كلية طب الأسنان - جامعة بغداد- فرع الجراحة
O. Surgery-3rd year -exodontias--Dr-Jamal abid
Lecture no :-4------2016-2017
contra-indications:
in general ,there is no absolute contra-indication for extraction of teeth but most of them are relative and temporary in nature ,that is to say that some conditions need :-
a- to postponed till the acute phase resolved ( acute myocardial infarction ,unstable angina, acute infection ,sever trismus ,pregnancy )
b .Other conditions may need physician consultation and special arrangement (hemophilia ,leukemia) and preparations , precautions like (aids,viral hepatitis ,patient on anticoagulant ) .
in general the contra-indications are divided into groups :-
1-local contra-indications .
2-systemic contra-indications
1- Local contra-indications (l.Cs)
There are several l.Cs for extractions of teeth :-
1-acute and uncontrolled infection :-
Extraction in the presence of acute and uncontrolled infection (acute peirapical abscess , facial abscess especially in medically compromised patient ) may lead to spread of infection locally or systemically leading to many complications some of them are dangerous and life threatening (e,g. cavernous sinus thrombosis, mediastinitis, ludwig's angina. in addition to that limitation of mouth opening (trismus ) due to infection may interfere with the accessibility to the operating area .
2- previous radiotherapy:-
Extraction in case of irradiated jaw may lead to osteoradionecrosis ( death of the bone ), Previous therapeutic radiation in oral and maxillofacial region for treatment of cancer lead to fibrosis and decreased vascularity of the tissue or area of extraction and end with a condition in the bone called osteoradionecrosis. This condition occurs 3-10% of patients. Osteoradionecrosis develops as irradiation diminishes the bone’s ability to withstand trauma and avoid infection ( hypoxia ,hypocellularity ,hypovascularity ), and it can be facilitated by poor nutrition and hygiene. This process may be spontaneous or result from trauma (extraction), leading to non-healing soft tissue and bone lesions (unhealed socket ), followed by bone necrosis. The non-healing bone may become secondarily infection leading to chronic unhealed area, sloughing of soft tissue , exposed bone ,continues pain and many other complications .
3- Teeth located within area of tumor (malignant growth) :-
Especially in cases of malignant tumors, teeth should not be extracted because extraction may lead to dissemination of the tumor , unhealed socket and other postoperative complications , such as postoperative and intraoperative bleeding .
4- Central hemangioma (inside the bone) and arteriovenous malformation .hemangioma is a benign tumor characterized by proliferation of blood vessels (vascular ), It occurred within the mandible and maxilla ,while arteriovenous malformation defined as an abnormal (usually congenital) connection betweenarteriesandveins , extraction in such conditions may lead to sever uncontrolled bleeding ,some of these bleeding may be fetal .
Systemic contra-indications :-
Systemic contra-indications preclude extraction because the patient's systemic health is such that the ability to withstand the surgical work may be compromised . so extraction should be postponed until the severity of the problem has been resolved and maybe arranged after consultation with physician to perform extraction safely without complications so caution is advised in the following conditions :-
1-sever uncontrolled metabolic disease , e.g. uncontrolled diabetes , end –stage renal disease.
2-uncontrolled leukemia's and lymphomas.
3-sever uncontrolled cardiac disease e.g myocardial infarctions , unstable angina pectoris , dysrhythmias .
4-sever uncontrolled hypertension .
5-pregnancy.
6-bleeding disorder e.g
- hemophilia , platelet disorder . patient on anticoagulants .
7-patients who take a variety of medications .
- patient on steroid and immunosuppressive drugs .
- chemotherapy .lead to (leukopenia, thrombocytopenia ,anemia ).
- bisphosphonate drug :- may lead to ( osteonecrosis).
8-uncontrolled epilepsy.
preoperative (Pre-extraction) evaluation for extraction patient :-
P.E.E is very valuable and necessary for successful extraction practice . hurry and inadequate P.E.E of the case my lead to many embarrassing intra-operatively for the operator , in addition to the postoperative problems to the patient P.E.E include :-
1-clinical preoperative evaluation.
2- radiological evaluation.
1-clinical P.E.E also includes:-
a) General evaluation.
b) Local evaluation.
General evaluation includes :-
· General impression of patient .
· History of general diseases ,nervousness, orientation .
· General oral hygiene .
· Gingival inflammation , calculus , neglected mouth .
Local factors or evaluation includes:-
1-Clinical examination to the accused tooth .
The tooth to be extracted is examined, teeth malpositioned lingually,palatally,rotated, or inclined ,or single standing teeth in occlusion are all potentially difficult .certain teeth frequently have abnormal root formation like the upper and lower third molars. Presence of periodontitis predispose to postoperative bleeding and infection.
2-Adjoining structures .
should be noticed for inflammation , swelling ,growth ,presence of traces of blood or oozing , Discharging sinus issue, abnormal discoloration of the surrounding soft tissue. heavy filled teeth ,crowned teeth ,
3-Access to the tooth . this includes the mouth opening , location of the tooth (e.g. buccally malposed, instanding) may present difficulty in positioning the dental forceps for extraction, so you may need to remove such a tooth surgically.
4- Tooth mobility: The mobility of the tooth to be extracted shou1dbe assessed preoperatively, greater than normal mobility is frequently seen with sever periodontal disease but sometimes it maybe because of the underlying pathology Like neoplasm.
v Condition of the crown:- e.g.
a) Carious destruction.
b) The presence of large restoration.
c) Presence or absence of the adjoining teeth.
d) Non-vitality.
e) State of the supporting tissue.
f) Shape, position, long axis and size of the crown.
g) Attrition.
Good P.O.E resulted from correction of data collected from history, clinical examination, radiographs and laboratory aids in addition to that P.E.E need good knowledge and experience in the basic sciences e.g. anatomy, physiology, pathology.
In general, P.O.E may help you in:
a) determine the method of extraction and type of anesthesia. .
b) Reduce the time spend for extraction.
c) Reduce the intra and post-operative crisis and complications.
2- Radiological evaluation:
Preoperative clinical assessment maybe supplemental some times by preoperative radiographs to have a complete preoperative assessment. it is not practicable to take a preoperative radiograph before every extraction ,but one should always be taken if any of the following positive indications exist :-
1) A history of difficult or unsuccessful extraction.
2) A tooth which is abnormally resist to forceps extraction.
3) Heavily restored teeth ,pulpless (non-vital ) ,these teeth are normally brittle and easily fractured during extraction .
4) If after clinical examination you decide to remove the tooth surgically by dissection .
5) Any teeth or roots in close relationship to important structures like inferior dental or mental nerve ,maxillary sinus, nasal cavity.
6) Attritioned teeth in elderly patient (maybe associated with hypercementosis).
7) if a tooth is partially erupted or unerupted or retained root.
8) Any tooth which has been subjected to trauma, fracture of the root and/or alveolar bone maybe present.
9) An isolated maxillary molar especially if it is unopposed and over erupted. The bony support of such a tooth is often weakened by an extension into it of maxillary sinus and this may predispose to either the creation of oro-antral communication or fracture of the maxillary tuberosity.
10) Whenever, underlying bony pathology is suspected e.g. cystic lesion, tumors.
11) All mandibular third molars, instanding premolars or misplaced canine , the root pattern of such teeth is often abnormal
12) Any tooth whose abnormal crown or delayed eruption might indicate the possibility of dilaceration ,gemination ,or the presence of odontome .
13) Any systemic condition which may predispose to dental or alveolar abnormality like:
a) Ostetitis deforms (Paget’s disease), in which the roots hypercementosed, ankylosis leading to difficult extraction, infection of socket (chronic osteomyelities ) .
b) Cleido-cranial dystosis, for pseudo-anadontia(multiple impactions, hooked roots occur, supernumerary teeth).
c) patient who have received therapeutic irradiation to the jaw who may have to predispose to osteoradionecrosis.
d) Osteopetrosis (marble bone disease), which cause extraction very difficult and predispose to chronic osteomyelities.
v Requirements of the pre-extraction radiograph :-
1- must show the whole root structure and the alveolar bone
investing the tooth .
2- in most cases an intra-oral periapical view will suffice ,but sometimes an extra-oral view like latteral oblique mandible or orthopantomograph (OPG) will be required to demonstrate this entire root ,or the state, structure ,and amount of the supporting bone .
v A good radiograph and careful interpretation may enable or aid the operator to detect many factors that may cause difficulty in extraction of teeth, e.g.:
1- Abnormal number of roots, and shape of roots.
2- An unfavorable root pattern.
3- Caries extending to the root mass.
4- Fracture or resorption of the root.
5- Hypercementosis of roots.
6- Ankylosis (there is no space in periodontal ligament), and sclerosis of the bone.
7- Germination (the development of two teeth from one bud).
8- Impacted teeth .
9- Bony sclerosis and pathological lesions.
v Also careful interpretation of the radiograph may also reveal or show the possibility of the following complications:
1) Involvement of, and damage to inferior dental nerve and mental nerve .
2) The creation oforo-antral or or-nasal communication.
3) The retention of intra-bony pathology e.g. cyst.
4) The displacement of root or tooth into maxillary sinus.
5) Fracture of maxillary tuberosity.