Vinnitsya national pirogov memorial



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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

Surgical stomatology of child's age

Module №

1

Rich in content module №

1

Theme of employment

3 Extraction of the teeth. Armamentarium used in oral surgery. Principlesof oral surgery. Pre-extraction clinical assessment.

Course

4

Faculty

stomatological

Autor

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

  1. Gistology

Histological structure of the oral mucous cavity. The mechanism of development and phase of inflammation

  1. Therapy, pediatrics

Know the features of a child's body. Know the basic diseases of importance in conducting the diagnosis of major dental diseases

  1. .Pharmacology

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

Determination

1. Postextraction complications

Сomplications which can occur a variable length of time after the extraction.

2.Immediate extraction complications

Complication which occur at the time of the extraction.

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



Basic stages of employment of their function and maintenance

Methods of control and studies

Materials of the methodical providing

Time (хв.)




Preparatory stage








20

1

Organizational measures










2

Raising of educational aims and motivation




See « the Educational aims»

See « Actuality of theme»






3

Control of initial level of knowledge, skills and abilities :

1.Features of anatomic structure jaw- facial area for children.

2.Classification of anaesthetizing


Methods of control of theoretical knowledge :

-Individual. theoretical questioning

-Decision of typical tasks

-Test control

-Writing theoretical control


Theoretical questions

Tasks


Tests

Writing


теорет.

task



Tables

Pictures


Structurally-.

logical


charts

Tool, equipment, patients.










Basic stage







60

4

Forming of abilities and skills.

1.To lay hands on methodologies of the local anaesthetizing for children




Practical тренін


Professional

algorithms for

forming of professional

abilities and practical

skills;Пацієнти.Інструментарій.








Final stage








10

5

Control and

correction of level of practical

skills and professional

abilities




Control methods

practical skills:

individual control

practical skills and them

results



Patients, tool





6

Tricking into

results

employment:

theoretical

practical

organizational



Result

evaluation

students

on criteria

knowledge,

skills, abilities




Offtype

situatioonal tasks

task and others like that.

Tests


Offtype situatioonal tasks





7

Domestic

task






Recommended

literature

(basic, additional, electron.sources)





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 long-term 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 strategically-located 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 figure-of-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 pre-extraction 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 24-72 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. 111-118.

  3. Бернадский Ю.И. «Основы хирургической стоматологии», К., 1998

  4. Евдокимова А.И. «Руководство по стом. детского возраста», 1976


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