UnitTwentyCOMPLICATIONSOFEXODONTICSComplicationsarisefromerrorsinjudgment,misuseofinstruments,exertionofextremeforce,andfailuretoobtainpropervisualizationpriortoacting.Theoldadage"todogood,youmustseegood"isapropostoexodontics,andonemightadd"Dowellwhatyousee."Becauseoftheanatomyofthemaxillaryantrumanditsproximitytothemaxillarypremolarandmolarroots,theantrumshouldalwaysbeconsideredwhenextractingteethinthisarea.Extremeforceappliedtouppermolarscanresultinremovalofthemolartoothalongwiththeentiremaxillaryalveolarprocessandtheflooroftheantrum.Thefirst,second,andthirdmolars,alongwiththetuberosity,havebeenremovedinonesegmentbecauseofimproperuseofforceinthemaxilla.Ifduringanextractionthesurgeonfeelslargesegmentsofbonemovingwiththetoothwhenpressureisapplied,theforcepsshouldbesetasideandaflapraised.Ifjudiciousremovalofpartofthealveolarboneallowsthetoothtoberemoved,thentheremainingbone,whichisattachedtoperiosteum,mayheretained,anditwillheal.Thiswillminimizethebonydefect.Ifthebonecannotberemovedfromthetooth,themucosashouldbeincisedandreflectedsothatthemucosawillnottearasthetoothandboneareremoved.Alacerationismuchmoredifficulttorepairthanawell-plannedincision.Largeantralperforationsresultingfromexodonticsshouldbeclosedatthetimeoftheextraction.Theboneintheareashouldbesmoothedwitharongeurorbonefile.Theniucoperiostealflapisreturnedtoposition,andawatertightclosureshouldbeaccomplishedwithoutputtingunduepressureontheflap.Ifthiscannotbedone,theflapshouldbefreedbymeansofanincisionextendingverticallyintothemucobuccalfoldandthemucosaoftheflapunderminedtoallowittoadvanceoverthedefect.Whentheantrumisenteredduringexodontics,thepatientshouldbemadeawareof(hesituationandaskedtonotblowthenosepostopcrativelyandalsotorefrainifpossiblefromcoughingorsneezing.Antibioticsandvasoconstrictivenosedropsareprescribedtoguardagainstinfectionofthesinusandtoallowforemptyingofthefluidthatwillcollectwithinthesinus.Occasionally,buccalrootsofpremolarsandmolarsarcpushedlaterallythroughthewallofthemaxillaandlieabovetheattachmentofthebuccinatormuscle.Whenlheoperatorusesrootcxolcvcrsinthisarea,afingerofthelefthandshouldbeheldagainstthebuccalplatesothatheorshecanbeawareofanymovementoflherootinthisdirection.Iftherootisdislodgedintothesetissues,asmallincisionismadeinthemucosainferiortotheroottipandtheroottipisremovedwithasmallhemostatorsimilarinstrument.Theinfratemporalspaceliesdirectlyposteriorandsuperiortothetuberosityofthemaxilla.Withinthisspaceliemanyimportantneurovascularstructures.Intheelevationofthirdmolarsorthirdmolarroottipsandintheremovalofsupernumerarymolars,caremustbetakennottodislodgethemposteriorly.Ifanobjectistoberemovedfromtheinfratemporalspace,adequatevisualizationandcarefuldissectionarenecessary.Theincisionshouldincludetheentiretuberosityandextendposteriorlytotheanteriorpillarofthefauces.Blinddissectionandgropingforobjectsinthisareacanbecomplicatedbymassivehemorhageornervedamage.Inthethirdmolarregionofthemandible,thelingualsurfaceofthemandiblecurveslaterally,closetotheapicesofthistooth.Thereforeitisnotdifficulttodislodgearoottipinferiorlyintothisspacewhenthelingualplateisfractured.Whenaroottipisdisplacedinthisarea,afingershouldbeplacedinferiortotheroottip(inthemouth)tostabilizethetipagainstthelingualplateofthemandible.Accesslo(hisareaisgainedbymakingamucoperioslealflaponthelingualsideofthemandibleandextendinganteriorlyenoughthatthetissuescanberetractedlinguallyforgoodvision.Recoveryofaroottipinthemandibularcanalisprincipallyaproblemofaccessandvision.Usuallyitisdifficulttoremoveboneoverlyingthecanalfromwithinthedepthsofthewound,whichisusuallythethirdmolarsocket.Accessmaybegainedbyremovalofbonefromthebuccalplateandbycarefulremovalofbonethatoverliesthecanal.Ifoneofthevascularcomponentsofthecanalhasbeeninjured,itmaybenecessarylopackthesocketwithgauze,allowing10minutesforcontrolofthehemorrhage.Ifhemorrhagecannotbecontrolledinthismanner,theinjuredvesselshouldbeseveredcompletelyandallowedtoretractintothecanal.Atthistimethesocketisagainpacked,andhemorrhagecontrolisusuallyaccomplished.POSTEXODONTICCOMPLICATIONSPostoperativehemorrhageisthemostcommoncomplicationafterexodontics.If(hepatientcallsfromhometoreportthathemorrhagehasstartedagain,heshouldbeadvisedfirsttoclearthemouthofanybloodclotswithagauzespongeandthenrinsethemouthwithwarmsaltwater.Allexcessivebloodclotsshouldberemovedfromthevicinityofthesocket,buttheclotinthesocketshouldnotberemoved.Thepatientisinstructedtobitefirmlyonasterilegauzespongethathasbeenfoldedsothatpressureisexertedontheareaofsurgery.Ifasterilegauzespongeisnotavailable,thepatientmayuseateabagthathasbeenplacedincoldwatertosoftenthetealeaves.Thepatientisadvised(obite(notchew)onthepadorteabagfor20minutes.Ifbleedingpersistsattheendofthisperiod,thepatientshouldbeseenbythedentist.Incasesofpersistenthemorrhage,gauzespongesandhemostaticagentssuchasGelfoam,topicalthrombin,oxidizedcellulose,andAvitenemaybehelpfulforthelocalcontrolofhemorrhageinadditiontoanadequatearmamentarium.Thepatientisseatedandalocalanestheticadministered.Theclotthathasformedwithinthesocketisremoved.Next,theareaofhemorrhageislocated.Ifthehemorrhageiscomingfromabonebleederwithinthesocket,thedullsideofacuretisusedloburnishtheboneintheareaofhemorrhage.Ifgeneralizedbonebleedingispresent,thesocketispackedwithahemostaticagentsuchasGelfoamsoakedinthrombin,andapurse-siringsutureisapplied(oholdthehemostaticagentinplace.Thepatientisaskedtobiteonamoistgauzesponge.Ifthehemorrhageisfromthesurroundingsofttissue,atensionsutureisplacedtoapplypressuretothearea.Inpatientswithadvancedperiodontaldisease,postoperativebleedingwilloccurifgranulationtissueisallowedtoremainafterremovaloftheaffectedteeth.Atthetimeofsurgeryafewminutesspentremovingthegranulationtissueandsuturingthealveolarmucosawillassuregoodhemorrhagecontrol.Infectioncanoccurasapostoperativecomplication.TreatmentofsuchinfectionismanagedbyusingtheprinciplesoutlinedinChapter10.Drysocket(localizedosteitis)isoneofthemostperplexingpostoperativecomplications.Theetiologyofthedrysocketisunknown,butthefollowingfactorsincreasetheincidenceofthispainfulpostextractionsequela:trauma,infection,decreasedvascularsupplyofthesurroundingbone,andgeneralsystemiccondition.Theconditionrarelyoccurswhenminimaltraumaticmethodsarcemployedduringdifficultorsimpleextractions.Meticulousdebridementofallextractionwoundsshouldbedoneroutinely.Theetiologymayberelatedtofactorsthatimpedeorpreventadequatenourishmentfromreachingthenewlyformedbloodclotwithinthealveolus.Patientswithdenseosteoscleroticboneorwithteeththathaveosteoscleroticalveolarwallsbecauseofchronicinfectionarepredisposedtodrysockets.Drysocketmostcommonlydevelopsonthethirdorfourthpostoperativedayandischaracterizedbysevere,continuouspainandnecroticodor.Clinicallytheconditionmaybedescribedasanalveolusinwhichtheprimarybloodclothasbecomenecroticandremainswithinthealveolusasasepticforeignbodyuntilitisremovedbyirrigation.Thisusuallyoccursafewdaysafterextraction,leavingthealveolarwallsdivestedoftheirprotectivecovering.Severepain,whichcanbecontrolledonlybylocalapplicationofpotentanalgesicsandoralorparenteraluseofanalgesicsornarcoticsaccompanythedenudedbone.Totreatasepticalveolusproperly,onemustunderstandthephysiologyofbonerepair.Ifthelossoftheprimarybloodclotresultsfromascleroticconditionofthealveolarwallsandtheabsenceofnutrientvessels,thentheresultingdenudedbonesurfacemustbeviewedasanyotherdenudedbonesurface,andthedentistmustrelyonnature'smethodsofbonerepairforultimaterecoveryandnotemployanyothermethodsthatwoulddisturbthehealingprocess.Asepticalveolusisadenudedbonesurface.Natureabhorsdenudedboneandrespondstorepairit.Behindthisdenudedandtraumatizedsurfaceanimmediatemechanismissetuptophysiologicallycorrectthedefect.Alldenudedbonebecomesnecroticandmustberemovedbeforeitcanbereplacedbynormalbone.Duringthisperiodthecontiguousregionbehindthealveolusisdefendedagainstinvasionofpyogenicorganismswithinthesepticalveolus,providednothingisdonetobreakthroughorviolatethiswalluntiltherepairmechanismisreadytoreplacethenonvitalstructure.Thisprocessusuallylakes2(o3weeks,dependingon(heregenerativecapacityoftheindividual.Withthecompletionofthiscyclethenonvitalalveolarwallissequestratedmolecularlyorenmasseandimmediatelybehinditisadefensiveandregenerativelayerofjuvenileconnectivetissuethatultimatelyfillsthevoidandundergoesosseousreplacement.Duringthisperiod,treatmentshouldbedirectedonlytomaintenanceofwoundhygiene,withemploymentofantiseptic,analgesicdressingswithinthealveolusofsufficientpotencytokeepthepatientcomfortable.Naturemustdo(herepairing.Curettageiscontraindicatedandwillnotonlydelayphysiologicalhealingandrepairbutmayalsopermitinvasionofinfectionintoandbeyondtheareaofdefenseimmediatelybehindthedenudedalveolus.Prevention,ofcoarse,isthebesttreatmenttothisend.atraumaticsurgery,avoidanceofcontamination,andmaintenanceofagoodlevelofgeneralhealthisimportant.Whenadrysocketdoesdevelop,treatmentshouldbepalliative.Thesocketisgentlyirrigatedwithwarmnormalsalinesolutiontoremovealldebris.Afterthesockethasbeencarefullydried,itislightlydressedwith1/4-inchplaingauzesaturatedwithanobtundentpaste,suchasequalpartsofthymoliodidepowderandbenzocainecrystalsdissolvedineugenol.Thedressingmaybechangedasnecessaryuntilpainhassubsidedandgranulationtissuehascoveredthewalkofthesocket.VOCABULARY1.exodontics拔牙學(xué)2.adage諺語(yǔ)，格言3.heaproposto對(duì)是恰當(dāng)?shù)?.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.undermine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.pillarofthefauces咽門(mén)柱28.dissectionandgroping剝離和摸索29.stabilize穩(wěn)定30.accessto開(kāi)口，進(jìn)路31.retract拉開(kāi)，翻轉(zhuǎn)32.sever切斷33.pack填塞34.excessivebloodclot過(guò)量的血塊35.sterilegauzesponge無(wú)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.curet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?jí)乃罋馕秳児饴懵兜墓怯辛Φ闹雇此幝樽韯┗撔约?xì)菌分離成分子狀憎惡年輕的姑息療法bepredisposedto49. necroticodordivest50. denudedbonepotentanalgesics51. narcoticspyogenicorganisms52. sequestratemolecularly53. abhorjuvenile54. palliative