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OS and Pain Management 2 > Principles of uncomplicated exodontia > Flashcards

Principles of uncomplicated exodontia Flashcards

1
Q

ESSENTIALS OF EXODONTIA
(5)

A
  • Finesse
  • Dexterity and Skill
  • Controlled force
  • Firm steady pressure
  • Knowledge of what to treat and what to refer out
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2
Q

PRE-EXTRACTION PREP

A
  • Medical history
  • Physical examination
  • Radiologic evaluation
  • Informed consent
  • Surgical plan
  • Pain, anxiety control
  • Patient and surgeon preparation
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3
Q

SURGEON & PATIENT PREP
* UNIVERSAL PRECAUTIONS
(6)

A
  • Over coat/garment
  • Mask
  • Surgical gloves
  • Hair out of surgical field (cap or hair tie)
  • Eye protection
  • Patient drape
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4
Q

BASIC PREPARATION
(4)

A
  • PROFOUND anesthesia is required
  • Check for signs and symptoms
  • If patient says they are not numb…BELIEVE THEM
  • Extractions should be painless and relatively quick
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5
Q
  • If patient says they are not numb…BELIEVE THEM
    (2)
A
  • May have to distinguish pain with pressure which often is difficult for patients
  • LA results in loss of pain, temperature, and touch. But DOES NOT anesthetize
    proprioceptive fibers, thus potentially can feel intense pressure
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6
Q

COMMON INJECTIONS
MANDIBLE

A
  • Inferior alveolar nerve block
  • Gow-Gates block
  • Akinosi block (closed mouth)
  • Long buccal block
  • Mental nerve block
  • PDL injection
  • Intrapulpal injection
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7
Q

COMMON INJECTIONS
MAXILLA

A
  • Posterior superior alveolar block
  • Middle superior alveolar block
  • Anterior Superior alveolar block
  • Infraorbital Nerve block
  • intraoral and extraoral approaches
  • Greater palatine
  • Nasopalatine nerve block
  • V2 block*
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8
Q

LOCAL ANESTHESIA
* 2% Lidocaine w/ 1:100k epi →
* 3% Mepivacaine plain →

A

7 mg/kg or 3.2 mg/lb
6.6 mg/kg or 3.0 mg/lb

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9
Q
  • Epi limit for healthy adult →
  • Epi limit for cardiac patients →
A

0.2 mg (works out to 11.76 cartridges of 1:100k epi)
0.04 mg (works out to 2 cartridges of 1:100k epi)

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10
Q

OPTIONS FOR THE ANXIOUS PATIENT
* TLC most important concept
(2)

A
  • Proper explanation of procedure
  • Assurance that sharp pain will not be felt, but significant pressure will still be present
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11
Q

Basic pharmacologic option available
(3)

A
  • Pre-operative oral sedation (valium)
  • Nitrous oxide analgesia
  • Intravenous Sedation
  • Fentanyl, versed, propofol, ketamine
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12
Q

INDICATIONS FOR TOOTH REMOVAL
* SHOULD BE COMPLETED BY GENERAL DENTIST PRIOR TO ORAL
SURGERY CONSULTAITON
* OMS is a CONSULTING service
(3)

A
  • We do not determine restorability of teeth
  • All options for treatment should be discussed prior to OMS consultation
  • If patient asks what could be done other than extraction, the patient should be sent back to general
    dentist for treatment discussion
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13
Q

Extractions are non-reversible, and if there is a questions about the procedure, the patient is

A

not fully informed

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14
Q

INDICATIONS FOR TOOTH REMOVAL

A
  • Caries
  • Pulpal necrosis
  • Periodontal disease
  • Orthodontic reasons
  • Malpositioned teeth
  • Fractured teeth
  • Impacted teeth
  • Supernumerary teeth
  • Teeth associated with pathology
  • Radiation therapy
  • Teeth involved with jaw fractures
  • Financial issues
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15
Q

CONTRAINDICATIONS FOR TOOTH REMOVAL
(5)

A
  • Severe uncontrolled metabolic issues
  • Uncontrolled lymphoma/leukemia
  • Pregnancy in 1st and 3rd trimester
  • Uncontrolled Blood/Bleeding disorders
  • Uncontrolled cardiac issues
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16
Q
  • Uncontrolled lymphoma/leukemia
    (2)
A
  • Concern for infection due to
    nonfunctioning white cells
  • Bleeding concern due to nonfunctioning
    platelets
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17
Q

Uncontrolled cardiac issues
(4)

A
  • Unstable angina
  • Recent MI
  • Malignant hypertension
  • Uncontrolled dysrhythmias
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18
Q

CLINICAL EVALUATION OF TEETH FOR REMOVAL
* Access to tooth
(3)

A
  • Small mouth, limited opening
  • Posterior more difficult to visualize
  • Severe crowding
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19
Q

CLINICAL EVALUATION OF TEETH FOR REMOVAL
* Mobility of tooth
* Periodontally involved teeth –

A

greater than normal mobility
* Increased amount of bleeding due to overgrowth of granulation
tissue
* Soft tissue management is more problematic
* Root fractures unpredictable

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20
Q

Less than normal mobility
(2)

A
  • Hypercementosis at root
  • Ankylosis
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21
Q

CLINICAL EVALUATION OF TEETH FOR REMOVAL
* Condition of crown
(2)

A
  • Extensive carious lesions causing destruction
    of crown during delivery with forceps
  • Similar with excessively large restorations
  • Endodontically treated roots over time cause
    brittle root structure prone to root fracture
    during extraction attempt
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22
Q

Check condition of adjacent teeth crowns

A
  • Large restorations or crowns could be
    damaged with improper luxation or forceps
    use
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23
Q

RADIOGRAPHIC EXAMINATION OF TEETH
* Need a periapical radiograph that is properly:
(3)

A
  • EXPOSED – proper contrast
  • POSITIONED – entire tooth structure visualized
  • PROCESSED – developed and fixated
  • Less of a concern with advent of electronic radiographs
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24
Q

Department policy for impacted third molar
evaluation is an —
radiograph of good diagnostic quality

A

ORTHOPANTOMOGRAM (PANO)

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25
Q

Relationship of associated vital structures
* Maxillary molars –
* Mandibular molars –
* Mandibular premolars –
(2)

A

sinus position
Inferior alveolar canal position
mental foramen position

  • Can easily be confused with a periapical abscess
  • Careful when creating and reflecting FTMP flap
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26
Q

Configuration of Roots
(6)

A
  • Number of roots and length
  • Curvature
  • Divergence
  • Shape
  • Associated pathology: Abscess, hypercementosis, external and internal
    root resorption
  • PDL space
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27
Q

RADIOGRAPHIC EXAMINATION OF TEETH
* Condition of surrounding bone
(2)

A
  • Increased bone density vs decreased bone density
  • As patient’s age, bone becomes less medullary →more cortical, thus more dense
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28
Q

SURGEON & PATIENT PREP
* UNIVERSAL PRECAUTIONS

A
  • Over coat/garment
  • Mask
  • Surgical gloves
  • Hair out of surgical field
  • Cap or Hair tie
  • Eye protection
  • Patient drape
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29
Q

SURGEON & PATIENT PREP

A
  • Sterile drape over patient
  • Antiseptic mouth rinses
  • Oral pharyngeal partition!!
  • No throat pack →immediate failure during comp exams
  • Sterilized instruments and equipment
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30
Q

CHAIR POSITION
* Standing vs sitting
* Choose the position that allows you:

A
  • To feel comfortable
  • The maximum amount of control over the forces being sued
  • Good visualization and access
  • Free hand for ancillary tasks
  • Does not block the light source
31
Q

SURGEON POSITION

A
  • Keep feet firmly planted on the floor
  • Keep elbows in close to body
  • Keep forceps, hands, wrist, and lower arm in a straight line
  • Transmit the force with the more stable and powerful upper arm and shoulder and not
    the wrist or hands
32
Q

FORCEPS EXTRACTION
* Frequent errors:
(4)

A
  • Chair is too high
  • Operator blocks out light
  • Elbows flailing
  • Bending over or craning neck
33
Q

Elbows flailing

A
  • Increased stress on deltoids and trapezius muscles
  • Causes fatigue which could potentiate mistakes at the end of the workday
34
Q

Bending over or craning neck

A
  • Causing potential career ending neck and back problems
35
Q

MAXILLARY EXTRACTIONS
(4)

A
  • Operator in front position
  • Chair recline so maxillary occlusal plane is 60º to 90º to the
    floor
  • Mouth at level of elbow
  • Patient’s head turned towards or away operator to degree
    necessary for appropriate visualization
36
Q

MANDIBULAR EXTRACTIONS
(5)

A
  • Patient in more upright position
  • Mandibular occlusal plane parallel to floor
  • Chair will be lower than for maxillary extractions
  • Mouth at level of elbow
  • Patient’s head turned towards or away operator to degree
    necessary for appropriate visualization
37
Q

REAR EXTRACTION POSITION
ADVANTAGES
(5)

A
  • Underhand grip allowing operator to use
    more powerful biceps instead of weaker
    forearm
  • Keeps elbows tight to body
  • Less light obstruction
  • More effective support of mandible for
    free hand
  • Easier for assistant to see
38
Q

REAR EXTRACTION POSITION
DISADVANTAGES
(3)

A
  • Acceptable technique for mandible,
    MORE DIFFICULT for maxilla
  • View of field is upside down
  • Causes operator to rely more on “feel”
    than direct vision
  • Especially with maxilla
39
Q

PRINCIPLES
(3)

A
  • The LEVER
  • The WEDGE
  • The WHEEL AND AXLE
40
Q

THE LEVER
* — are used primarily as levers
* —CLASS lever system

A

Elevators
FIRST

41
Q

THE LEVER
Mechanical advantage:
(2)

A
  • Long lever arm with short effector arm
  • Transforms small force and large movement to small movement and large force
42
Q

THE WEDGE
(3)

A
  • Wedge can be used to expand, split, and displace portions of
    the substance that receives it
  • Elevators wedged into PDL space expanding bony socket as
    well as displacement of root toward occlusal surface
  • Forceps seated below crestal bone to aid in crestal bony
    expansion
43
Q

THE WHEEL AND AXEL
(3)

A
  • More closely identified with use of Cryer elevators
    (flag elevator)
  • Handle serves as the axel
  • Tip of elevator serve as the wheel and engages and
    elevates the root from socket
44
Q

DENTAL ELEVATORS
(3)

A
  • Used to LUXATE teeth, not to remove them
  • Minimizes root fracture
  • Requires fulcrum point
45
Q

RULES FOR LUXATION
(5)

A
  • Never use adjacent tooth as fulcrum, UNLESS the tooth is also
    to be extracted
  • Never used the buccal/lingual plates at the gingival line as
    fulcrum
  • Always use finger guards to protect the patient in case elevator
    slips
  • Be certain that the forces applied by the elevator are under
    control
  • Elevator tip should exert pressure in the right direction
46
Q

STRAIGHT GOUGE ELEVATORS
* The ONLY elevators that use all 3 principles
(3)

A
  • Lever
  • Wedge
  • Wheel and Axel
47
Q

FORCEPS
* The PRIMARY instrument for

A

removal of teeth

48
Q

FORCEPS’
Goals:
(3)

A
  • Expansion of bony socket by movement of the tooth against alveolar socket
  • Separation of the PDL attachment
  • Removal of tooth from socket
49
Q

FORCEPS FORCES
(5)

A
  • Apical
  • Buccal
  • Lingual
  • Rotational
  • Traction
50
Q

FORCEPS FORCE
(4)

A
  • Apical force
  • The first force applied
  • Used on all teeth
  • Seat forceps beak on firm root structure
51
Q
  • Seat forceps beak on firm root structure
    (2)
A
  • Expands crestal bony cortex
  • Displace center of rotation as apically as possible
52
Q

Seat forceps beak on firm root structure
* Expands crestal bony cortex
* Displace center of rotation as apically as possible
(2)

A
  • Reduces apical root fracture
  • If fulcrum is too high, there is increased force placed on
    apical region of root →root fracture
53
Q

FORCEPS FORCE
* Buccal force

A
  • After apical force applied
  • Most frequently used to expand socket
  • Buccal plate usually thinner than palatal or lingual plate
  • Possible to fracture buccal plate without expansion of socket if
    large buccal force and thin alveolus present
54
Q

FORCEPS FORCE
* Lingual force
(2)

A
  • Similar to buccal force, but with lingual/palatal bony expansion
  • Rare to get lingual plate or palatal plate fracture with this force
55
Q

FORCEPS FORCE
* Rotational force
(3)

A
  • Create internal expansion of socket
  • Best application is teeth with single conical roots
  • Least chance to fracture bony plates, roots, or tooth
56
Q

FORCEPS FORCE
* Traction force

A
  • Limited to the final phase of the extraction process
  • To deliver the tooth
  • Should be very minimal force
  • If proper bony expansion and PDL disjunction achieved with
    previous applied force
57
Q

PRE-EXTRACTION PREP

A
  • Medical history
  • Physical examination
  • Radiologic evaluation
  • Informed consent
  • Surgical plan
  • Pain, anxiety control
  • Patient and surgeon preparation
58
Q

PRE-PROCEDURE PREP

A
  • Proper chair position
  • Mandibular occlusal plane parallel to floor
  • Maxillary occlusal plane 60º to 90º
  • Universal precautions
  • Instrument selection
  • Discussion with faculty
59
Q

Closed extraction technique

A
  • Simple extraction →elevators and forceps
  • Most frequently used technique for extraction
  • Always attempted first
60
Q

Fundamentals for a proper extraction
(3)

A
  • Adequate visualization and access
  • You can’t complete what you can’t see
  • Unimpeded path for removal
  • Controlled force to luxate and remove tooth
61
Q

PROCEDURE FOR CLOSED EXTRACTION
* Steps for closed extraction

A
  • Loosening gingival attachment
  • Luxation with elevator
  • Proper adaptation of forceps
  • Luxation of tooth with forceps
  • Removal of tooth from socket
62
Q

ROLE OF OPPOSITE HAND

A
  • Reflect cheek, lips, possibly tongue
  • Stabilize patient head
  • Support lower jaw
  • Prevent damage to TMJ
  • Support alveolar process
  • Feel cortex expanding
  • Stabilize neighboring dentition
63
Q

Maxillary incisors
(2)

A
  • Primarily rotational
  • # 13 forceps
64
Q
  • Maxillary canine
    (4)
A
  • Longest tooth
  • Combination of all 5 forces (mild rotational)
  • Fracture buccal plate very common
  • Upper Universal #150 forceps
65
Q

Maxillary 1st premolar

A
  • Highest chance of all premolars to have multiple
    roots
  • Buccal force > palatal force
  • Want to break buccal root instead of palatal
    root
  • Avoid rotational force
  • # 150 forceps
66
Q

Maxillary 2nd premolar

A
  • Thick, blunt root
  • Usually relatively simple extraction
  • # 150 forceps
67
Q

Maxillary Molars

A
  • Can be difficult due to large divergent roots and
    proximity of sinus
  • Apical force, with slow steady buccal force with
    less palatal force (buccal plate thinner)
  • # 150 vs #88 R/L vs #53 R/L
68
Q

Maxillary 3rd molar

A
  • One tooth that can be frequently removed with
    elevators only
69
Q

Mandibular anterior teeth

A
  • Apical →buccal & lingual (equal pressure) →
    rotational →labial traction
  • Roots and buccal bone fracture very easily
  • Be sure the smooth sharp areas of bone
  • Lower universal #151 vs #13 Ash forceps
70
Q

Mandibular premolars

A
  • Next to max central incisors & max 2nd premolars,
    lower premolars are among the easier to extract
  • # 151 vs #13
  • Apical →buccal & lingual (equal force) →
    rotational (short and conical roots) →buccal
    traction
71
Q

Mandibular molars

A
  • Like max first molar, can be the most difficult of all teeth
    to deliver
  • Long, strong, divergent roots
  • Buccal and lingual bone more dense
  • Roots may converge at apex (“locking” tooth into place)
  • # 23 Cowhorn forceps vs #17
72
Q

COWHORN FORCEPS USE

A
  • Seat lingual beak first, then buccal beak
  • Can easily crush crestal lingual cortex and inadvertently severe lingual nerve
  • Lingual nerve is on average ~ 2.5 mm medial and inferior to lingual cortex crest
  • ~15% lingual nerve is oriented superior to lingual cortex crest
  • Push beaks apically
  • Pumping motion vs Rocking motions vs gentle rotational movements
  • Squeeze handles together as beaks come together in the bifurcation
  • Figure of 8 motion
  • Occlusal plane of tooth will elevate above remaining mandibular occlusal plane
  • Gradual traction to deliver
73
Q

DECIDUOUS TEETH

A
  • Roots are long and thin
  • Easy to fracture
  • If unable to retrieve small root segment, leave
    it in place and advise the parent
  • If deciduous molar roots grasp around
    permanent crown, tooth should be surgically
    sectioned
  • DO NOT CURETTE SOCKET
  • Do not want to damage permanent bud
    underneath
74
Q

POST EXTRACTION CARE FOR SOCKET

A
  • If periapical pathology is present, curettage is indicated
  • If no pathology, no need for forceful curettage
  • Smooth any sharp areas of bone around alveolar socket
  • Irrigate socket, usually with normal saline
  • Suture if indicated (if mucosa does not lay passively to
    alveolus)
  • Place 4x4 gauze over socket
  • Instruct patient to bite for 1 hour, FIRMLY
  • Most common cause of post-operative bleeding from not
    putting enough pressure over socket

OS and Pain Management 2 (10 decks)

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