatening and may require immediate hospitalization with intravenous antibiotics, incision and drainage, and referral/consultation with an oral and maxillofacial surgeon. Extraction of erupted teeth Maxillary and mandibular anterior teeth Most primary and permanent maxillary and mandibular central incisors, lateral incisors, and canines have conical single roots. In most cases, extraction of anterior teeth is accomplished with a rotational movement, due to their single root anatomies. However, there have been reported cases of accessory roots observed in primary canines.radiographic examination is helpful to identify differences in root anatomy prior to extraction.care should be taken to avoid placing any force on adjacent teeth that could become luxated or dislodged easily due to their root anatomy.

4 Maxillary and mandibular molars Primary molars have roots that are smaller in diameter and more divergent than permanent molars. Root fracture in primary molars is not uncommon due to these characteristics as well as the potential weakening of the roots caused by the eruption of their permanent successors. To avoid inadvertent extraction or dislocation of or trauma to the permanent successor, careful evaluation of the relationship of the primary roots to the developing succedaneous tooth should be completed. Primary molars with roots encircling the successor s crown may need to be sectioned to protect the permanent tooth s location. Molar extractions are accomplished by using slow continuous palatal/lingual and buccal force allowing for the expansion of the alveolar bone to accommodate the divergent roots and reduce the risk of root fracture. When extracting mandibular molars, care should be taken to support the mandible to protect the temporomandibular joints from injury. Fractured primary tooth roots The dilemma to consider when treating a fractured primary tooth root is that removing the root tip may cause damage to the succedaneous tooth, while leaving the root tip may increase the chance for postoperative infection and delay eruption of the permanent successor.radiographs can assist in the decision process. The literature suggests that if the fractured root tip can be removed easily, it should be removed. If the root tip is very small, located deep in the socket, situated in close proximity to the permanent successor, or unable to be retrieved after several attempts, it is best left to be resorbed. Complications 1. Infection: although rare, it does occur on occasion. The dentist may opt to prescribe antibiotics pre- and/or post-operatively if he/she determines the patient to be at risk. 2. Prolonged bleeding: The dentist has a variety of means at his/her disposal to address bleeding, however, it is important to note that small amounts of blood mixed in the saliva after extractions are normal--even up to 48 hours after extraction. 3. Swelling: Often dictated by the amount of surgery performed to extract a tooth (e.g. surgical insult to the tissues both hard and soft surrounding a tooth). Generally, when a surgical flap must be elevated (i.e. and the periosteum covering the bone is thus injured), minor to moderate swelling will occur. A poorly-cut soft tissue flap, for instance, where the periosteum is torn off rather than cleanly elevated off the underlying bone will often increase such swelling. Similarly, when bone must be removed using a drill, more swelling is likely to occur. 4. Sinus exposure and oral-antral communication: This can occur when extracting upper molars (and in some patients, upper premolars). The maxillary sinus sits right above the roots of maxillary molars and premolars. There is a bony floor of the sinus dividing the tooth socket from the sinus itself. This bone can range from thick to thin from tooth to tooth from patient to patient. In some cases it is absent and the root is in fact in the sinus. At other times, this bone may be removed with the tooth, or may be perforated during surgical extractions. The doctor typically mentions this risk to patients, based on evaluation of radiographs showing the relationship of the tooth to the sinus. It is important to note that the sinus cavity is lined with a membrane called the Sniderian membrane, which may or may not be perforated. If this membrane is exposed after an extraction, but remains intact, a

5 "sinus exposed" has occurred. If the membrane is perforated, however, it is a "sinus communication". These two conditions are treated differently. In the event of a sinus communication, the dentist may decide to let it heal on its own or may need to surgically obtain primary closure--depending on the size of the exposure as well as the likelihood of the patient to heal. In both cases, a resorbable material called "gelfoam" is typically placed in the extraction site to promote clotting and serve as a framework for granulation tissue to accumulate. Patients are typically provided with prescriptions for antibiotics that cover sinus bacterial flora, decongestants, as well as careful instructions to follow during the healing period. 5. Nerve injury: This is primarily an issue with extraction of third molars, however, can technically occur with the extraction of any tooth should the nerve be in close proximity to the surgical site. Two nerves are typically of concern, and are found in duplicate (one left and one right side): 1. the inferior alveolar nerve, which enters the mandible at the mandibular foramen and exits the mandible at the sides of the chin from the mental foramen. This nerve supplies sensation to the lower teeth on the right or left half of the dental arch, as well as sense of touch to the right or left half of the chin and lower lip. 2. The lingual nerve (one right and one left side), which branches off the mandibular branches of the trigeminal nerve and courses just inside the jaw bone, entering the tongue and supplying sense of touch and taste to the right and left half of the anterior 2/3 of the tongue as well as the lingual gingiva (i.e. the gums on the inside surface of the dental arch). Such injuries can occur while lifting teeth (typically the inferior alveolar), but are most commonly caused by inadvertent damage with a surgical drill. Such injuries are rare and are usually temporary, but depending on the type of injury (i.e. Seddon classification: neuropraxia, axonotmesis, & neurotmesis), can be prolonged or even permanent. 6. Displacement of tooth or part of tooth into the maxillary sinus (upper teeth only). In such cases, almost always the tooth or tooth fragment must be retrieved. In some cases, the sinus cavity can be irrigated with saline (antral lavage) and the tooth fragment may be brought back to the site of the opening through which it entered the sinus, and may be retrievable. At other times, a window must be made into the sinus in the canine fossa--a procedure referred to as "Caldwell luc". Injuries to the soft tissue of the oral cavity are almost always the result of the surgeon's lack of adequate after tion to the delicate nature of the mucosa and the use of excessive and uncontrolled force. The surgeon must continue to pay careful attention to the soft tissue while working primarily on the bone and tooth structure. 1.Tearing Mucosal Flap. The most common soft tissue injury is the tearing of the mucosal flap during surgical extraction of a tooth. This is usually the result of an inadequately sized envelope flap, which is retracted beyond the tissue's ability to stretch.this results in a tearing, usually at one end of the incision. Prevention of this complication is twofold: (1) create adequately sized flaps to prevent excess tension on the flap, and (2) use small amounts of retraction force on the flap. If a tear does occur in the flap, the flap should be carefully repositioned once the surgery is complete. In most patients, careful suturing of the tear results in adequate but delayed healing. If the tear is especially jagged, the surgeon may consider excising the edges of the torn flap to create a smooth flap margin for closure. This latter step should be performed with caution, because excision of excessive amounts of tissue leads to closure of the wound under tension and probable wound dehiscence.if the area of surgery is near the apex of a tooth, an increased incidence of envelope-flap tearing exists as a result of excessive

6 refractional forces. In this situation a release incision to create a three-cornered flap should be used to gain access to the bone. 2.Puncture Wound of Soft Tissue.The second soft tissue injury that occurs with some frequency is inadvertent puncturing of the soft tissue. Instruments, such as a straight elevator or periosteal elevator, may slip from the surgical field and puncture or tear into adjacent soft tissue. Once again, this injury is the result of using uncontrolled force instead of finesse and is best prevented by the use of controlled force, with special attention given to the supporting fingers or support from the opposite hand in anticipation of slippage. If the instrument slips from the tooth or bone, the fingers thus catch the hand before injury occurs. When a puncture wound does occur, the treatment is aimed primarily at preventing infection and allowing healing to occur, usually by secondary intention. If the wound bleeds excessively, its hould be controlled by direct pressure on the soft tissue. Once hemostasis is achieved, the wound is usually left open and not sutured, so that if a small infection were to occur, there would be an adequate pathway for drainage. 3.Stretch or abrasion injury. Abrasions or burns of the lips and corners of the mouth are usually the result of the rotating shank of the bur rub- bing on the soft tissue. When the surgeon is focused on the cutting end of the bur, the assistant should be aware of the location of the shank of the bur in relation to the cheeks and lips. If such an abrasion does develop, the dentist should advise the patient to keep it covered with Vaseline or an antibiotic ointment. It is important that the patient keeps the ointment only on the abraded area and not spread onto intact skin, because it is quite likely to result in a rash. These abrasions usually take 5 to 10 days to heal. The patient should keep the area moist with the ointment during the entire healing period to prevent eschar formation, scarring, and delayed healing, as well as to keep the area reasonably comfortable. Complications with the tooth being extracted 1. Root Fracture. 2. Root displacement.the tooth root that is most commonly displaced into unfavorable anatomic spaces is the maxillary molar root, which is forced into the maxillary sinus. If a root of a maxillary molar is being removed, with a straight elevator being used with excess apical pressure as a wedge in the periodontal ligament space, the tooth root can be displaced into the maxillary sinus. If this occurs, the surgeon must make several assessments to prescribe the appropriate treatment. First, the surgeon must identify the size of the root lost into the sinus. It may be a root tip of several millimeters, an entire tooth root, or the entire tooth. The sur- geon must next assess if there has been any infection of the tooth or periapical tissues. If the tooth is not infected, management is easier than if the tooth has been acutely infected. Finally, the surgeon must assess the preoperative condition of the maxillary sinus. For the patient who has a healthy maxillary sinus, it is easier to manage a displaced root than if the sinus has been chronically infected. If the displaced tooth fragment is a small (2 or 3 mm) root tip and the tooth and sinus have no preexisting infection, the surgeon should make a minimal attempt at removing the root. First, a radiograph of the fractured tooth root should be taken to document its position and size. Once that has been accomplished, the surgeon should irrigate through the small opening in the socket apex and then suction the irrigating solution from the sinus via the socket. This occasionally flushes the root apex from the sinus through the socket. The surgeon should check the suction solution and confirm radiographically that the root has been removed. If this technique is not successful, no additional surgical procedure should be performed through the socket,

7 and the root tip should be left in the sinus. The small, noninfected root tip can be left in place, because it is quite unlikely that it will cause any troublesome sequelae. Additional surgery in this situation will cause more patient morbidity than leaving the root tip in situ. If the root tip is left in the sinus, measures should be taken similar to those taken when leaving any root tip in place. The patient must be informed of the decision and given proper follow-up instructions. The oroantral communication should be managed as discussed later, with a figure-ofeight suture over the socket, sinus precautions, antibiotics, and a nasal spray to pre vent infection and keep the ostium open. The most likely occurrence is that the root apex will fibrose onto the sinus membrane with no subsequent problems. If tooth root is infected or the patient has chronic sinusitis, the patient should be referred to an oral and maxillofacial surgeon for removal of the root tip. If a large root fragment or the entire tooth is displaced into the maxillary sinus, it should be removed. The usual method is a Caldwell-Luc approach into the maxillary sinus in the canine fossa region and then removal of the tooth. The oral and maxillofacial surgeon (to whom the patient should be referred) performs this procedure. 3.Tooth Lost into Oropharynx. Injuries of adjacent tooth 1.Fracture of Adjacent Restoration. 2.Luxation of Adjacent Teeth. Injuries of osseous structure 1.Fracture of alveolar processes. 2.Fracture of Maxillary Tuberosity. Postoperative bleeding Extraction of teeth is a surgical procedure that presents a severe challenge to the body's hemostatic mechanism. Several reasons exist for this challenge: First, the tissues of the mouth and jaws are highly vascular. Second, the extraction of a tooth leaves an open wound, with both soft tissue and bone open, which allows additional oozing and bleeding. Third, it is almost impossible to apply dressing material with enough pressure and sealing to prevent additional bleeding during surgery. Fourth, patients tend to play with the area of surgery with their tongues and occasionally dislodge blood clots, which initiates secondary bleeding. The tongue may also cause secondary bleeding by creating small negative pressures that suction the blood clot from the socket. Finally, salivary enzymes may lyse the blood clot before it has organized and before the ingrowth of granulation tissue.as with all complications, prevention of bleeding is the best way to manage this problem.one of the prime factors in preventing bleeding is the taking of a thorough history from the patient regarding this specific potential problem. Several questions should be asked of the patient concerning any history of bleeding. If affirmative answers to any of these questions are given, the surgeon should take special efforts to control bleeding. The first question that patients should be asked is if they have ever had a problem with bleeding in the past. The surgeon should inquire about bleeding after previous tooth extractions or previous surgery (such as a tonsillectomy) and persistent bleeding after accidental lacerations. The surgeon must listen carefully to the patient's answers to these questions, because the patient's idea of "persistent" may actually be normal. For example, it is quite normal for a socket to ooze small amounts of blood for the first 12 to 24 hours after extraction. However, if a patient relates a history of bleeding that persisted for more than 1 day or that required special attention from the dentist, then the

8 surgeon's degree of suspicion should be substantially elevated. The surgeon should inquire about any family history of bleeding. If anyone in the patient's family has or had a history of prolonged bleeding, further inquiry about its cause should be pursued. Most congenital bleeding disorders are familial, inherited characteristics. These congenital disorders vary from very mild to very profound, the latter requiring substantial efforts to control. The patient should next be asked about any medications currently being taken that might interfere with coagulation. Drugs such as anticoagulants may cause prolonged bleeding after extraction. Patients receiving anticancer chemotherapy or who are alcoholics may also tend to bleed. The patient who has a known or suspected coagulopathy should be evaluated by laboratory testing before surgery is performed to determine the severity of the disorder. It is usually advisable to enlist the aid of a hematologist if the patient has a familial coagulation disorder. The means to measure the status of intentional anticoagulation is to use the International Normalized Ratio (INK). This value takes into account both the patient's prothrombin time (PT) and the control. Normal anticoagulated status for most medical indications will have an INR of 2.0 to 3.0. It is reasonable to perform extractions on patients who have an INR of 2.5 or less without reducing the anticoagulant dose. With special precautions, it is reasonably safe to do minor amounts of surgery in patients with an INR of up to 3.0, if special local hemostatic measures are taken. 5. Self-control materials. А. Questions to be answered: 1. To define the terms of resorption of tooth root. 2. Types of resorption of tooth root. 3. Anatomic features of the deciduous teeth. 4. The structure and setting of forceps. 5. Using of dental elevators. 6. Indications and contra-indications for extraction of deciduous teeth. 7. Indications and contra-indications for extraction of permanent teeth. 8. Common complications of exodontia in children. 9. Local complications of exodontia in children. 10. Prophylaxis of complications and their treatment. 11. Features of exodontia in children with associated diseases. 12. Extraction of impacted teeth. B. Self-control tests: 1. How called the forceps, which the axis of cheeks and handles are congruent? : а) S-similar; b) straight; c) bayonet-shaped; d) beak-shaped. 2. What forceps have the sign of teeth side? : а) straight; b) S-similar without a pin; c) S-similar for extraction molars; d) beak-shaped. 3. What type of resorption of roots of temporal teeth is physiological? а) I - equal resorption of all roots; b) II - resorption with predominance of process in region of one root;

9 c) III - resorption with predominance of process in region of root furcation; d) resorption of roots as a result of chronic inflammation in periodontum; e) I, II, III types of resorption of tooth roots. 4. Define the terms of rudiment of follicles of the permanent teeth: а) 1st month of fetal life; b) 5-6 month of fetal life; c) 5-6 month of postnatal development; d) 2nd year of postnatal development; e) 4-5 year of postnatal development. 6. The cause of syncope in patient is: а) Hungry patient; b) Long expectation in turn; c) Restless conduct of other patients; d) Harshness of doctor; e) angiospasm of cerebrum. 7. Main procedure of critical care by syncope is: а) introduction of Suprastinum *; b) introduction of cardioactive drug ; c) horizontal position of patient; d) horizontal position of patient and reflex stimulation of respiration and circulation of blood. 8. Which step of exodontia can t be performed during removal of deciduous tooth? a) Loss of soft tissue; b) Application of beaks; c) Motion beaks to neck of tooth; d) Luxation of tooth; e) Traction of tooth. 9. Contra-indication for removal of deciduous tooth is: a) Absence of root resorption; b) Primary adentia of successor permanent tooth; c) Dystopia of successor permanent tooth; d) Abnormality of tooth structure. 10. C. Situation tasks for self-control: 1. Patient (7 years old) has complaints: toothache during mastication of hard food. Clinical findings: 55 tooth discolor crown, defect of filling, painfull percussing of tooth, hyperemic mucous membrane, painfull palpation, mobile tooth. Tooth was treated some times. To make diagnosis. To define treatment. 2. The patient has: chronic granulating periodontitis of 54 tooth. The pale face, clammy sweat, giddiness, blackout, nausea and short-term loss of consciousness are appeared during exodontia. Clinical findings: dilatation of pupils, tachycardia, deficient pulse. The loss of consciousness was lasted 1 minute. To make diagnosis. To define critical care. Literature recommended: а) main sources: 1. Atlas of Minor Oral Surgery (2nd Edition) by D McGowan ISBN Publisher: Thieme Medical Publishers, May pages Hardcover

10 2. Tooth Extraction by P Robinson ISBN Publisher: Butterworth-Heinemann Medical, June pages Paperback b) additional sources: 3. Pediatric Oral and Maxillofacial Surgery by Leonard Kaban and Maria Troulis ISBN: Publisher: W. B. Saunders, Mar pages 850 illustrations, Hardcover Methodical Instruction is composed by as.gogol A.M.