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1、UnitTwenty
COMPLICATIONSOFEXODONTICS
Complicationsarisefromerrorsinjudgment,misuseofinstruments,exertionofextremeforce,andfailuretoobtainpropervisualizationpriortoacting.Theoldadage"todogood,youmustseegood"isapropostoexodontics,andonemightadd"Dowellwhatyousee."
Becauseoftheanatomyofthemaxillaryan
2、trumanditsproximitytothemaxillarypremolarandmolarroots,theantrumshouldalwaysbeconsideredwhenextractingteethinthisarea.
Extremeforceappliedtouppermolarscanresultinremovalofthemolartoothalongwiththeentiremaxillaryalveolarprocessandtheflooroftheantrum.Thefirst,second,andthirdmolars,alongwiththetuberos
3、ity,havebeenremovedinonesegmentbecauseofimproperuseofforceinthemaxilla.Ifduringanextractionthesurgeonfeelslargesegmentsofbonemovingwiththetoothwhenpressureisapplied,theforcepsshouldbesetasideandaflapraised.Ifjudiciousremovalofpartofthealveolarboneallowsthetoothtoberemoved,thentheremainingbone,whichi
4、sattachedtoperiosteum,mayheretained,anditwillheal.Thiswillminimizethebonydefect.Ifthebonecannotberemovedfromthetooth,themucosashouldbeincisedandreflectedsothatthemucosawillnottearasthetoothandboneareremoved.Alacerationismuchmoredifficulttorepairthanawell-plannedincision.
Largeantralperforationsresu
5、ltingfromexodonticsshouldbeclosedatthetimeoftheextraction.Theboneintheareashouldbesmoothedwitharongeurorbonefile.Theniucoperiostealflapisreturnedtoposition,andawatertightclosureshouldbeaccomplishedwithoutputtingunduepressureontheflap.Ifthiscannotbedone,theflapshouldbefreedbymeansofanincisionextendin
6、gverticallyintothemucobuccalfoldandthemucosaoftheflapunderminedtoallowittoadvanceoverthedefect.
Whentheantrumisenteredduringexodontics,thepatientshouldbemadeawareof(hesituationandaskedtonotblowthenosepostopcrativelyandalsotorefrainifpossiblefromcoughingorsneezing.Antibioticsandvasoconstrictivenosed
7、ropsareprescribedtoguardagainstinfectionofthesinusandtoallowforemptyingofthefluidthatwillcollectwithinthesinus.
Occasionally,buccalrootsofpremolarsandmolarsarcpushedlaterallythroughthewallofthemaxillaandlieabovetheattachmentofthebuccinatormuscle.Whenlheoperatorusesrootcxolcvcrsinthisarea,afingeroft
8、helefthandshouldbeheldagainstthebuccalplatesothatheorshecanbeawareofanymovementoflherootinthisdirection.Iftherootisdislodgedintothesetissues,asmallincisionismadeinthemucosainferiortotheroottipandtheroottipisremovedwithasmallhemostatorsimilarinstrument.
Theinfratemporalspaceliesdirectlyposteriorands
9、uperiortothetuberosityofthemaxilla.Withinthisspaceliemanyimportantneurovascularstructures.Intheelevationofthirdmolarsorthirdmolarroottipsandintheremovalofsupernumerarymolars,caremustbetakennottodislodgethemposteriorly.Ifanobjectistoberemovedfromtheinfratemporalspace,adequatevisualizationandcarefuldi
10、ssectionarenecessary.Theincisionshouldincludetheentiretuberosityandextendposteriorlytotheanteriorpillarofthefauces.Blinddissectionandgropingforobjectsinthisareacanbecomplicatedbymassivehemorhageornervedamage.
Inthethirdmolarregionofthemandible,thelingualsurfaceofthemandiblecurveslaterally,closetoth
11、eapicesofthistooth.Thereforeitisnotdifficulttodislodgearoottipinferiorlyintothisspacewhenthelingualplateisfractured.Whenaroottipisdisplacedinthisarea,afingershouldbeplacedinferiortotheroottip(inthemouth)tostabilizethetipagainstthelingualplateofthemandible.Accesslo(hisareaisgainedbymakingamucoperiosl
12、ealflaponthelingualsideofthemandibleandextendinganteriorlyenoughthatthetissuescanberetractedlinguallyforgoodvision.
Recoveryofaroottipinthemandibularcanalisprincipallyaproblemofaccessandvision.Usuallyitisdifficulttoremoveboneoverlyingthecanalfromwithinthedepthsofthewound,whichisusuallythethirdmolar
13、socket.Accessmaybegainedbyremovalofbonefromthebuccalplateandbycarefulremovalofbonethatoverliesthecanal.Ifoneofthevascularcomponentsofthecanalhasbeeninjured,itmaybenecessarylopackthesocketwithgauze,allowing10minutesforcontrolofthehemorrhage.Ifhemorrhagecannotbecontrolledinthismanner,theinjuredvessels
14、houldbeseveredcompletelyandallowedtoretractintothecanal.Atthistimethesocketisagainpacked,andhemorrhagecontrolisusuallyaccomplished.
POSTEXODONTICCOMPLICATIONS
Postoperativehemorrhageisthemostcommoncomplicationafterexodontics.If(hepatientcallsfromhometoreportthathemorrhagehasstartedagain,heshouldbe
15、advisedfirsttoclearthemouthofanybloodclotswithagauzespongeandthenrinsethemouthwithwarmsaltwater.Allexcessivebloodclotsshouldberemovedfromthevicinityofthesocket,buttheclotinthesocketshouldnotberemoved.Thepatientisinstructedtobitefirmlyonasterilegauzespongethathasbeenfoldedsothatpressureisexertedonthe
16、areaofsurgery.Ifasterilegauzespongeisnotavailable,thepatientmayuseateabagthathasbeenplacedincoldwatertosoftenthetealeaves.Thepatientisadvised(obite(notchew)onthepadorteabagfor20minutes.Ifbleedingpersistsattheendofthisperiod,thepatientshouldbeseenbythedentist.
Incasesofpersistenthemorrhage,gauzespon
17、gesandhemostaticagentssuchasGelfoam,topicalthrombin,oxidizedcellulose,andAvitenemaybehelpfulforthelocalcontrolofhemorrhageinadditiontoanadequatearmamentarium.
Thepatientisseatedandalocalanestheticadministered.Theclotthathasformedwithinthesocketisremoved.Next,theareaofhemorrhageislocated.Ifthehemorr
18、hageiscomingfromabonebleederwithinthesocket,thedullsideofacuretisusedloburnishtheboneintheareaofhemorrhage.Ifgeneralizedbonebleedingispresent,thesocketispackedwithahemostaticagentsuchasGelfoamsoakedinthrombin,andapurse-siringsutureisapplied(oholdthehemostaticagentinplace.Thepatientisaskedtobiteonamo
19、istgauzesponge.Ifthehemorrhageisfromthesurroundingsofttissue,atensionsutureisplacedtoapplypressuretothearea.
Inpatientswithadvancedperiodontaldisease,postoperativebleedingwilloccurifgranulationtissueisallowedtoremainafterremovaloftheaffectedteeth.Atthetimeofsurgeryafewminutesspentremovingthegranula
20、tiontissueandsuturingthealveolarmucosawillassuregoodhemorrhagecontrol.
Infectioncanoccurasapostoperativecomplication.TreatmentofsuchinfectionismanagedbyusingtheprinciplesoutlinedinChapter10.
Drysocket(localizedosteitis)isoneofthemostperplexingpostoperativecomplications.Theetiologyofthedrysocketisu
21、nknown,butthefollowingfactorsincreasetheincidenceofthispainfulpostextractionsequela:trauma,infection,decreasedvascularsupplyofthesurroundingbone,andgeneralsystemiccondition.
Theconditionrarelyoccurswhenminimaltraumaticmethodsarcemployedduringdifficultorsimpleextractions.Meticulousdebridementofallex
22、tractionwoundsshouldbedoneroutinely.
Theetiologymayberelatedtofactorsthatimpedeorpreventadequatenourishmentfromreachingthenewlyformedbloodclotwithinthealveolus.Patientswithdenseosteoscleroticboneorwithteeththathaveosteoscleroticalveolarwallsbecauseofchronicinfectionarepredisposedtodrysockets.
Drys
23、ocketmostcommonlydevelopsonthethirdorfourthpostoperativedayandischaracterizedbysevere,continuouspainandnecroticodor.Clinicallytheconditionmaybedescribedasanalveolusinwhichtheprimarybloodclothasbecomenecroticandremainswithinthealveolusasasepticforeignbodyuntilitisremovedbyirrigation.Thisusuallyoccurs
24、afewdaysafterextraction,leavingthealveolarwallsdivestedoftheirprotectivecovering.Severepain,whichcanbecontrolledonlybylocalapplicationofpotentanalgesicsandoralorparenteraluseofanalgesicsornarcoticsaccompanythedenudedbone.
Totreatasepticalveolusproperly,onemustunderstandthephysiologyofbonerepair.Ift
25、helossoftheprimarybloodclotresultsfromascleroticconditionofthealveolarwallsandtheabsenceofnutrientvessels,thentheresultingdenudedbonesurfacemustbeviewedasanyotherdenudedbonesurface,andthedentistmustrelyonnature'smethodsofbonerepairforultimaterecoveryandnotemployanyothermethodsthatwoulddisturbtheheal
26、ingprocess.
Asepticalveolusisadenudedbonesurface.Natureabhorsdenudedboneandrespondstorepairit.Behindthisdenudedandtraumatizedsurfaceanimmediatemechanismissetuptophysiologicallycorrectthedefect.Alldenudedbonebecomesnecroticandmustberemovedbeforeitcanbereplacedbynormalbone.Duringthisperiodthecontiguo
27、usregionbehindthealveolusisdefendedagainstinvasionofpyogenicorganismswithinthesepticalveolus,providednothingisdonetobreakthroughorviolatethiswalluntiltherepairmechanismisreadytoreplacethenonvitalstructure.Thisprocessusuallylakes2(o3weeks,dependingon(heregenerativecapacityoftheindividual.
Withthecom
28、pletionofthiscyclethenonvitalalveolarwallissequestratedmolecularlyorenmasseandimmediatelybehinditisadefensiveandregenerativelayerofjuvenileconnectivetissuethatultimatelyfillsthevoidandundergoesosseousreplacement.Duringthisperiod,treatmentshouldbedirectedonlytomaintenanceofwoundhygiene,withemployment
29、ofantiseptic,analgesicdressingswithinthealveolusofsufficientpotencytokeepthepatientcomfortable.Naturemustdo(herepairing.Curettageiscontraindicatedandwillnotonlydelayphysiologicalhealingandrepairbutmayalsopermitinvasionofinfectionintoandbeyondtheareaofdefenseimmediatelybehindthedenudedalveolus.
Prev
30、ention,ofcoarse,isthebesttreatmenttothisend.atraumaticsurgery,avoidanceofcontamination,andmaintenanceofagoodlevelofgeneralhealthisimportant.
Whenadrysocketdoesdevelop,treatmentshouldbepalliative.Thesocketisgentlyirrigatedwithwarmnormalsalinesolutiontoremovealldebris.Afterthesockethasbeencarefullydr
31、ied,itislightlydressedwith1/4-inchplaingauzesaturatedwithanobtundentpaste,suchasequalpartsofthymoliodidepowderandbenzocainecrystalsdissolvedineugenol.Thedressingmaybechangedasnecessaryuntilpainhassubsidedandgranulationtissuehascoveredthewalkofthesocket.
VOCABULARY
1.exodontics
拔牙學(xué)
2.adage
諺語，格
32、言
3.heaproposto
對(duì)……是恰當(dāng)?shù)?
4.maxillaryantrum
上頜竇
5.proximityto
鄰近
6.extractingteeth
拔牙
7.alveolarprocess
牙槽突
8.tuberosity
（上頜）結(jié)節(jié)
9.judiciousremoval
審慎地除去
10.mucosa
粘膜
11.antralperforation
上頜竇穿孔
12.rongeurorbonefile
骨鉗或骨挫
13.mucoperiostealflap
骨粘膜瓣
14.mucobuccalfold
頰粘膜皺囊
15.und
33、ermine
潛掘
16.refrainfrom
制止
17.antibiotics
抗生素
18.vasoconstrictive
血管收縮的
19.buccinatormuscle
頰肌
20.exolevers
牙挺
21.dislodge
逐出
22.hemostat
止血鉗
23.infratemporalspace
額下間隙
24.inferiorto(superiorto)
在……下方（上方
25.posteriorly(anteriorly)
在后部（在前部）
26.supernumerarymolar
多生的磨牙
27.pill
34、arofthefauces
咽門柱
28.dissectionandgroping
剝離和摸索
29.stabilize
穩(wěn)定
30.accessto
開口，進(jìn)路
31.retract
拉開，翻轉(zhuǎn)
32.sever
切斷
33.pack
填塞
34.excessivebloodclot
過量的血塊
35.sterilegauzesponge
無菌海綿紗布
36.gelfoam
明膠海綿
37.topicalthrombin
局部凝血酶
38.oxidizedcellulose
氧化纖維素
39.armamentarium
裝備
40.cure
35、t
刮匙
41.purse-stringsuture
荷包縫合
42.granulationtissue
肉芽組織
43.drysocket(osteitis)
干槽癥
44.perplexing
復(fù)雜的
45.sequela
繼發(fā)癥
46.meticulousdebridement
小心的清創(chuàng)
47.impede
阻礙
48.osteosclerotic
骨硬化的
易患
壞死氣味剝光
裸露的骨有力的止痛藥麻醉劑
化膿性細(xì)菌分離成分子狀
憎惡年輕的姑息療法
bepredisposedto
49. necroticodordivest
50. denudedbonepotentanalgesics
51. narcoticspyogenicorganisms
52. sequestratemolecularly
53. abhorjuvenile
54. palliative
專業(yè)英語 Unit 20教案.docx
