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To avoid periodontal defects after the eruption of the canine viagra with dapoxetine 100/60mg for sale, the availability of Limitations and Contraindications adequate keratinized gingival soft tissue should be ascer- tained cheap viagra with dapoxetine 100/60mg with mastercard. Tis factor (discussed later in the chapter) also helps Surgical exposure of impacted canines and orthodontic erup- determine the type of exposure technique used safe viagra with dapoxetine 100/60mg. When these conditions are present, extrac- tion of the impacted canine may be indicated. Such conditions Upon localization of the impacted tooth, the type of proce- include9: dure can be selected. Te type of exposure may vary, depend- • Ankylosis of the tooth ing on the availability of keratinized gingiva in the edentulous • Severe root dilaceration area, the vertical position of the tooth in the alveolus, and the • Severe lack of arch space (positioned between roots in labiopalatal position of the tooth. Incisions should be avoided over a bony defect Examining the area of impaction and attention to surface morphol- or the tooth crown itself because this can lead to breakdown or ogy (e. Bone in the path of eruption also must be removed bracket and to allow optimal eruption of the tooth. Once the site is hemostatic, the bracket is bonded to performed to bond an orthodontic bracket with composite resin. Bonding Hemostasis is achieved by packing the pericoronal space with of the bracket is confrmed with a tug on the chain attached to cotton pledgets soaked in a local anesthetic solution containing the bracket (Figure 12-2, D). A #9 periosteal elevator is used to Te fap margin with attached gingiva is returned to its refect a full-thickness mucoperiosteal fap, exposing the original position and sutured to allow primary closure. Two other techniques can be used Te bone covering the tooth is removed with a Molt elevator in this situation. In one variant, the orthodontic traction chain bracket at the chain is bonded, as described previously. Te exits under the fap through the incision line; in the other chain either is fed through the palatal mucosa or simply variant, the chain is fed through the palatal mucosa over the attached to the arch wire without passing through the palatal tooth and then attached to the orthodontic wire. Te prerequisite for success for labially impacted 3-mm band of keratinized gingiva should be found between canines is availability of attached gingiva. Placing incisions in the unat- of Intraoperative Complications tached mucosa can lead to the orthodontic chain causing clefting of the labial periodontium when pulled through Apart from choosing the right technique for surgical expo- the keratinized mucosa. Inappropriate fap design cannot only limit bracket is being bonded; if this is not done, debonding of access intraoperatively but can also give rise to periodontal the bracket can result. Cases in which the closed technique defects including loss of attached, keratinized gingiva. Approximately two thirds of the crown • Immediate postoperative considerations must be exposed to obtain stable bracketing and further • Oral hygiene maintenance application of orthodontic forces. Ericson S, Kurol J: Longitudinal study and impacted maxillary canines, J Oral Maxillofac treatment, Angle Orthod 79:442, 2009. Johnson W: Treatment of palatally impacted canine eruption, Community Dent Oral Epide- canine teeth, Am J Orthod 56:589, 1969. Tis shape provides optimal stability to Indications for the Use of the Procedure the removable prosthesis. In 1853 Willard1 described con- touring of the alveolar bone and contouring of the alveolar Reshaping of the alveolar bone has multiple indications in mucosa to obtain primary closure in preparation for denture maxillofacial surgery. He stated that this should allow the patient to be or restructuring of the alveolar bone to provide a functional restored sooner because the bone and tissue healed faster. Te indications for alveoplasty range 1876 Beers2 described radical alveolectomy with cutting from debulking procedures for pathologic conditions of the forceps. Tis was aggressive treatment, and clinicians reverted bone to recontouring the bone in preparation for prosthetic to being more conservative over the next 50 years. If bone loss was thought to be due to the periosteal stripping the alveolus has a sharp edge, the bone must be smoothed and large faps developed to provide access for the bone down to help with the healing process and prevent sequestra contouring surgery. His idea was to Te contouring of the alveolus after extractions also aids preserve bone and to maintain an appropriate vestibule. Any sharp bone projections or edges under dentures labial cortex and contoured intraradicular bone. Tis allowed create pain when the prosthesis compresses and rubs against him to compress the labial plate. Te shape of the ridges for denture fabrication should tion leads to less pain, swelling, and bone resorption. Undercuts must be addressed to immediate denture placement and the amount of resorption allow for smooth placement of the prosthesis. Te goals are associated with diferent surgical techniques, such as extrac- to lose as little bone as possible after extraction, to maintain tion without alveoplasty, extraction with labial alveolectomy, a wide alveolar ridge with the ideal U shape, and to get rid and extraction with intraseptal alveoplasty as described by of undercuts that prevent smooth use and placement of a Dean. With respect to dental implant rehabilitation, the reshap- Te advent of implant dentistry has turned the table. Now, ing of the alveolus is done to provide a stable base to place contemporary therapy focuses on maintaining as much bone the dental implants and to create enough room for the pros- as possible to facilitate implant placement. Compression of the Alveolar Ridges Compression is done after extractions when the labial, buccal, Limitations and Contraindications and lingual or palatal plates are expanded and create under- cuts. Alveoplasty is limited by the local architecture and volume Tis is simply done with fnger pressure on the labial and of bone in the surgical site. It is contraindicated if removing palatal or buccal and lingual cortices to compress them the bone would harm vital structures. It is typically intended to remove that should be as conservative as possible (Figure 13-1, A sharp edges, bony prominences, or undercuts in preparation and B). Simple Alveoloplasty Compression of palatal and labial plates A1 Bone smoothing using bur or file A3 Rongeur removal A2 of sharp bone Figure 13-1 A, Simple alveoloplasty technique. The amount of refection depends on how much bone needs A full-thickness envelope fap is raised. Minimal refection may the crest of the alveolus or in the gingival sulcus of remaining lessen postoperative edema, pain, and hematoma formation. Keep in mind that the more aggressive Once the fap has been raised and bone exposed, a rongeurs, the removal of bone, the more resorption occurs (Figure 13-1, bone fle, or rotary instrumentation is used to smooth or recontour C and D). Perhaps Complex Maxillary Alveoloplasty/Alveolectomy supereruption of the dentition occurred and then the teeth were lost. Pneumatization of the sinus into the posterior Anatomic considerations in the maxilla for reshaping of the maxillary alveolus may create a very thin layer of remaining alveolar bone include the maxillary sinus, nasal cavity/nasal bone between the oral cavity and the sinus cavity. If the foor, prominence of the canine eminences, palatal tori, and tuberosity is vertically hypertrophic and needs to be removed tuberosity anatomy. Te incisive foramen and incisive nerve to create interarch space for either dentures or dental implants, may be an issue when reshaping the anterior maxilla. Maxillary Tuberosity Reduction Maxillary tuberosity reduction is usually soft tissue in nature due to the thick alveolar mucosa in the region.

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Organic lesions of pituitary origin require a diligent search for coexisting hormone deficiencies generic 100/60mg viagra with dapoxetine mastercard. Acute adrenal insufficiency from inadequate replacement of steroids on chronic steroid therapy is rare and can present as refractory buy 100/60 mg viagra with dapoxetine fast delivery, distributive shock generic viagra with dapoxetine 100/60 mg on-line. In critically ill patients, adrenal insufficiency may not present with classic symptoms. A high degree of suspicion must32 be maintained if the patient has cardiovascular instability without a defined cause. Biochemical evidence of impaired adrenal or pituitary secretory reserve unequivocally confirms the diagnosis. Patients who are clinically stable may undergo testing before treatment is initiated. Those believed to have acute adrenal insufficiency should receive immediate therapy. Treatment and Anesthetic Considerations Normal adults secrete about 20 mg of cortisol (hydrocortisone) and 0. Glucocorticoid therapy is usually given twice daily in sufficient dosage to meet physiologic requirements. A typical regimen in the unstressed patient may consist of prednisone, 5 mg in the morning and 2. The daily glucocorticoid dosage is typically 50% higher than basal adrenal output to cover the patient for mild stress. Replacement dosages are adjusted in response to the patient’s clinical symptoms or the occurrence of intercurrent illnesses. Mineralocorticoid replacement is also administered on a daily basis; most patients require 0. The mineralocorticoid dose may be reduced if severe hypokalemia, hypertension, or congestive heart failure develops, or it may be increased if postural hypotension is demonstrated. Glucocorticoid substitution follows the same guidelines previously outlined for primary adrenal insufficiency. Immediate therapy of acute adrenal insufficiency is mandatory, regardless of the etiology, and consists of electrolyte resuscitation and steroid replacement (Table 47-6). After adequate fluid resuscitation, if the patient continues to be hemodynamically unstable, inotropic support may be necessary. Invasive monitoring is extremely valuable as a guide to both diagnosis and therapy. The normal adrenal gland can secrete up to 100 mg/m of cortisol per day or2 more during the perioperative period. The pituitary–adrenal axis is usually36 considered to be intact if a plasma cortisol level higher than 19 μg/dL is measured during acute stress, but there is no precise threshold. The degree of adrenal responsiveness has been correlated with the duration of surgery and the extent of surgical trauma. The mean maximal plasma cortisol level measured during major surgery (colectomy, hip osteotomy) was 47 μg/dL. Minor surgical procedures (herniorrhaphy) resulted in mean maximal plasma cortisol levels of 28 μg/dL. Regional anesthesia is effective in postponing the elevation in cortisol levels during surgery of the lower abdomen and extremities. Although symptoms indicative of clinically significant adrenal insufficiency 3343 have been reported during the perioperative period, these clinical findings have rarely been documented in direct association with glucocorticoid deficiency. There is evidence in adrenally suppressed primates that38 subphysiologic steroid replacement causes perioperative hemodynamic instability and increased mortality. Table 47-7 Management Options for Steroid Replacement in the Perioperative Period Identifying which patients require steroid supplementation can be difficult. There is no proven optimal regimen for perioperative steroid replacement (Table 47-7). This39 low-dose cortisol replacement program was used in patients with proven adrenal insufficiency and resulted in plasma cortisol levels as high as those seen in healthy control subjects subjected to a similar operative stress. One study with a limited number of patients found no problems with cardiovascular instability if patients received their usual dose of steroids. An40 extensive review concluded that the best evidence was that patients should receive their usual daily dose but no supplementation. Although the low-41 dose approach appears logical, many clinicians are unwilling to adopt this regimen until further trials have been undertaken in patients receiving physiologic steroid replacement. A popular regimen calls for the administration of 200 to 300 mg of hydrocortisone per 70 kg body weight in divided doses on the day of surgery. The lower dose is adjusted upward for longer and more extensive surgical procedures. Patients who are using steroids at the time of surgery receive their usual dose on the morning of surgery and are supplemented at a level that is at least equivalent to the usual daily replacement. Glucocorticoid coverage is rapidly tapered to the patient’s normal maintenance dosage during the postoperative period. Although no conclusive evidence supports an increased incidence of infection or abnormal wound healing when supraphysiologic doses of supplemental steroids are used 3344 acutely, the goal of therapy is to use the minimal drug dosage necessary to adequately protect the patient. Exogenous Glucocorticoid Therapy The therapeutic use of supraphysiologic doses of glucocorticoids has expanded, and the anesthesiologist should be familiar with the various preparations (Table 47-8). Dexamethasone, methylprednisolone, and prednisone have less mineralocorticoid effect than cortisone or hydrocortisone. Prednisone and methylprednisolone are precursors that must be metabolized by the liver before anti-inflammatory activity can occur and should be used cautiously in the presence of liver disease. Group I control patients, n = 8 (closed circles), had never received corticosteroids. These patients and control patients received no corticosteroid substitution during the perioperative period. Physiological cortisol substitution of long-term steroid-treated patients undergoing major surgery. A feature common to all patients with hypoaldosteronism is a failure to increase aldosterone production in response to salt restriction or volume contraction. Most patients present with hypotension, hyperkalemia that may be life- threatening, and a metabolic acidosis that is out of proportion to the degree of coexisting renal impairment.

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