外科牙齿拔除术

ExtractionofTeethShiZongdao(shizd0664@163.com)外科牙齿拔除术1/48Extractionisasurgery

Theextractionofteeth,howeveraccomplished,isasurgicaloperationinvolvingbonyandsofttissuesoftheoralcavity,accesstowhichisrestrictedbythelipsandcheeks,andfurthercomplicatedbythemovementofthetongueandmandible.外科牙齿拔除术2/48外科牙齿拔除术3/48

Itisessentialthatthisphaseoforalsurgerybegiventhesamecarefulstudyandapplicationofsoundsurgicalprinciplesasisgiventosurgeryinanyotherpartofthehumanbody.外科牙齿拔除术4/48IndicationsfortheextractionofteethThefollowingareindicationsfortheextractionofteeth.(a)teeththatarefociofinfections;(b)teethwithnonvitalpulps,oracuteorchronicpulpitiswhenrootcanaltherapyisnotindicated;外科牙齿拔除术5/48

外科牙齿拔除术6/48

(c)incasesofsevereperiodontoclasiainwhichexcessivebonysupportoftheteethisdestroyed;外科牙齿拔除术7/48Indicationsfortheextractionofteeth(d)teethnottreatablebyapicoectomy;(e)teethmechanicallyinterferingwiththeplacementofrestorativeappliances;(f)teethnotrestorablebyoperativedentistry;外科牙齿拔除术8/48

(g)impactedteeth;(h)supernumeraryteeth;(i)retaineddeciduousteethwhenasuccedaneoustoothispresent,andinnormalpositiontoerupt;外科牙齿拔除术9/48Indicationsfortheextractionofteeth(j)teethwithfracturedcrown;(k)malposedteethnotamenabletoorthodontictreatment;(l)roots;(m)teeththataretraumatizingsofttissues,ifothertreatmentwillnotpreventthistrauma.外科牙齿拔除术10/48Contraindications:systemicdiseases11.Uncontrolleddiabetesmellitus2.Cardiacdisease,suchascoronaryarterydisease.hypertension,andcardiacdecompensation,e.g.postinfarctionwithin6months3.Blooddyscrasiassuchasanemias,hemorrhagicdiseasese.g.hemophilia,andtheleukemias.4.Debilitatingdiseasesofanykindmakingpatientspoorrisksforfurthertraumaticinsults.5.Addison'sdiseaseoranysteroiddeficiency,suchasthepatientwhohasbeentreatedforanydiseasewithsteroidtherapymaynothavesufficientadrenalcortexsecretiontowithstandthestressofanextractionwithouttakingadditionalsteroids.

外科牙齿拔除术11/48Contraindications:systemicdiseases26.Feverofunexplainedoriginisrarelycuredandoftenisworsenedbyextraction,e.g.subacutebacterialendocarditiswouldbecomplicatedconsiderablybyanextraction.7.Nephritis8.Pregnancy:extractionisbettertobedoneinthesecondtrimester.Menstruation:electiveexodontiaisnotdoneduringtheperiodbecauseoflessnervousstabilityandgreatertendencytowardhemorrhageofalltissues.9.Senility:greatercareinovercomingapoorphysiologicresponsetosurgeryandaprolongednegativenitrogenbalance.10.Psychosesandneuroses外科牙齿拔除术12/48Localcontraindications1.Acuteinfectionwithanuncontrolledcellulitis,toxemiauntiladequatebloodlevelofaspecificantibiotichadbroughtsystemicfactorsundercontrolandtheinfectionhadbecomelocalized,thepuswasdrained,andtheinfectionhadsubsidedtoachronicstate.2.Acutepericoronitis3.Acuteinfectiousstomatitis4.Malignantdisease5.Irradiatedjawsmaydevelopanacuteradio-osteomyelitisafterextraction外科牙齿拔除术13/48specialinstrumentsfortheextractionThespecialinstrumentsfortheextractionofteethandrootsareforceps,elevators.Inspecialcases,wherebonehastoberemoved,otherinstrumentsrequiredsuchaschiselsandmallet,burs,etc..外科牙齿拔除术14/48

Averylargevarietyofforcepsandelevatorshavebeendevised.Afewwell-selectedinstrumentswillsufficeallhutveryextraordinarycases.外科牙齿拔除术15/48StraightelevatorPhysicalcharacteristics1.Large,bulboushandle.2.Workingendresemblesasharp,narrow,elongatedspoon.3.Straightshank,paralleltotheworkingend.Use1.Toseparateandloosenthetoothinitsalveolus.2.Toremovelargetoothfragments.ApplicationPositionedbetweenthetoothanditsalveolus.外科牙齿拔除术16/48Maxillaryposteriorforceps

UniversalmaxillaryforcepsPhysicalcharacteristics1.Plierslikeappearance.Beakshavesmoothedgesthatallowthemtofitaroundthebifurcatedareasofallmaxillarymolarteeth.apointonthebuccalbeakthatallowsthemtofitintothebuccalbifurcationarea.UseToextractmaxillaryposteriorteethfromtheiralveoli.外科牙齿拔除术17/48Maxillarypremolarforceps/universalforcepsPhysicalcharacteristics1.Plierslikeappearance.2.Instrumentswithbayonet-shapedbeaksareUniversal.UseToremovepremolarteethfromtheiralveoliinthemaxillaryarch.外科牙齿拔除术18/48MandibularposteriorforcepsPhysicalcharacteristics1.Plierslikeappearance.2.Universaldesignandthereforefunctionalineitherquadrantofthearch.3.Oftenreferredtoasacowhornforceps.UseToremovemandibularposteriorteethfromtheiralveolisockets.外科牙齿拔除术19/48MandibularincisorandpremolarextractionforcepsPhysicalcharacteristicsl.Plierslikeappearance.2.Beaksdesignedtoremoveallmandibularteeth,butmostoftenusedonincisorsandpremolars.UseToextractmandibularincisorandpremolarteeth.PedodonticextractionforcepsPhysicalcharacteristics1.Designidenticaltoforcepsmanufacturedforuseonpermanentteeth.2.Smallerinsizethanstandardforceps.UseToremoveprimaryteethfromtheoralcavity.外科牙齿拔除术20/48Bonechisel/surgicalMalletPhysicalcharacteristics

Chisel1.Lengthandwidthoftheshaftvary.2.Cuttingendavailableinsingle-bevelanddouble-beveldesigns.

Mallet1.Hammershaped.2.Headavailableinleadornylon.UseTotrimorreshapebonetosectionteeth.外科牙齿拔除术21/48INSTRUMENTSTERILIZATION

Aprofessionengagedindeliveringhealthcaremustbeconcernedwithinfection.Itisimperativethatsterilizationofdentalinstrumentsbearoutineprocedureineverydentaloffice.Variousmethodsofdisinfectionandsterilizationcanbeemployedtoreducetheprobabilityofinfectionandcrosscontamination.Itismandatorythatthedentalteamunderstandandproperlyusethesemethods.外科牙齿拔除术22/48SterilizationSterilizationistheactofdestroyingallformsoflife.Themostacceptedmethodsindentistryandmedicineforachievingtruesterilizationareextendedperiodsofhighheatandsteamheat.外科牙齿拔除术23/48Disinfection

Disinfectiononlyinhibitsthegrowthofdisease-causingmicroorganismsandisnotnearlyaseffectiveassterilization.Onlydentalinstrumentsthatcannotwithstandthehightemperatureofheatsterilizationshouldbeplacedinadisinfectantsolution.Someofthechemicalsavailableforuseasdisinfectantsarebenzalkoniumchloride,hexachlorophene,andrubbingalcohol.Amorepopulartermforchemicaldisinfectionis"coldsterilization.”Theinstrumentsareplacedinanopendisinfectantbathfortherequiredlengthoftime.外科牙齿拔除术24/48IMPACTEDTEETHAtoothisspokenofasbeingimpactedwhenitseruptionispartiallyorwhollyobstructedbyboneorsomeotherteeth.外科牙齿拔除术25/48ImpactedTeeth

ClassificationofMandibularImpactedTeeth

Theclassificationofmandibularimpactedteethmaybestatedsimplyas(l)mesioangular,(2)horizontal,(3)vertical,and(4)distoangular.Inaddition,thetoothmaybedisplacedtothebuccalortothelingual.Furthermoreitmaybelocatedatahighocclusallevel(neartheridgesurface)oralowocclusallevel.外科牙齿拔除术26/48外科牙齿拔除术27/48EtiologyManypathologicconditionsbringaboutretardederuption,displacementandimpactionofteeth.Thegrowthofthejawsandthemovementoftheteethareinaforwarddirection;consequently,anythingwhichinterfereswiththisforwardmovementorgrowthwillcauseimpactionoftheteeth.Acuteinfectiousfeversofchildhood,suchasscarletfeverandmeasles,mayinterferewiththeforwardmovementbyproducingadepositofdensebone.外科牙齿拔除术28/48EtiologyLocalincreaseinthedensityofthebonemayalsobebroughtaboutbyinflammationoftheperidentalmembrane,extendingintothealveolarprocess.Severetraumatismtothejawsmaycauseadepositoflimesaltsinthecancellatedbonetissueandthusbringaboutimpaction.Ankylosisofthemandibularjointinchildhood,resultinginarrestofgrowthofthejaws,mayleaveinsufficientspacefortheeruptionofallteeth.Tooearlyextractionofdeciduousteethmaycausearresteddevelopmentofthejawsandmalpositionsofthepermanentteeth,thisleadinginturntoimpactionofuneruptedteeth.外科牙齿拔除术29/48DisturbancescausedbyimpactedteethImpactedteethmaybepresentwithoutgivingrisetoanysymptomswhatever.Otherscausemanycomplicationssuchassomeoflocalandgeneraleffects.外科牙齿拔除术30/48(I)LocaleffectsAnimpactedthirdmolarmaypressagainstthecrownofthesecondmolarandcausedecayofthetooth,oritselfbecomestheseatofcariesaroundthepointofcontact.Itmayalsocausepressureabsorptionoftherootofthesecondmolar.Exposureanddevitalizationofthepulpfromthesecausesmaygiverisetoneuralgia.Neuralgiamaybecausedinanotherwaybypressureoftheimpactedtoothontheinferiordentalnerveoritsbranches.外科牙齿拔除术31/48(I)Localeffects-cont.Sometimes,especiallyinthecaseofthelowerthirdmolar,pericoronalinfection,pericoronalabscess,cellulitisandosteomyelitisaresetup,oftenaccompaniedbytrismus.Inanypatientsufferingfromacutecellulitisinthebackpartofthemouthandinabilitytoopenthemouth,animpactedlowerthirdmolarshouldbesuspected.外科牙齿拔除术32/48(Il)GeneraleffectsImpactedteethmaybethecauseofobscureheadaches.Casesofmoreseriousnervousorevenmentaldisturbancehavebeenattimestracedtothiscause.Insuchconditionsasepilepsy,choreaanddementiaprecox,impactedteethmayatleastbeacontributingfactor.Inthesecasestheremaybenolocalsignsoftrouble.外科牙齿拔除术33/48DiagnosisIfthetoothispartiallyerupted,thediagnosisisatonceapparentoninspection,butinothercasesthediagnosisdependsonabsenceofthetoothfromthedentureandtheX-rayfindings.TheX-rayismostvaluablenotonlyindetectingthepresenceofimpactedanduneruptedteeth,butalsoinaccuratelylocalizingthemanddeterminingtheshapeandpositionofthecrownandroots,andrelationtoadjoiningteeth.外科牙齿拔除术34/48TreatmentIftreatmentisindicated,itconsistsasageneralruleinremovalbyoperationoftheimpactedtooth外科牙齿拔除术35/48PrincipleofRemovalofMandibularImpactedTeethTheunderlyingprincipleintheremovalofmandibularimpactedteethisasectioningtechnique.Boneisremovedtoexposethecrown.Thetoothissplitwithafreshsharpchiselsothatagoodportionofthecrownisseparatedfromthetooth.Whenthisportionisremoved,spaceisobtainedsothattheremainderofthetoothcanbeelevatedintothedefect.Beforethistechniquewasdeveloped,spaceforelevationwasobtainedbymoreextensiveboneremovalandconsequentlymoretrauma.外科牙齿拔除术36/48外科牙齿拔除术37/48Complicationsofextractionofteeth(1)Looseningofadjacentteethiscausedbyinappropriateuseofforcepsandelevators.(2)Fractureofadjacentteethandrestorationsoccasionallyoccursduringaroutineextractionprocedure.Thismostcommonlyoccurswiththeinappropriateuseofelevators.Teethcanbefracturedifthetoothbeingextractedsuddenlyyieldstouncontrolledforceandtheforcepsstriketheopposingteeth.外科牙齿拔除术38/48Complications(3)Fractureofthebuccalorlabialplatemayoccur.Thesurgeonwhofrequentlyfracturesthebuccalorlabialplatemustanalysehistechniques,sincethisisconsidered"heavyhanded"surgeryinthelightofmoreappropriaterefinedtechniques.(4)Teethorrootsintothemaxillarysinusispossibleeitherduringforcepsextractionorrootretrieval.Itisquiteeasytodisplacerootsofuppermolarteethintothemaxillarysinus.外科牙齿拔除术39/48Injurytotheinferioralveolarnerve(5)Injurytotheinferioralveolarnervemayoccurwhentheinferioralveolarnerveiscloselyassociatedwithrootsandsometimeswiththecrownofthemandibularthirdmolar.Operationsinthisregioncaneasilydamagethenerve.Perhapstheeasiestwayofdamagingthenerveisduringsectioningofahorizontallyimpactedthirdmolarlyingdirectlyabovethemandibularcanal.Thiscomplicationcanbepreventedbysurgeon'sprecautionandrefinedtechniques.外科牙齿拔除术40/48Postoperativehemorrhage'sleadingcauses(6)Postoperativehemorrhage'sleadingcausesare:①patient'smanipulationofthewound.②foreignbodyinthesocket,suchasboneortoothfragments.③sharpbonemarginsandfracturedsocketwalls.④excessivegranulationtissuenotremovedattimeofsurgery.⑤hypertension.⑥clottingdeficiencyorvasculardisorder.外科牙齿拔除术41/48Postoperativepain(7)Postoperativepainwhichthepatientexperiencesafterthesecondandthirdpostoperativedaysshouldbecarefullyexamined,sincethisisnotanormalpostoperativecourse.Itiscausedbydrysocketorsharpbonespine.外科牙齿拔除术42/48Drysocket'sclinicalappearance(8)Drysocket'sclinicalappearanceiswellknown.Twoorthreedaysafterremovalofthetooth,thebloodclotdisintegrates.Thealveolusisempty,withcompletelyorpartiallydenuded,verysensitiveblancsurfaces,coveredbyagrey-yellowlayerofdetritusandnecrotictis