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Oral and Maxillofacial Trauma Management

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Oral and Maxillofacial Trauma Management X-Ray, Block, and Extract Alexander M. Reiter, Dipl. Tzt., Dr. med. vet., Dipl. AVDC, EVDC, FF-AVDC-OMFS Professor of Dentistry and Oral Surgery Head of the Dentistry and Oral Surgery Service Matthew J. Ryan Veterinary Hospital of the University of Pennsylvania reiter@vet.upenn.edu Introduction Local and regional anesthesia is characterized by the loss of sensation only in the area of the body where an anesthetic drug is injected or applied. This is in contrast to general anesthesia, which provides anesthesia to the entire body and brain. Local and regional anesthesia preferably with longer lasting local anesthetics should be utilized in addition to systemic pain medication. This can reduce medical expenses by decreasing the concentration needed of an inhalant anesthetic, minimize complications from hypotension, bradycardia and hypoventilation, enable faster recovery, and provide analgesia in the postoperative period. Local Anesthesia Local anesthesia (infiltration anesthesia) refers to injection/application of a local anesthetic solution into/onto tissues at a surgical site. It is less commonly performed in oral and maxillofacial surgery. Examples include injection of local anesthetic along planned incisions. Splash block (wound irrigation) refers to dropping local anesthetic directly onto an incision or wound. The procedure is usually done at the end of surgery prior to closure of the surgical site (e.g., mixture of 50 mL lidocaine 2% and 0.25 mL phenylephrine 1% dropped into nasal cavity after maxillectomies [maximum dose: 0.05-0.1 mL/kg in cats and 0.1-0.2 mL/kg in dogs]). Regional Anesthesia Regional anesthesia (nerve blocks) refers to injection of a local anesthetic solution around a major nerve utilizing 22 to 27-gauge (depending on whether going through skin or mucosa), 1 ¼ to 1 ½ inch needles (depending on depth of penetration) on 1 to 3 ml syringes (depending on volume to be injected). This is usually performed in oral and maxillofacial surgery for the maxillary, infraorbital, major palatine, inferior alveolar, and middle mental nerve. Local Anesthetics Local anesthetics commonly used include bupivacaine 0.5% (effective for up to 6 hours, sometimes longer) and lidocaine 2% (effective for up to 2 hours). The onset time for analgesia is longer with longer acting local anesthetics (few minutes for lidocaine, up to 15 minutes for bupivacaine). The total maximum dosage for bupivacaine in cats and dogs is 2 mg/kg and for lidocaine in the dog 5 mg/kg and the cat 1 mg/kg. There are 5 mg of an agent in 1 ml of a 0.5% 1 solution and 20 mg of an agent in 1 ml of a 2% solution. Some dentists and oral surgeons mix 0.2 ml lidocaine 2% with 0.8 ml bupivacaine 0.5% per 4.53 kg (10 lbs) as maximum patient dosage to benefit from the short onset time of lidocaine and long-acting features of bupivacaine. Specific Nerve Blocks The maxillary nerve block is usually given intraorally just caudal to the last molar where the maxillary nerve enters the infraorbital canal through the maxillary foramen. Care must be taken not to inject anesthetic into the globe. The areas blocked include the incisive bone, maxilla and palatine bone, all maxillary teeth on that side and adjacent soft tissues. An extraoral approach is available with the needle advanced penetrating the skin at the side of the face through a palpable space encompassed by the caudal maxilla, zygomatic arch and mandibular ramus. The infraorbital nerve block is usually given intraorally at the infraorbital foramen or within the infraorbital canal. The needle is inserted through labial mucosa at the level of the maxillary second/third premolar and advanced in a caudal direction (keeping it parallel to the hard palate). The areas blocked include the incisive bone and maxilla, maxillary incisors, canine, and premolars (depending how far the needle is advanced into the infraorbital canal) and adjacent soft tissues. The major palatine nerve block is given intraorally through the palatal mucosa. The needle is inserted into the palatal mucosa at the level of the maxillary third premolar and advanced caudally towards the major palatine foramen (near the transverse palatine suture between the median palatine suture and the maxillary fourth premolar tooth). The areas blocked include the palatine shelf of the maxilla and adjacent soft tissues. The inferior alveolar nerve block can be given intraorally (at a relatively flat angle through the alveolar mucosa at the medial aspect of the mandible) or extraorally (through the skin at an unnamed notch at the ventrolingual surface of the mandible). The areas blocked include the mandibular body, all mandibular teeth and adjacent soft tissues. The middle mental nerve block is given intraorally at the middle mental foramen ventral to the mesial root of the second premolar (dog) or rostroventral to the third premolar (cat). The areas blocked include the rostral mandibular body, teeth rostral to the injection site and adjacent soft tissues. Basics of Tooth Extraction Tooth extraction is one of the most frequently performed surgical procedures in small animal practice. The most common indications for tooth extraction in dogs are periodontal disease and tooth fracture, and in cats tooth resorption and stomatitis. If the disease process is too advanced for the teeth to be saved, extraction is necessary. Financial and other considerations may lead the client to request extraction. Tooth extraction is contraindicated in patients (1) that cannot be anesthetized due to health concerns; (2) that have had radiation therapy involving the 2 jaws that would inhibit healing; (3) with bleeding disorders that cannot be controlled; or (4) are on medications that cause prolonged bleeding times or prevent healing. Teeth are anchored to the alveolar bone of the mandible, incisive bone and maxilla by soft tissue components of the periodontium, the gingiva and periodontal ligament. During the extraction process, these tissues must be severed (junctional epithelium and gingival connective tissue) or stretched and torn (periodontal ligament) to allow delivery of the tooth to be extracted. Gentle tissue handling is important to minimize trauma and to allow rapid healing of both soft and hard tissues. In the dog the incisors, canines, first premolars, and lower third molars are single-rooted teeth; in the cat, the incisors, canines, and commonly the upper second premolars are single-rooted. The cat’s upper first molars may be treated as single-rooted teeth even though they have more than one root (the roots are usually fused together). The upper fourth premolar in the cat and dog and the upper first and second molars in the dog are three-rooted. All other teeth are two-rooted. Equipment, Instruments and Materials for Tooth Extraction The basic equipment, instrument and material needs for tooth extraction include: • High-speed dental unit with water irrigation and 3-way syringe • Non-surgical- and surgical-length friction-grip (FG) burs such as round ((¼, ½, 1, 2, 4; to remove alveolar bone), cross-cut fissure (700, 701, 702; to section multi-rooted teeth) and round diamond burs (9, 14, 23; to smooth alveolar bone) • Number 3 or 5 scalpel handle with blades 11, 15 or 15C • Sharp and narrow-tipped (2-6 mm) periosteal elevators (such as Mead #3 or Periosteal #EX-9M for mid-sized and larger dogs, Glickman #24G or Periosteal #EX-9 for small dogs and cats) • Adson 1 x 2 thumb forceps (smaller version) • Dental elevators (#1, 2, 3, 4, 5, and 6) • Dental luxators • Small extraction forceps • Root tip elevators • Root tip forceps • Small spoon curettes • Irrigation solutions (dilute chlorhexidine, lactated Ringer’s) • Gauze sponges • Small Metzenbaum scissors • Needle holders • Synthetic, absorbable monofilament suture material (4.0, 5.0) with swaged on, taper- point round, non-cutting needle • Suture scissors (or designated pair of Mayo scissors) 3 Proper Holding of Instruments Blades of dental luxators are designed to penetrate into the periodontal space and cut periodontal ligament fibers. Blades of dental elevators are worked into the space between the tooth and the alveolar bone and carefully rotated to create a slow, gentle and steady pressure on the tooth. Both instruments are grasped with the butt of the handle seated in the palm and the index finger extended along the blade of the instrument to act as a stop should the instrument slip and to prevent iatrogenic damage. The blades of extraction forceps should be applied as far apically on the tooth as possible to reduce the chances of root fracture. Closed Extraction of Teeth Extractions can be performed using the closed technique (without raising a mucoperiosteal flap) or open technique (raising a mucoperiosteal flap to expose alveolar bone). The closed technique should always start with cutting the gingival attachment around the tooth. A luxator or elevator is then inserted between the gingival margin or alveolar bone and the tooth. Pressure is applied while slowly rotating the elevator through a small arc and holding the instrument firmly against the tissues for at least 10 seconds. As the periodontal space widens, it is helpful to change from smaller to larger instruments. When the tooth is sufficiently loose, forceps are placed as far apically on the tooth as possible, and the tooth is rotated slightly on its long axis with a steady pull and removed from its socket. Granulation tissue, debris, pus, and bony fragments are removed from the extraction site, which is rinsed with chlorhexidine digluconate prior to closure. Leaving a blood clot in the alveolus is an essential part of healing. Packing the alveolus with osteogenetic, osteoinductive or osteoconductive materials may be done in selected cases. Multi-rooted teeth require sectioning into crown-root segments, which are extracted using the same principles as for single-rooted teeth. Sectioning is performed with a cutting bur in a high-speed handpiece and water irrigation, starting from the furcation through the tooth crown.
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