Download Reasons why teeth are extracted

MINISTRY of PUBLIC HEALTH of UKRAINE
VINNITSYA NATIONAL PIROGOV MEMORIAL
MEDICAL UNIVERSITY
It is "confirmed"
on a methodical meeting of
department of pediatric dentistry
head-chair
doc.Filimonov Yu.V.__________
"____ " ___________ in 20
Educational discipline
Module №
Rich in content module №
Theme of employment
Course
Faculty
Autor
Surgical stomatology of child's age
1
1
№3 Extraction of the teeth. Armamentarium used in
oral surgery. Principlesof oral surgery. Pre-extraction
clinical assessment.
4
stomatological
Isakova N.M.
Vinnytsya 2012
1. Actuality of theme : Exodontia as well as anaesthetizing in stomatological
practice it is the very important stage in treatment. But it and one of more
dangerous stages of treatment, because requires knowledge not only from the
topography of certain area and methodology of realization, and it is necessary to
have knowledge of ї from surgery, neurology, physiology of therapy, paediatrics
and others like that. Realization of moving away has very many features of
anatomic, physiology, age-old. It is also had much disadvantages it is necessary to
spare the special attention the That study of this theme .
2. 1. Concrete aims:
1. A student must familiarize with the problem of realization of exodontia for
children, among the different age-related groups.
2. A student must know the features of anatomic structure of maxillufacial area for
the children of the different age related groups and feature of physiology processes
for children
3. A student must lay hands on the technique of teeth extraction for children.
4. A student must conduct differential diagnostics of the different urgent states and
complications during an teeth extraction for children
3.Educator aims:
1. To develop professional internalss and feelings of responsibility during
realization of teeth extraction for children
2. Able to carry out deontological and psychological approach in process with
children.
3 Base knowledges, abilities, habits which are necessary for study the topic.
Names of previous disciplines
Skills are got
1. General anatomy
The structure of the maxillofacial region, the
blood and nerve supply
2. Gistology
Histological structure of the oral mucous
cavity. The mechanism of development and
3. Therapy, pediatrics
4. .Pharmacology
phase of inflammation
Know the features of a child's body. Know
the basic diseases of importance in
conducting the diagnosis of major dental
diseases
To know the basic groups of preparations
which are used for the general and local
anaesthetizing and stop of bleeding.
4.Task for independent work during preparation to employment.
4.1. List of basic terms, parameters, descriptions which a student must
master at preparation to employment :
Term
1. Postextraction
complications
Determination
Сomplications which can occur a variable length of time
after the extraction.
2.Immediate extraction Complication which occur at the time of the extraction.
complications
3. Extraction forceps
Instrument mostly used in dental extraction, it composed
of three parts:1.Two handles, 2. One join, 3. Two blades.
4.2Theoretical questions
1. A testimony is to extraction of temporal teeth .
2. Children have a technique of realization and feature of teeth extraction .
3. Tactics of doctor at the break of tooth which retires, whether its root, break
or dislocation of nearby tooth .
4. Treatment of dislocation of upper jaw .
5. A clinic and tactics of doctor are at the break of bottom jaw and tearing
away of hillock of supramaxilla.
6. Clinic and diagnostics of perforation of maxillary sinus .
7. Tactics of doctor during a perforation and pushed through root in a
maxillary sinus .
8. Methodology of stop of bleeding from the small hole of tooth which retires,
possible reasons .
9. A prophylaxis and grant of help are at general complications .
10. Treatment of alveolitis and alveolalgia.
11. Neurological complication after the teeth extraction; of their treatment and
prophylaxis
4.3 Practical works (tasks)
To conduct of teeth extraction different groups of teeth on phantoms.
5.Plan and organizational structure of employment
№
1
2
3
Basic stages of Methods of Materials of the methodical Time
employment
of control and providing
(хв.)
their function and studies
maintenance
20
Preparatory stage
Organizational
measures
Raising
of
educational
aims
and motivation
Control of initial Methods of
level of knowledge, control
of
skills and abilities : theoretical
knowledge :
-Individual.
1.Features
of theoretical
anatomic structure questioning
jaw- facial area for
children.
-Decision of
typical tasks
2.Classification of
anaesthetizing
-Test control
See « the Educational aims»
See « Actuality of theme»
Theoretical
questions
Tasks
Tests
Tables
Pictures
Structurally-.
logical
charts
Tool, equipment,
patients.
Writing
теорет.
task
-Writing
theoretical
control
4
Basic stage
Forming of abilities Practical
and skills.
тренін
1.To lay hands on
methodologies of
the
local
anaesthetizing for
children
60
Professional
algorithms for
forming of professional
abilities and practical
skills;Пацієнти.Інструментарій.
10
Final stage
5
Control and
Control
Patients, tool
correction of level methods
of practical
practical
skills
and skills:
professional
individual
abilities
control
practical
skills
and
them
results
6
Tricking into
results
employment:
theoretical
practical
organizational
7
Result
evaluation
students
on criteria
knowledge,
skills,
abilities
Domestic
task
Offtype
situatioonal tasks
task and others like that.
Tests
Offtype situatioonal tasks
Recommended
literature
(basic,
electron.sources)
additional,
Maintenance of theme
Extraction of the teeth
Reasons why teeth are extracted
There are a number of reasons why a person might need a tooth, or even multiple
teeth, extracted. They include:
1)Damaged teeth.
a) Broken, cracked, or extensively decayed teeth.
The obstacles associated with repairing some teeth that have extensive decay or
else have broken or cracked in an extreme manner may make extraction the only
choice. In other cases, the needed treatment's cost, or else a question of its longterm success, may make extraction the most reasonable option.
b) Teeth that are unsuitable candidates for root canal treatment.
If the option of receiving needed root canal treatment is not possible, the only
alternative is to extract the tooth.
c) Teeth that have advanced gum disease.
In those cases where periodontal disease (gum disease) has caused a significant
amount of bone damage and the affected teeth have become excessively mobile,
extraction may be the only option.
2)Malpositioned or nonfunctional teeth may need to be extracted.
a)Malpositioned teeth.
Some teeth are extracted because they have a poor alignment or positioning. For
example, some third molars are extracted because they are a constant source of
irritation to a person's cheek (they either rub against it or causing the person to bite
it).
b) Nonfunctionalteeth.
Some teeth are extracted because they just provide minimal benefit but place the
person at substantial risk for experiencing dental problems.
As an example, some third molars come into place but have no matching tooth to
bite against. Since these teeth lie in a region of the mouth that is hard to clean, both
it and its neighboring 2nd molar are at increased risk for developing tooth decay
and/or periodontal disease. In this type of situation, it may make sense to have the
tooth extracted.
c) Impacted teeth.
Impacted teeth are malpositioned and usually non-functional. This combination of
factors makes them common candidates for extraction.
3) Tooth extractions may be required for orthodontic reasons.
When orthodontic treatment is performed, the dentist may be limited by the
amount of jaw space (length) they have to work with. If so, some strategicallylocated teeth may need to be sacrificed.
Risk assessment in tooth extraction
Teeth should be assessed preoperatively to anticipate potential difficulties with
extractions. Preoperative assessment can be carried out using the history,
examination and special investigations.
A history of difficult extractions or postoperative complications can give an early
indication of potential problems. The age of the patient is also important: the bone
of older patients is less flexible than that of younger patients, making standard
techniques such as buccalexpansion more difficult.
Examination
Clinical examination will reveal gross caries, which can make forceps placement
very difficult. Imbrication or crowding can make forceps placement and delivery
of the tooth difficult. Wear facets, indicating increased occlusal load, increase
supporting bone strength making extractions more difficult.
Radiography
Radiographs are helpful in showing the number, shape and relationship of the roots
of the tooth. They also reveal whether the roots of a lower molar tooth are
convergent or divergent. Radiographs can also indicate areas of
hypercementosisand bony pathology that may complicate the extraction.
Equipment
Most teeth are extracted with dental forceps of which a variety of types are
available.
Lower forceps have their blades at 90° to the handles and upper forceps have the
blades either angled slightly forwards or straight in relation to their handles.
Forceps design has developed over many years and is based around the principle of
creating a displacing force on the roots of the tooth, not the crown. When teeth
fracture during extraction it is most commonly the result of poor forceps
placement. Forceps are therefore designed around the root morphology of the tooth
they are intendedto remove.
Root forceps that have smaller beaks for smaller teeth or fractured roots are
available. There are other specific forceps with more limited application, such as
upper third molar forceps, which have an elongated «gooseneck» for access to the
posterior maxilla.
Elevators may be used as an alternative method ofmobilizing or extracting teeth.
There has been a recent increase in the use of instruments known as luxators to
assist with extractions.Luxators are designed to help the operator gain space for
application of the forceps. They are very sharp-bladed elevators that are used to
increase the gap between the tooth and the surrounding bone, thus loosening the
tooth and producing more space for forceps application. They can be very helpful
but care must be taken due to the potential soft tissue damage. They should be used
to «unscrew» the tooth, not to elevate it.
Technique
Having chosen the forceps that best fit the root morphology of the tooth to be
removed, surgeons must first position themselves and the patient to achieve good
access and vision, as well as allowing the surgeon to put appropriate force on the
tooth. It is usual practice to remove lower teeth before upper teeth, and posterior
teeth before anterior teeth, to avoid blood obscuring the doctor's view if a number
of teeth are to be extracted.
The patient's head should be at the level of the surgeon's elbow. The next stage is
to position the surgeon's non-dominant hand. This is important because it improves
access by retracting soft tissues and allows the surgeon to place a counterforce on
the jaw to assist tooth extraction. For example, when buccally expanding an upper
molar it is necessary to have an opposing force provided by the operator's passive
hand. It is conventional to place a finger and a thumb on either side of the tooth to
be extracted.
Application of the forceps is the most important stage and the basic principle of
tooth removal must always be borne in mind: application of the beaks of the
forceps to the root rather than the crown of the tooth. It should usually be as easy
to remove a tooth fractured at gingival level as a fully intact tooth because the
forceps blades are placed on the root face not on the enamel of the tooth.
This application involves the placing of the blades under the gingivae, taking care
to minimize soft tissue damage. The forceps should then be pushed apically,
completing this stage of the procedure. This may require considerable force.
There are exceptions to these general rules, for example, cow-horn forceps fit into
the bifurcation of lower molars and, because of their unique design, produce an
upwards force. Their application is therefore different.
To remove the tooth efficiently, the forceps must be pushed together firmly to
engage on to the root surface, with the handles of the forceps being gripped with
the palm of the hand with an apical force applied at the same time as forcing the
handles together. This avoids the beaks of the forceps sliding around the root of the
tooth on rotation rather than the efficient transfer of forces from doctor to tooth.
Displacement
Displacement depends on root morphology. Teeth can be removed in two ways: by
rotational movement or buccalmovement (expansion).
Upper incisors and lower premolars can be rotated. All other teeth are best
removed by controlled buccalexpansion. Upper first premolars are an exception as
they often present with two thin roots. The best extraction technique is a
combination of gently wiggling the teeth and slight expansion, both bucally and
palatally.
Rotational movement involves increasing destruction of the periodontal ligament
by a circular movement both clockwise and anticlockwise. Buccal expansion
involves the enlargement of the bony socket allowing tooth delivery. This is
usually a staged process where the tooth is forced bucally and, with sustained
pressure on the buccal alveolar bone, the tooth is extracted.
There are variations of the above basic movements: lower molars can often be
removed efficiently by a combination of rotation and buccal expansion (a figureof-eight movement is often suggested); also lower third molars can be expanded
lingually where the lingual plate is thinner than the buccal bone.
Postdelivery
The extraction socket usually heals without incident, even when multiple
extractions have produced a large, open wound. Healing can be aided by a number
of procedures: sockets that have been expanded should be squeezed to replace the
bone to its original position; sharp pieces of bone can be removed and the patient
should be instructed to bite on to a damp piece of gauze to aid hemostasis. Once
hemostasis has been achieved, postoperative instructions should be given.
Postoperative instructions should include leaving the socket undisturbed for 4-6 h
and then gentle rinsing with hot saline mouthwashes after each meal. Patients
should also be advised of control measures if bleeding occurs postoperatively and
how to contact the appropriate emergency service in case of complications.
Complications of extractions
Complications can arise during the procedure of extraction or may manifest
themselves some time following the extraction.
Immediate extraction complications.
These occur at the time of the extraction.
Fracture of the crown of a tooth
This may be unavoidable if the tooth is weakened either by caries or a large
restoration. However, the forceps may have been applied improperly to the crown
instead of to the root mass, or the long axis of the beaks of the forceps may not
have been along that of the tooth. Sometimes, crown fracture arises from the use of
forceps whose beaks are too broad or as a result of the doctor trying to 'hurry' the
operation. The management of this complication is to remove all debris from the
oral cavity and review the clinical situation. Surgical extraction of the remaining
fragment may then be necessary.
Fracture of the root of a tooth
Ideally, it should be possible to ensure that the whole tooth is removed every time
an extraction is carried out. However, when a root breaks a decision about
management of the retained piece of root has to be made.
Further management depends on the size of the root fragment, whether it is mobile,
whether it is infected, how close it is to major anatomical structures such as the
maxillaryantrum or inferior dental canal, patient cooperation and the ability of the
surgeon to successfully complete the procedure taking into account the constraints
of time, equipment and surgical expertise. If the decision is made to leave the root
then this must be written in the case notes and the patient fully informed. If the
procedure is deferred, the root fragment should have the pulp removed and a
dressing placed.
If the decision is made to leave the root then this must be written in the case notes
and the patient fully informed. If the procedure is deferred, the root fragment
should have the pulp removed and a dressing placed.
If a deciduous tooth is being removed, it must be kept in mind that the roots are
usually being resorbed with the roots being pushed towards the surface by the
permanent tooth. It is often prudent therefore to leave these fragments, as
injudicious use of elevators can cause damage to the underlying permanent tooth.
Fracture of the alveolar plate
This is a common complication and is often seen when extracting canine teeth or
molars. If the alveolar plate has little periosteal attachment and is hence liable to
lose its blood supply then it should be carefully removed by stripping off any
remaining periosteum with a periosteal elevator. If, however, it is still adequately
attached to theperiosteum, a mattress or simple suture over the socketmargin will
stabilize the plate and allow its incorporation into the healing process.
Fracture of the mandible
This is an uncommon complication of dental extraction, which is usually heralded
by a loud crack. The most important thing is to stop the extraction and reassess the
situation. The patient should be informed of the possibility that his or her mandible
might be broken and a radiograph should be taken. If a jaw fracture is confirmed
then the patient should be referred to a maxillofacial center as an emergency. It
would be advisable to administer another inferior dental block injection. If this
involves a significant delay, then further analgesia should be provided and
appropriate antiseptic mouthwashes and antibiotics prescribed.
Soft tissue trauma
Soft tissues must not be crushed. For example, the lower lip is at risk from the
handles of the forceps when removing maxillary teeth. It should be ensured that
recently sterilized instruments are not too hot and the patient's eyes should be
protected from instruments and fingers using safety spectacles. Soft tissue damage
is more likely to be encountered when the patient is under a general anesthetic and
cannot communicate. Care should be exercised to avoid application of the beaks of
forceps over the gingival soft tissues, especially linguallyin the lower molar region
where the lingual nerve may be damaged. Protective finger positioning is required
when using elevators that may slip and damage the tongue,floor of mouth or the
soft tissues of the palate. The softtissues at the angle of the mouth may also be
damaged by excessive lateral movement of forceps particularly when extracting an
upper tooth when an ipsilateral inferior dental block has been administered or
where the patient is having general anesthesia.
Involvement of maxillary antrum
Oroantral fistula (OAF)
The roots of the maxillary molar teeth (and occasionally the premolar teeth) lie in
close proximity to, or even within, the maxillary antrum. When the tooth is
extracted, a communication between the oral cavity and the antrum may be
created. The doctor may be aware of this possibility from the study of a preextraction radiograph or may suspect the creation of an OAF by inspection of the
extracted tooth or the socket. An upper molar may have a saucer-shaped piece of
bone attached to the trifurcation of the roots, indicating that the floor of the antrum
has been detached. The socket itself may show abnormal architecture such as loss
of the interradicular bony septum. To confirm the presence of an OAF the patient
can be asked to pinch the nostrils together and blow air gently into the nose. The
doctor can then hold cotton wool in tweezers under the socket and look for
movement of the fibres. Sometimes, the blood in the socket can be observed to
bubble or the noise of the air moving through the fistula can be detected. Some
doctors favour inspection of the socket with good lighting and efficient suction
using a blunt probe to explore the integrity of the socket. The noise of the suction
often becomes more resonate if a communication exists between socket and sinus.
Once confirmed, an OAF can be treated in two ways: if small, the socket can be
sutured and a hemostatic agent such as Surgicel can be used to encourage clot
formation. Strict instructions should be given to avoid nose blowing because this
can increase the intrasinuspressure and break-down the early clot that covers the
defect. The patient should be prescribed an antibiotic because of the risk of
infection, which would prevent the sinus healing and lead to a chronic oroantral
fistula. The patient should be reviewed 1 week later to check progress and then 1
month later to ensure that the socket has healed.
If the OAF is large then it should be closed immediately by means of a surgical
flap. Most commonly this is done by means of a buccal advancement flap. This is a
U-shaped flap with vertical relieving incisions taken from the mesial and distal
margins of the socket. The flap is mucoperiosteal, which means that the periosteal
lies on its inner aspect. Periosteal is a thin sheet of osteogenicsoft tissue that has no
elasticity and must therefore be incised to allow the whole flap to be advanced to
the palatal margin of the socket. The incision is made horizontally along the whole
length of the base of the flap; it need not be deep because the periosteal is
relatively thin. Some surgeons reduce the height of the buccal plate of bone to
reduce the length of the advance. Horizontal mattress sutures encourage wound
margin eversion and aid primary healing. A prophylactic antibiotic would normally
be prescribed and the patient asked to avoid nose-blowing.
Loss of the root (or tooth) into the antrum
Another complication involving the antrum is pushing part or all of a tooth into the
antral cavity. Normally the doctor should arrange for the removal of this root as the
patient is again at risk of the development of maxillary sinusitis with or without
anoroantral fistula. The patient should have radiographs taken to confirm the
presence of the root in the antrum and the operator should then raise a buccal flap
from the mesial and distal margins of the socket. Access to the antrum should then
be increased bybone removal with bone nibblers and drills. The root canthen be
removed from the antrum by a variety of techniques including suction, the use of
small caries excavators or direct removal by tweezers. If these methods are
unsuccessful then theantrum can be flushed-out with sterile saline in an attempt to
'float' the root out, or the antrum can be packed with ribbon gauze, which might
dislodge the root when it is removed. Once the root has been removed from the
antrum, the resulting defect should be closed with abuccal advancement flap, as in
the closure of an oroantral fistula. In the rare circumstances where a whole tooth is
dislodged into the maxillary antrum, its removal is often paradoxically easier.
Damage to nerves or vessels
This complication applies more commonly to the surgical removal of teeth rather
than simple extractions but one must always be aware of difficulties when
operating in the region of the inferior dental, lingual or mental nerves.
Dislocation of the temporomandibular joint
Occasionally, a patient will open the mouth so widely during an extraction that the
mandible is dislocated; or the doctor might apply force to an unsupported
mandible, causing it to dislocate. In this event, the doctor should try, as quickly as
possible, to reduce the dislocation by pushing the mandible downwards and
backwards. If this is not done relatively quickly, muscle spasm of the powerful
elevator muscles of the mandible will ensue and the patient will require sedation,
or indeed even a general anesthetic, to reduce the dislocation. When extracting
teeth under general anesthesia the mandible can dislocate due to the loss of
muscular tone. It is important to ensure the mandible is repositioned before the
patient recovers from the anesthesia.
Damage to adjacent teeth
When extracting teeth, fillings from adjacent teeth may become dislodged and this
should be dealt with appropriately. Inexperienced doctors sometimes damage teeth
in the opposing jaw when the tooth being removed comes out of its socket rather
more quickly than expected. It is important to recognisethat damage has been
caused and to deal with it appropriately.
Extraction of a permanent tooth germ along with the deciduous tooth
When extracting deciduous teeth there is occasionally asignificant amount of soft
tissue attached to the apex of the deciduous root. It is often difficult to ascertain
clinically whether this is a granuloma or abscess, or whether it is the permanent
tooth germ attached to the root. If there is concern, the specimen should be sent for
histopathological investigation to confirm whether the permanent tooth germ has
been removed.
Extraction of the wrong tooth
Extraction should be considered to be an irreversible procedure and therefore
extreme vigilance should be employed to ensure that the correct tooth is extracted.
The most vulnerable clinical situation is where one is extracting teeth for
orthodontic reasons and the teeth have no obvious clinical problem. Extracting the
wrong tooth is medicolegally indefensible.
Postextraction complications
Postextraction complications can occur a variable length of time after the
extraction.
Postextraction hemorrhage
Hemorrhage is one of the complications that clinicians worry about most and it can
seriously complicate the extraction of teeth. Prevention of hemorrhage is desirable.
To achieve this, the patient must be questioned carefully as to any previous history
of excessive hemorrhage particularly in relation to previous extractions. If a history
of postextraction hemorrhage is elicited it is important to try and ascertain for how
long the bleeding continued and what measures were used to stop the bleeding on
previous occasions. It is also important to discover when the bleeding started in
relationship to the time of the extraction. General questions regarding a history of
prolonged bleeding after trauma or other operations, or a family history of
excessive bleeding or known hemorrhagic conditions may be relevant. It is also
important to question the patient about the use of drugs, such as anticoagulant
drugs.
A postextraction hemorrhage is first dealt with by removing any clot from the
mouth and establishing from where the bleeding is originating. The patient can
then be asked to apply firm pressure by biting on a gauze pack for 10–15 min. It is
advantageous to infiltrate local anesthetic with a vasoconstrictor into the region, as
this will make any manipulation of the socket more comfortable and the
vasoconstrictor in the local anesthetic will also aid in reducing the hemorrhage.
Suturing is essential in the management of a postextraction hemorrhage and a
horizontal mattress or interrupted sutures should be used to tense the
mucoperiostem over the underlying bone so that the hemorrhage can be controlled.
The use of hemostatic agents such as Surgicel is helpful. Agents like bonewax can
help to stop bleeding from the bony walls of the socket. Although postextraction
hemorrhage can be dramatic, significant blood loss is unusual. Patients should,
however, be assessed for evidence of shock if bleeding appears significant.
Dry socket
Dry socket is also known as focal or localisedosteitis and manifests clinically as
inflammation involving either the whole or part of the condensed bone lining the
tooth socket (lamina dura). The features of this are a painful socket that arises 2472 h after extraction and may last for 7-10 days. Clinically, there is an empty
socket with possibly some evidence of broken-down blood clot and food debris
within it. An intense odour may be evident and can be confirmed by dipping cotton
wool into the socket and passing it under the nose. The overall incidence of dry
socket is about 3% but this figure is much higher if the definition of postextraction
pain is used as the sole diagnostic criterion.
Osteomyelitis
This rare complication is often a result of an immunecomprisedstate or a reduction
in the blood supply, usually of the mandible following radiotherapy. The patient is
usually systemically unwell: there is an increase in temperature and severe pain.
Often the mandible, which is more commonly involved, is tender on extraoral
palpation. The onset of disturbance of labial sensation after an extraction is
characteristic of acute osteomyelitis. The patient will often be admitted to hospital
for management of this condition. The principles of treatment are the drainage of
pus, the use of antibiotics and the later removal of sequester once the acute
infection has been controlled. Prevention is best achieved, in a predisposedpatient,
by ensuring primary closure of the socket bybone trimming and suturing.
Sequester
There will be occasions when small pieces of bone become detached and cause
interruption to the healing process. The patient will return, complaining of
something sharp in the area of the socket and may feel that the doctor has left a
root fragment behind. These sequester can be dealt with either by reassuring the
patient and wait shedding of the piece of bone or by administering some local
anesthesia and removing the piece of loose bone with tweezers. In some cases,
granulation tissue may be apparent with pus discharging especially on probing the
socket. This will respond well to a curettage of the socket, thus removing the
sequestrum in the curettings.
Trismus
Trismus is a common feature after the removal of wisdom teeth and may be
associated with other extractions. It can also be related to the use of inferior dental
block local anesthesia. It is important to ascertain the cause of the trismus and then
to manage it appropriately. On most occasions the trismus will resolve gradually
over a period of time, which will vary depending on whether the condition is due
to inflammatory edema or perhaps direct damage to the muscles following local
anesthesia.
Prolonged anaesthesia
This is usually a feature of the removal of difficult or impacted teeth, particularly
wisdom teeth.
Chronic oroantral fistula
This complication arises when a communication between the socket of an upper
molar (or more rarely premolar) and the maxillary air sinus has not been noted at
the time of extraction and infection both in the socket and the air sinus occurs. The
patient may present with a variety of symptoms and signs either within a week or
two following the extraction or many months (and even years) later. Common to
all, however, is failure of the normal healing process and persistence of the socket.
As infection of the air sinus becomes acute, symptoms of diffuse unilateral
maxillary pain, nasal stuffiness, bad taste and intraoral pus discharge may occur;
these can be intermittent in character.
On examination, the socket can appear empty or be filled with granulation tissue.
Occasionally, distinctly polypoidal tissue can grow down from the opening,
reflecting the sinus origin of the tissue. In other cases, the socket can appear almost
totally closed, with only a very small opening into the sinus. Diagnosis by careful
probing is normally straightforward and anradiograph will show the extent of
infection within the sinus.
The management involves two stages. First, the acute infection must be controlled,
then the opening should be closed surgically. Initially, any accumulation of pus in
the sinus should be drained. This often requires excision of the infected granulation
tissue and polyps from the socket to allow free drainage and also to ensure
histologically that the formation of the fistula is not related to downgrowth of an
antral neoplasm. Nasal decongestants and antibiotics also help to control more
acute infections.
Once the acute phase is controlled, most fistulae can be closed using the buccal
flap advancement. The margins of the opening must be freshened by excising a rim
of soft tissue, because epithelium will often have grown-up into the opening and, if
not removed, will prevent healing. Where infection is limited to the immediate
vicinity of the fistula, a limited curettage is carried out. However, where the whole
sinus is filled with polypoidal granulation tissue, a more thorough exploration of
the sinus may be required, and this often is performedunder general anesthesia.
Literature.
Basic:
1.Lecture material .
Additional
1. Колесов А.А “ Стоматологія дитячого віку “ , 1978 ,ст. 44-63.
2. Дунаевський В.А. “Хірургічна стоматологія “ , 1979 ,ст. 111118.
3. Бернадский Ю.И. «Основы хирургической стоматологии», К.,
1998
4. Евдокимова А.И. «Руководство по стом. детского возраста»,
1976