DMD - Oral Surgery 2: Basic Principles PDF

DMD – ORAL SURGERY 2 BASIC PRINCIPLES OF ORAL SURGERY REFERENCES Laboratory Studies Contemporary Oral and Maxillofacial Surgery, 6 th Edition o Determine pres...

DMD – ORAL SURGERY 2 BASIC PRINCIPLES OF ORAL SURGERY REFERENCES Laboratory Studies Contemporary Oral and Maxillofacial Surgery, 6 th Edition o Determine presence of abnormality o Determine status of existent problem SURGERY o Determine subsequent treatment protocol The branch of medicine that deals with the diagnosis and Need for referral treatment of injury, deformity, and disease by manual and o Confirm initial findings instrumental means o Control medical condition ORAL AND MAXILLOFACIAL SURGERY o Recommendations for management A specialty of dentistry concerned with the diagnosis and ASA: American Society of Anesthesiologist Physical Status surgical treatment of congenital or acquired diseases, Evaluation dysfunction, defects, or injuries of the mouth, jaws, face, neck, and adjacent craniofacial structures ATTRUBUTES OF A GOOD SURGEON Adept diagnostic skills Adequate understanding of medical relationships Conservative attitude Sound knowledge of - Anatomy - Physiology, and - Basic principles of Oral Surgery SURGERY OR NOT The decision to do surgery should be the result of several diagnostic processes Only after logical analysis of all available data should a decision be made whether surgery is indicated or not PHARMACOLOGIC CONSIDERATIONS Understanding of drugs should not be limited to drugs that PRE-OPERATIVE PROTOCOLS we intend to prescribe Diagnostic process Drugs taken by the patient may suggest the presence of o History systemic conditions o Clinical examination Drug interactions must be considered o Imaging Physiologic changes associated with drug intake Review of medical history o ASA Classification Preoperative medications are given to address expected o History of Systemic Disease episodes that may ensue as part of a surgical procedure o Laboratory studies Pain relief and swelling o Need for referral o Consider giving a loading dose Pharmacologic considerations o Usually given 1 hr prior to surgery o Pre-medications o Consider existing conditions and medications o Intra-operative Antibiotic use should be limited to indicated cases o Post-operative Steroid for swelling may be considered o Drug interactions Anti-hemorrhagic drugs are usually not necessary Informed consent RADIOGRAPHS IN ORAL DIAGNOSIS DIAGNOSTIC PROCESS An integral part of the diagnostic process in clinical dentistry Thorough history of the patient Often obtained as part of a complete examination Clinical examination Used along with clinical information and other tests to o Vital signs formulate a differential diagnosis o Physical examination Never used as a final diagnosis o Oral examination In order to be of value for diagnosis radiographs and other Imaging imaging techniques should reveal vital information about o Radiographs the condition o Special imaging: Qualities of a good radiograph should show complete CT Scans, MRI, Others object and surrounding structures REVIEW OF MEDICAL HISTORY EFFICIENT SURGERY DEPENDS ON ASA Classification Adequate access o May indicate presence of dse Adequate visibility o Provide baseline for physiological changes o Adequate lighting History of Systemic Disease o Efficient evacuation device o Medical questionnaire o Well trained assistant o Interview Adequate access is achieved by: o Surgically created exposure o Patient’s mouth opening KARMIR | ROMANS 8:18 1  DMD – ORAL SURGERY 2 – BASIC PRINCIPLES OF ORAL SURGERY Adequate lighting TRAPEZOIDAL FLAP o Light should be of adequate strength and go into the 2 vertical incisions mouth 1 horizontal incision o Light should not be too strong and be limited to Offers maximal access and visibility for procedures immediate area of surgery requiring wide exposure Field of operation should be clearly visible o Use an efficient evacuation device MODIFIED TRAPEZOIDAL FLAP (LEUBKE-OCHSENBEIN) o Adequate exposure Design similar to trapezoid Good assistance requires that all move movements Preserves interdental papilla attachment between the operator and the assistant is well planned and Preserves attached gingiva coordinated to allow efficient delivery of service Same exposure as semilunar PROPER WOUND HEALING DEPENDS ON May be more prone to scarring 1. Patient’s ability to resist infection VERTICAL TUNNELING FLAP 2. Presence of essential nutrients for use as building materials 3. Ability to carry out reparative cellular processes Singular vertical incision Not a true flap Medical conditions may greatly affect wound healing Limited surgical exposure PRIMARY INTENTION SECONDARY INTENTION Often used as an access incision for creating a space No loss of tissue Gap exists between the 2 between bone and overlying mucosa for bone wound edges augmentation Tissues are placed back in Tissue loss prevents PEDICLE FLAP the original position reapproximation Minimal scar tissue occurs More scar formation Usually employed as a transpositional flap Healing is more rapid Slower healing Intended for covering defects or abnormal openings Less risk of infection Higher risk of infection Commonly used in repair of oro-antral fistulas PRINCIPLES OF INCISION GENERAL PRINCIPLES TO REMEMBER WHEN Blade orientation should be oriented perpendicular to epithelial PERFORMING INCISIONS: surface Sharp blade of the proper size Easier to re-approximate and suture o Make clean incisions Decreases susceptibility to necrosis o Bone and ligament dull blades more rapidly Incisions in the Oral Cavity should be properly placed Surgeon should carefully avoid cutting vital structures More desirable to incise through attached gingiva and over Common Blades Used In Oral Surgery healthy bone than through unattached gingiva and over No. 15 General utility blade for practically all minor oral unhealthy or missing bone surgical procedures No. 12 For incisions performed distal to posterior teeth PRINCIPLES OF INCISION No. 11 For stab incisions such as incision and drainage The incision should be made with a firm continuous stroke No. 10 For extra oral skin incisions The blade should not be lifted from the bone until incision is complete Types of Blade Grasp Soft tissue tags created by discontinuity in incision may produce poor healing due to poor blood supply Pen Grasp Allows greater control of the blade for fine incisions PRINCIPLES OF INCISION STEP BY STEP Palm Grasp Allows greater force during incisions 1. Make sure that the blade is always in contact with bone to ensure that the FLAP DESIGNS periosteum is incised together with the SEMILUNAR FLAP mucosa Half moon incision design Preserves interdental papilla attachment Preserves attached gingiva Limited exposure Tendency to cross bony defect May be more prone to scarring 2. The base of the flap should be wider than the free end ▪ Base of flap is the only portion of flap that remains HORIZONTAL FLAP attached Single horizontal incision ▪ This is the only source of blood supply for the free end Limited exposure ▪ Wide base ensures adequate blood supply for the flap Usually used for periodontal surgery and open extractions TRIANGULAR FLAP 1 vertical incision 1 horizontal incision Adequate exposure for variety of minor oral surgery procedures KARMIR | ROMANS 8:18 2  DMD – ORAL SURGERY 2 – BASIC PRINCIPLES OF ORAL SURGERY 3. Incision should not cross a bony defect present prior to ATRAUMATIC SURGERY surgery or that which will be created by the surgery Factors that damage tissues: ▪ Edges of the wound should be supported by sound Excessive pulling bone Excessive crushing ▪ Consider that the clinical defect is larger than Extremes of temperature radiographic appearance Dessication Use of non-physiologic chemicals Gentle handling of tissues WOUND HEALING COMPLICATIONS 1. Dehiscence 2. Tearing 3. Tissue necrosis 4. Vertical incision should be made on concavities between bony eminences DEHISCENCE ▪ The mucosa in the concavities is thicker and more Separation of flap margins resistant to laceration Failure of wound closure ▪ Being thicker, the mucosa is more vascular Causes o Poor flap design planning o Flap under tension o Lacerated margins o Scar contraction Effects of Dehiscence Dehiscence exposes underlying bone producing o Pain o Bone loss 5. Vertical incision should terminate at a line angle of a tooth o Increased scarring ▪ The integrity of the interdental papilla should be Prevention of Dehiscence maintained o Approximating edges of flap over healthy bone ▪ Splitting the papilla will encourage periodontal o Gentle handling of flap edges problems o Avoidance of flap tension PREVENTION OF FLAP TEARING Creating a flap large enough for adequate access and visibility to avoid o Unnecessary flap extension o A properly prepared long incision heals just as quickly as a short one Placing releasing incisions Generally started at the line angle of the tooth or in adjacent THE PERIOSTEUM MUST BE RAISED AS AN INTEGRAL PART OF interdental papilla THE FLAP Properties of the Periosteum: TISSUE NECROSIS 1. Highly vascular Death of a tissue due to deprivation of blood supply 2. Osteogenic properties Causes 3. Connective tissue Infections Because of changes in the shape of crestal bone reflection Damage to vital structures by the periosteal elevator may prove difficult if approach is Compression of blood supply made in an apical direction Poor flap design Failure of graft revascularization Medications (Bisphophonates) Chemicals (Paraformaldehyde) Radiation HEMOSTASIS Bleeding is an obvious part of surgical procedures Excessive loss of blood may prove life threatening for FLAP RETRACTION AND HANDLING surgical patients The flap should not be excessively twisted, stretched, or Prevention of excessive blood loss grasped with anything that might lacerate the flap or damage Uncontrolled bleeding leads to vessels o Loss of blood Flap retraction - Retractors should rest on bone and not o Poor visibility impinge on soft tissue o Hematoma formation KARMIR | ROMANS 8:18 3  DMD – ORAL SURGERY 2 – BASIC PRINCIPLES OF ORAL SURGERY Hematocrit – test measurement determining how much of POST OPERATIVE ASSESSMENT OF BLOOD LOSS the blood is composed of rbc Compensat Mild Moderate Severe o Normal M: 41-50% ; F: 36-48% ion o Loss of blood and response to transfusion is reflected Blood 500-1000ml 1000- 1500- 2000- in Hct loss 10-15% 1500ml 2000ml 3000ml o In acute hemorrhage, the immediate hct may not reflect 15-25% 25-35% 35-45% actual blood loss Blood none Slight fall Marked Severe Hemoglobin – iron containing oxygen transport pressu (60- fall (70- (50- metalloprotein in rbc re 100mmH 80mmHg) 70mmH o Normal M: 13.5-17.5 g/dl change g) g) o Normal F: 12-15.5 g/dl (systoli c) Replacing blood loss Signs Palpitation Weaknes Restlessn Collaps Usually, blood loss is replaced with crystalloids to maintain and Dizziness s ess e intravascular volume sympto Tachycardia Sweating Pallor Air Blood transfusion is usually indicated when anemia m Tachycar Oliguria hunger outweighs risk of transfusion dia Anuria o 7-10 g/dl o 21-30% Hct HEMATOMA Below 7g/dl hemoglobin or 21%Hct, the resting cardiac Escape of blood into tissue spaces output has to increase greatly to maintain normal Appears immediately at the area of involvement oxygen delivery a. Increased pressure b. Decreased vascularity RISK ASOCIATED WITH UNNECESSARY TRANSFUSION c. Tension on wound edges d. Media for bacterial growth 1. Infection 2. Allergic reaction Methods of bleeding control 3. Hemolytic reaction Application of pressure on bleeding vessels 4. Non-hemolytic reaction o Dab the wound rather than wipe o Better to use moist gauze Average blood volume (ABV) Pressure application Infants: 80 mll/kg o Pressure may be applied by packing or biting firmly on Adult men: 75 ml/kg gauze Adult women: 65 ml/kg o Finger pressure using gauze 1. Small vessels: 20-30 secs Estimated blood volume (EBV) 2. Larger vessels: 5-10mins w/ continuous pressure Body weight (kg) x Average blood volume Example: SUTURING Body weight of adult man: 70kg Method of approximating wound edges using a variety of thread ABV od adult man: 75 ml/kg like materials called sutures 70kg x 75 ml/kg = 5250 ml or 5.25 L Control bleeding Close wound Eliminate dead space ESTIMATION OF ALLOWABLE BLOOD LOSS Minimize scar formation EBV: estimated blood volume Hi: initial hemoglobin (patient’s hemoglobin) TYPES OF SUTURES Hf: final hemoglobin (lowest allowable hemoglobin) Non-Resorbable Suture do not readily dissolve and ABL: allowable blood loss requires removal. Less inflammatory reaction o Silk – natural; braided (multifilament) Formula: ABL = EBV x Hi – Hf / Hi o Nylon – natural; monofilament o Cotton – synthetic; braided (multifilament) Example: o Polypropylene – synthetic; monofilament Male patient weighs 70kg Hi – 15g/dl Resorbable undergoes dissolution and does not require Hf – 10g/dl removal. More inflammatory reaction ABL = EBV (5025ml) x Hi (15) – Hf (10) / Hi (15) = 1748.25m o Catgut – biological product from sheep intestine; monofilament ESTIMATION OF BLOOD LOSS DURING SURGERY Plain – difficult to use; resorbs in 5-7 days Measurement of amount of blood in suction bottle Chromic – easier to handle. Resorbs in about 2 wks o Measure total content of bottle o Polyglycolic acid and polyglactin – totally synthetic; o Subtract amount of fluid from irrigation Available monofilament and multifilament; resorbs in o Residual amount accounts for blood loss about 6 wks Consider blood from gauze or sponges o Polydioxanone (PDS) and polyglyconate – synthetic o 2x2 gauze ~ 3.5 ; resorbs in about 120 days; used seldomly for cases where long term resorption is required KARMIR | ROMANS 8:18 4  DMD – ORAL SURGERY 2 – BASIC PRINCIPLES OF ORAL SURGERY TYPES OF SUTURE NEEDLES LIGATION WITH SUTURES Tying off larger vessels tat may prove difficult to manage by mere pressure Use non-resorbable sutures USE OF ABSORBABLE HEMOSTATIC PACKS Gelfoam Surgical BONE WAX Made of beeswax with a softening agent such as paraffin or vaseline Smeared across the bleeding edge of the bone Blocks the holes and causing immediate bone hemostasis SUTURING TECHNIQUES through a tamponade effect Interrupted Bone wax inhibits bone healing Bone wax forms a physical barrier, preventing bone union In defects were bone wax was applied an removed after just 10 minutes, researchers discovered complete inhibition of bone regeneration Bone wax increases infection rates Continuous Beeswax has been proven to significantly impair the bone’s ability to clear bacteria Bone wax causes inflammation Bone wax remains as a foreign body for many years, causing a giant cell reaction and local inflammation at the site of application USE OF ELECTROCOAGULATION Continuous locking 3 conditions for proper thermal coagulation Patient must be grounded Cautery tip and the metal instrument it contacts should touch only the bleeding vessel Excess fluid must be removed USE OF PRESSURE DRESSINGS Horizontal mattress Creates pressure on small vessels promoting coagulation Too much pressure compromises wound vascularity Purpose of pressure dressing o Helps control bleeding o Helps prevent hematoma o Helps eliminate dead space o Helps prevent excessive post-operative edema Vertical mattress o Helps monitor exudates from wounds PLACING VASCONSTRICTIVE SUBSTANCES Epinephrine (Vasoconstrictor) Adverse effect: o Systemic effect o Effect is too transient Subcuticular o Rebound vasodilation Use of vasoconstrictors o Use must be for immediate control only o Not reliable means of controlling bleeding - Effect is too transient - Rebound vasodilation - Systemic effects Use of Systemic Hemostatics o Tranexamic acid injection o Vit K3 injections KARMIR | ROMANS 8:18 5  DMD – ORAL SURGERY 2 – BASIC PRINCIPLES OF ORAL SURGERY DEAD SPACE Place ice packs on freshly wounded area Any area that remains devoid of tissue after closure of the o Decreases vascularity hence, decreases transudation wound Patient positioning Created by o Keep head elevated during the 1st few days after 1. Removing tissue in the depths of the wound surgery 2. By not re-approximating tissue planes during Short term high-dose systemic corticosteroids Consequence of dead space o Effective only if administration is started before surgery Dead space > fills with blood > hematoma formation > risk of infx PATIENT GENERAL HEALTH AND NUTRITION Elimination of dead space Proper wound healing depends on the patient’s ability to o Suturing tissue planes together 1. Resist infection o Placement of packing into the void until bleeding has 2. Provide essential nutrients for use as building materials stopped 3. Carry out cellular processes o Pressure packs Placement of pressure WRITTEN AND ORAL INSTRUCTIONS 1. Dressings over repaired Thermal packs 2. Wound for 12-18 hrs Nutrition 3. Compresses tissue planes together until they are Hygiene bound by fibrin or by surgical edema or both Diet Use of drains Expected post op recovery o Suction drains – continually removes blood until Return to clinics bleeding stops o Non-suction drains – allows any passive bleeding to “In theory, theory and practice is the same. In practice, they drain to the surface rarely are!” DEBRIDEMENT AND DECONTAMINATION Principles were not made just to be read on books or literatures but to guide the surgeons for optimal patient care and Debridement removal of damaged tissue or foreign objects management from a wound Decontamination removal of microorganisms or hazardous substances from a wound DECONTAMINATION AND DEBRIDEMENT Bacteria contaminates open wounds o External environment o Oral cavity Risk of infection increases with size of the inoculum, therefore a decrease in bacterial count means a decrease in chances of infection IRRIGATION Dislodges bacteria and other foreign matter out of the wound by forcing large volumes of fluid under pressure Use sterile saline or sterile water w or w/o antibiotics WOUND DEBRIDEMENT Careful removal from injured tissue of necrotic, foreign, and severely ischemic materials that would impede wound healing Used for traumatically incurred wounds or for severe tissue damage caused by a pathologic condition EDEMA CONTROL Occurs after surgery as a result of tissue injury Accumulation of fluid in the interstitial space because of transudation from damaged vessels and lymphatic obstruction by fibrin VARIABLES CONTRIBUTING TO DEGREE OF SURGICAL EDEMA Increase amount of tissue injury = increase amount of edema More loose connective tissue contained in the region = more edema present CONTROL OF POST SURGICAL EDEMA Minimize tissue injury KARMIR | ROMANS 8:18 6  DMD – ORAL SURGERY 2 COMPLICATED EXODONTIA AND OTHER DENTAL COMPLICATIONS MEDICAL HISTORY THE DEGREE OF DIFFICULTY OF EXTRACTING A TOOT DEPEDS ON: Updated Density and elasticity of the surrounding bone Previous disease Integrity of the crown Current & Past drug therapy Root form of the tooth to be extracted Anesthetic Allergies DENSITY AND ELASTICITY OF THE SURROUNDING BONE DENTAL HISTORY Fracture of the tooth may occur as a result of the inability of Traumatic treatment episodes the bone to expand to allow movement of the tooth during extraction History of loss of consciousness The density of the bone varies: Prolonged bleeding o From individual to individual Prolonged healing o Depending on location Anesthetic allergies o Diet Attitude towards dental treatment o Bruxism o Age of the patient THOROUGH CLINICAL EXAMINATION o Existing systemic and local conditions Density of bone INTEGRITY OF THE CROWN Associated pathology Remaining dentition Extensive caries, root caries, large amalgam restoration, Soft tissue lesions previously root canalled tooth increases the chance of the crown to fracture leaving the root and increasing the difficulty of RADIOGRAPHS extraction Periapical ROOT FORM OF THE TOOTH TO BE EXTRACTED Occlusal Panoramic Difficulty in extraction may be encountered depending on root anatomy Other imaging OPEN EXTRACTIONS INFORMED CONSENT Tooth extraction procedures the require raising a flap to deliver Diagnosis the tooth Nature of procedure Extractions that require additional access and visibility Length of procedure Teeth that offer greater resistance to routine closed Healing course extractions Risk and complications Extractions that will require adjunctive procedures after Transfusion (if indicated) tooth removal Prognosis Removal of sharp bone in multiple adjacent extractions Cost of treatment Bone augmentation procedures DENTAL EXTRACTION IS THE MOST COMMON PROCEDURE IN Possible oro-antral closure THE PHILIPPINES COMPLICATED EXTRACTION NEED NOT REALLY BE Delay of more conservative treatment intervention COMPLICATED o Lack of time, money, and understanding A rational approach to varying anatomical situations Regarded as the cheapest treatment option Extractions maybe routine but they are never “simple WHEN ROUTINE BECOMES NEGLECT extraction” History of difficult extraction Envelope flap design is often times adequate Lack of anatomical considerations THE CONCEPT OF OPEN EXTRACTION IS BASED ON Lack of diagnostic supplements Lack of surgical technique/skill Raising a flap for better access and visibility Bone removal to expose a or part of a tooth to facilitate MISCONCEPTIONS THAT MAY LEAD TO COMPLICATED delivery EXTRACIONS Sectioning the tooth to lessen the force of tooth luxation 1. Dentists pull teeth – in reality we apply controlled against surrounding bone movements in various directions in order to dislodge a tooth out of its socket ADVANTAGES OF OPEN EXTRACTION 2. Dentists should be powerful to extract teeth – in reality, injudicious force may result in injury to adjacent tooth, Reduces the risk of unnecessary damage or trauma to the surrounding soft tissue and supporting bone tooth and surrounding structures 3. Raising a flap is traumatic and time consuming – rising a Facilitates difficult removal of teeth within a shorter period flap increases access and visibility thereby allowing of time controlled and safe delivery of a tooth Reduces the incidence of more complicated procedures 4. Open extractions should be performed only by oral surgeons – all dentists should be equipped with the basic skill and knowledge of open extractions 5. All extractions are the same – dentists should consider the degree of difficulty of extraction for each patient KARMIR | ROMANS 8:18 7  DMD – ORAL SURGERY 2 – COMPLICATED EXODONTIA AND OTHER DENTAL COMPLICATIONS DISADVANTAGES OF OPEN EXTRACTION 4. Care should be made in the use of elevators so as to not force the root tip to nearby vital structures or spaces like the Need for additional materials that may not be readily sinus available in the dental office Need to further explanation to the patient regarding the WINDOW APPROACH TO ROOT FRAGMENT RETRIEVAL procedure Windowed approach can be used to for root tip retrieval Dentist is uncomfortable with doing a flap and suturing without much removal of buccal alveolar bone More costly for the patient Surrounding anatomic structures must be considered in creating a window IMAGING Radiographs or other imaging techniques are valuable in determining the approach to tooth removal o Allows better assessment of tooth to be removed o Allows evaluation of possible involvement of vital structures o Allows incidental detection of other pathologic processes Importance of radiographs Careful radiographic assessment can spell the difference between minutes of controlled removal to hours of difficult retrieval Root can be push out through the apical end PHILIPPINE SITUATION Dentists do not consider radiographs as part of clinic set up Mindset that radiographs are additional expense rather than diagnostic advantage Most people who undergo extractions come from marginalized communities Goes without saying… Dentist doing this should already have a foundation on the basic principles of surgery, anatomy of the surgical sites, principles of flap design and suturing RETAINED ROOT FRAGMENT ENCLOSED IN BONE MODIFIED FORCEPS APPROACH IN REMOVING Retained roots that are enclosed in bone are removed SUPERFICIAL ROOTS utilizing techniques similar to impacted tooth odontectomy Modify the forceps technique by creating minimal flap to attempt The root fragment is localized with radiographs or other to reseat the forceps under direct visualization to achieve a imaging techniques better mechanical advantage o Sharp bone edges are filed o Area is irrigated Extending the grasp of the forceps o Flap is repositioned and sutured Beaks engage portion of crestal bone for allow more Bone removal should be extended to expose a greater contact portion of the tooth to facilitate removal specially in cases Beaks displace the bone labially by inserting the beaks of aberrant anatomy or pathology of the root like between the tooth and socket hypercementosis o Inspect the socket CREATING A GROOVE BETWEEN THE TOOTH AND BONE o Remove any sharp bony protuberance Exposes a greater amount of tooth that can be engaged by o Debride the surgical field irrigation of the op site with the elevator NSS can aid in removal of debris like bone chips Provides a space where the elevator can be positioned o Reapproximate flap and suture using the bone as a fulcrum DIFFICULTY WITH MULTI-ROOTED TEETH Multi-rooted teeth are more difficult to remove than mono- CREATING A NOTCH ON THAT TOOTH rooted teeth because each of the roots will offer their The notch created on the tooth itself using a round or fissure individual resistance to tooth luxation from the socket bur o Splitting a tooth into individual roots may facilitate Allows insertion of the tip of the elevator to better engage removal the tooth o Bi-rooted tooth with extensively broken-down crown Extraction of maxillary molars with widely divergent buccal BUCCAL BONE REMOVAL AND BUCCAL DELIVERY and palatal roots that require excessive force during 1. Buccal bone removal done to expose approx. ½ to 2/3 extraction can be removed prudently by dividing the root length of the root. Copious irrigation is performed during into several sections bone removal If crown is intact, the 2 buccal roots are sectioned from the 2. Straight elevator is applied like a shoe horn at the palatal tooth and the crown removed with the palatal root in a side bucco-occusal direction, then the remaining buccal roots 3. Attention should be made on the finger guard to prevent are removed individually with a root forceps or with instrument slippage elevators KARMIR | ROMANS 8:18 8  DMD – ORAL SURGERY 2 – COMPLICATED EXODONTIA AND OTHER DENTAL COMPLICATIONS After separating the roots, each root can be delivered using Complications that occur hours to days following surgery forceps or elevators IMMEDIATE COMPLICATION DELAYED CONDITIONS TO LEAVE A TOOTH ROOT COMPLICATIONS Root fragment must be small usually no more than 4-5mm Primary bleeding Secondary hemorrhage Root must be deeply embedded in bone and not superficial Hematoma Ecchymosis The tooth involved must not be infected and there must be Accidental extraction of adjacent Post op pain-dry socket no radiolucency around the root apex Dislodgment of adjacent Soft/bony tissue Nerve injury laceration RISK IS TOO GREAT IF TMJ dislocation Pathologic fracture If removal of the root will cause excessive destruction of Fracture of MX or MD Trismus surrounding tissues Soft tissue lacerations Carcinoma If removal endangers vital structures Oro antra fistula If attempts at recovering the root rip can displace the root into tissues spaces or into the maxillary sinus PRIMARY BLEEDING Common sites of Hemorrhage IF LEFT IN PLACE Inferior alveolar vessels Patient must be informed Anterior mandibular vessels Radiographic documentation of the root tip’s presence and Greater and lesser palatine arteries position must be recorded Incisive canal vessels Patient recall for several routine periodic F/U to track the fate of the root TYPES OF HEMORRHAGE BASED ON VESSEL INVOLVED MULTIPLE TOOTH EXTRACTION Arterial Venous Capillary Extraction multiple teeth in sequence Bright red Dark red Most common o Posterior teeth leaving first molar > Anterior teeth type leaving canine > M1 > C Pulsating / Steady flow Steady ooze o M3 > M2 > PM2 > PM1 > M1 > LI > CI > C spurting Rationale of sequence May lead to rapid May cause Trickling w/ o Empty extraction socket between the tooth decreases loss of blood vol significant blood minimal blood loss the hold of bone to the tooth making the tooth easy to loss extract o In multiple extraction alveoloplasty can be done in TYPES OF HEMORRHAGE BASED ON TIME conjunction to pre-prosthetic considerations Primary Reactionary Secondary Occurs at time of Within 24 hrs after After more than 24 MINOR ORAL SURGERY COMPLICATIONS 1-10% injury surgery hrs PAIN Usually by trauma Caused by Due to secondary 1st 24-48 hrs post op to vessels physical infection More than 4 days = investigate disturbance of clot Caused by Consider SWELLING infection or possibility of Inflammatory response malignancy systemic causes More than 4 days = investigate Challenges to hemostatic mechanism Every attempt should be made to minimize the amount of Highly vascular tissues surgical swelling and pain Extraction site leaves open wound Almost impossible to apply dressing material with enough Surgery should be atraumatic as possible pressure Sharp instruments Patients explore area with tongue Careful retraction Lysis of clot by salivary enzymes Lubricant Coolant PREVENTION OF HEMORRHAGE 1. Obtain history of bleeding PRE-MEDICATION 2. Use of atraumatical surgical techniques 3. Obtain good hemostasis at surgery Steroids 4. Provide excellent patient instruction NSAID’s Sedatives HISTORY TAKING (5 A’S) Antibiotics Aspirin COMPLICATIONS CAN ARISE Antibiotic Anti-coagulant Peri/intra-operatively (immediate) Alcohol Complications arising from the time just before surgery to Anti-cancer drugs the time immediately following surgery Postoperatively (delayed) KARMIR | ROMANS 8:18 9  DMD – ORAL SURGERY 2 – COMPLICATED EXODONTIA AND OTHER DENTAL COMPLICATIONS USE ATRAUMATIC SURGICAL TECHNIQUES HEMATOMA Escape of blood into tissue spaces Use sharp instruments Appears immediately at the area of involvement Protection of vital tissues Presents as a fluctuant swelling with bluish/black Careful retraction discoloration Avoid excessive use of force o Usually self-limiting Careful reflection of mucoperiosteal flaps o Monitor progress Socket should be curetted only when necessary o May result in infection if it fails to resolve by itself Compressing bony plates except when implants are ▪ Incision and drainage contemplated ▪ Antibiotic therapy COMMON METHODS OF CONTROLING BLEEDING ECCHYMOSIS Application of pressure packs Occurs days after the surgical procedure and represents Absorbable sponges - gelfoam, oxycel, surgicel blood that escaped into the interstitial tissues Locally acting hemostatic agents like tannic acid, ferric Management: chloride, silver nitrate o Self-limiting o Warm compress Tea bag Suture EMPHYSEMA Electrocautery Passage and collection of gas in tissue spaces or fascial planes APPLICATION OF PRESSURE PACKS Usually caused by high pressure air instruments and Common method of bleeding control is placing gauze pack injections over the extraction site o High speed handpiece Important to note that gauze must actually effect pressure o Air syringes on the extraction site o Air in anesthetic cartridge Usually sufficient for capillary bleeding of soft tissues and Signs and symptoms bony walls o Sudden swelling Profuse bleeding from within the socket caused by injury to o Crepitus larger vessels may require packing the socket tightly with o Erythema gauze Prevention o Use of low speed handpieces ABSORBABLE SPONGES o Caution with high speed instruments Gelfoam o Make sure to expel air from syringe Commonly applied agent to control minor bleeding Management Prepared from porcine skin o Usually no management is required as air will be Does not affect the clotting mechanism absorbed in blood stream Provides a mechanical matrix to facilitate clotting o Usually resolves in 3 to 10 days o Rare complication of pneumo mediastinum may occur Surgicel Chemo prophylaxis may be indicated Oxidized regenerated cellulose Basically the same as gelfoam GINGIVAL ND MUCOSAL LACERATIONS Lowers the pH and contributes to bacteriostatic effect Trauma due to injury Stimulates production of thrombin and fibrinogen o Vehicular accidents o Violence ELECTROCOAGULATION o Sports Is another manner to control bleeding using electrical currents Iatrogenic causes to seal exposed blood vessels o Caused by dentist or deliberate self harm Limitations of electrocoagulation ▪ Elevator slippage o Expensive equipment ▪ Electrosurgery o Electrodes must come in contact with bleeding vessels ▪ Inadequate flap relaxation o Not effective in areas flooded by blood ▪ Anesthesia related lip or cheek biting o Saliva may reduce efficiency May be prevented with good patient instruction RETRACTION TRAUMA PROVIDE EXCELLENT PATIENT INSTRUCTION This condition occurs as a result of injudicious retraction of the Do not spit or suck on straws tissues Do not smoke Prevention No alcohol Application of petroleum jelly Avoid hot foods Gentle retraction Do not touch extraction site with tongue Management Avoid strenuous activities Self limiting Avoid vigorous mouth washing Palliative KARMIR | ROMANS 8:18 10  DMD – ORAL SURGERY 2 – COMPLICATED EXODONTIA AND OTHER DENTAL COMPLICATIONS GINGIVAL AND MUCOSAL LACERATIONS ANESTHESIA / PARESTHESIA Management May result due to injudicious handling of tissue whereby there is Debridement and cleaning of wounds stretching, compression or actual damage to the nerves in the Remove tissue tags that are necrotic area Small wound may be left to heal by themselves Management: Antitetanus toxoid must be considered for dirty wound Tissue mapping Usually self-limiting SUTURE BREAKDOWN Vit B complex This my result due to misconception that wounds must be Microvascular surgery sutured tightly resulting in tissue tension Prevention DRY SOCKET (3-20%) o Suture with passive coaptation of tissues Alveolalgia, localized osteitis, alveolitis Management Faulty healing of extraction site o Re-suture the wound Results from clot dissolution o Allow re-epithelialization Pain and foul-smelling alveolus BUR TRAUMA Predisposing factors of Dry socket Accidental trauma due to friction from bur contact during the Existing periapical infection surgical procedure History of pericoronitis Management Collapsed or destroyed alveolar bone o Self limiting Multiple infiltration puncture o Palliative Excessive use of mouthwash Smoking NERVE INJURY Immunocompromised patient Sensory Motor Lack of coolant Inferior dental nerve Marginal mandibular Contraceptives Mental nerve Buccal Menstruation Infraorbital Long buccal Radiographs are of practically no value in the diagnosis of dry Incisive socket Lingual SURGICAL DRESSING NEURAPRAXIA Zinc oxide Low severity injury Eugenol Structure remains intact but electrical conduction down the Cotton fibers axon is interrupted typically by ischemia or compression Cotton fibers are incorporated into the mixture of zinc oxide injury and eugenol to act as a binder Secondary injuries can be caused by vascular damage leading to intrafascicular edema Keep in mind Effects of injury typically last from hours to weeks Complication is part of every treatment AXONOTMESIS Complications are minimized by proper good treatment planning and treatment techniques Disruption of the neuronal axon takes place but the myelin Consider the whole patient sheath is still intact Be aware of potential complication Caused by a crush based injury and not laceration Be prepared to manage complication Regeneration may occur over the timescale of weeks to years NEUROTMESIS Characterize loss of nerve conduction Damage to surrounding nerve trunk connective tissue In extreme complete transection occurs Commonly a neuroma forms over the proximal stump of the nerve Requires surgical repair SENSORY AFFECTATIONS Hypoesthesia decreased sensitivity to stimulation Hyperesthesia – increased sensitivity to stimulation Paresthesia – abnormal sensation , spontaneous or evoked Dysesthesia – unpleasant abnormal sensation, spontaneous or evoked Anesthesia – total loss of sensation KARMIR | ROMANS 8:18 11  DMD – ORAL SURGERY 2 SURGICAL MANAGEMENT OF IMPACTED TEETH IMPACTED TOOTH DEFINITION PERIODONTAL DISEASE An impacted tooth is developmental anomaly caused by Is common in at the between the contact area of the second and Obstruction in the eruption path third molars o Tooth Root resorption of distal surface of 2nd molar 24.2% o Dense bone Periodontal ligament destruction 42% o Hypertrophied soft tissue Incidence of > 5mm probing depth distal to 2nd molar when Ectopic position of the tooth 3rd molar was visible More commonly associated with mesioangular and ETIOLOGICAL THEORIES OF TOOTH IMPACTION horizontal impactions Mendelian theory Third molar removal can negatively impact the periodontium of Theory dictates that hereditary traits cause the tooth to be the adjacent second molar impacted Factors that may predict adverse outcomes: Theory suggests that if patient inherits the big teeth from Existence of an intrabony defect on the distal of the second one parent and small jaws from the other parent then lack molar of space will result Age at the time of surgery. Higher incidence >25 yrs old Size of the third molar / second molar contact area Phylogenic theory Inadequate post-extraction plaque control Theory dictates that evolution plays a role in tooth impaction Theory suggests that because of the softer diet today the Reduction of post-operative bone loss need for large powerful jaws has decreased and has No single surgical approach to the will minimize loss of become to small to accommodate all the teeth periodontal attachment was identified GTR and/or DBP may be beneficial pre-existing attachment Orthodontic theory loss > 3mm Theory stares that teeth become impacted because of o Further research for post-operative periodontal defects interference in growth Scaling, root planning and plaque control have the potential Theory suggests that anything that interferes with to reduce post-operative loss of attachment downward forward growth of mandible such as development disease, trauma, systemic disease or local PERICORONITIS disease Pericoronitis is the inflammation of the operculum overlying SHOULD WE REMOVE IMPACTED TEETH? a partially impacted third molar Where there is evidence of disease management is o Operculum – flap of soft tissue overlying a partially generally straightforward erupted tooth Uncertainty is more explicit in the case of patients who have It is the most common indication for odontectomy asymptomatic, “disease free” third molars Management of Acute Pericoronitis CAN THE COURSE OF AN IMPACTED TOOTH BE PREDICTED Determine if airway is compromised Only space available but not eruption course of eruption o Difficulty in breathing can be determined o Cannot swallow own saliva Impacted teeth can change position up beyond third decade ▪ Send to hospital emergency of life If airway is not compromised Adequate space is necessary for eruption of third molar o Adequate pain relief Eruption to occlusal plane does not imply good state of o Gentle lavage under operculum with 0.2% health particularly of soft tissue support chlorhexidine o Antibiotics if signs of spreading infection INDICATIONS o Enamelplasty of opposing when indicated Dental caries/root resorption Subsequent care Periodontal disease o Scaling and debridement Pericoronitis o Operculectomy o Tooth removal Facilitation of orthodontic treatment Pain of unknown origin OPERCULECTOMY Prosthetic consideration Surgical removal of loose flap of tissue overying a partially Jaw fracture erupted tooth Presence of cysts and tumors Possible treatment option for vertical third molars in class I DENTAL CARIES / ROOT RESORPTION position A or B Partially impacted third molars are susceptible to caries FACILITATION OF ORTHODONTIC TREATMENT because they may prove difficult to clean Impacted teeth may prevent proper orthodontic movement Pressure from the erupting third molar can cause resorption by way of obstruction of the distal surface of the second molar Some believe erupting third molars may cause anterior “Even in situations in which no obvious communication crowding between the mouth and the impacted third molar exists, IMPACTED THIRD MOLARS AND ANTERIOR CROWDING there may be enough communication to allow for caries initiation Etiology of dental crowding is complex and multi factorial KARMIR | ROMANS 8:18 12  DMD – ORAL SURGERY 2 – SURIGICAL MANAGEMENT OF IMPACTED TEETH While most suggest that third molars play at least some role ASA II Mild systemic disease in crowding, their role may not be clinically significant ASA III Severe non incapacitating disease No presently available study is designed in a manner that ASA IV Severe incapacitating disease that is constant isolates the effect f third molars from all other factors that threat to life may be associated with crowding Teeth can be moved orthodontically PAIN OF UNKNOWN ORIGIN Presence of jaw pain in the area of an impacted third molar ASYMPTOMATIC IMPACTED THIRD MOLARS: TO REMOVE OR with no clinical or radiographs signs NOT? All other possible sources of pain must be ruled out “If impacted teeth are left in the alveolar process, it is highly Patient must be informed that removal may or may not probable that one or more of a number of problems will result in relief of pain result” “Third molars should be removed in the younger age patient PROSTHETIC CONSIDERATIONS because there is less transitory or permanent morbidity” Undetected impacted third molars may give rise to pain as IMPACTED TEETH AND AGE RELATIONSHIP they become niece superficial due to bone resorption Removal may alter ridge and make denture less esthetic Periodontal health deteriorates with increasing age in the and functional presence of retained third molars. Bone may become atrophic and become susceptible to Caries in erupted third molars increases in prevalence with fracture increasing age. More complications associated with advanced age The incidence of postoperative morbidity following third molar removal is higher in patients > 25 years. Position and disposition of unerupted teeth has been found to be dynamic and unpredictable Germectomy may be associated with a lower incidence of postoperative morbidity. Decision regarding the management of is best made by an expert clinician after clinical examination and review o INFORMED CONSENT factors o Age of the patient Prior to any procedure informed consent should be obtained o Position of the tooth from the patient: o Anticipated difficulty of removal o Nature of planned procedure o Type of overlying prosthesis o Need for the procedure o Risks associated with removal o Risk of refusing procedure o Alternative procedures JAW FRACTURE o Post-operative course o Cost Presence of impacted tooth occupies space that should have filled in with bone ANATOMIC CONSIDERATIONS IN DETERMINING THE DEGREE OF Removal may result in fracture DIFFICULTY OF REMOVAL o Depth Space available o Position o Forces applies 5 Depth of impaction Presence of fracture at the angle of the mandible may Axial orientation necessitate removal of impacted tooth Root form Stage of root development PREVENTION OF CYST AND TUMORS Size of the crown There were 231 cysts (2.31%) and 79 tumors (0.79%) found Density of surrounding bone that were associated with 9994 impacted third molars Proximity to vital structures There were 70 cases (61.4% cysts/tumors and 38.6% Status of the periodontal space chronic inflammatory reaction) found that were associated Mouth opening with 2778 patients) CLASSIFICATION BY PELL AND GREGORY OF Development of cysts can occur even at a relatively AVAILABLE SPACE - MANDIBULAR THIRD MOLARS advanced age Class I – The mesiodistal diameter of the impacted third molar is less than the distance between the distal surface CONTRAINDICATIONS of the second molar and the anterior surface of the ramus Possible damage to adjacent vital structures of the mandible Compromised physical status Class II – The mesiodistal diameter of the impacted third Advanced age molar is more than the distance between the distal surface Impacted teeth can be moved orthodontically of the second molar and the anterior surface of the ramus of the mandible DAMAGE TO ADJACENT STRUCTURES Class III – third molar is completely within the ramus of the Neurovascular bundle mandible Maxillary sinus Adjacent functional teeth COMPROMISED PHYSICAL STATUS ASA I Normal healthy patient KARMIR | ROMANS 8:18 13  DMD – ORAL SURGERY 2 – SURIGICAL MANAGEMENT OF IMPACTED TEETH CLASSIFICATION BY PELL AND GREGORY OF PERIODONTAL STATUS AND SURROUNDING BONE RELATIONSHIP TO OCCLUSAL PLANE - MANDIBULAR Impacted teeth with wide periodontal space are more THIRD MOLARS readily removed Position A – Highest convexity of the impacted third molar Impacted teeth with large follicular sac is also readily is at the same level as occlusal surface of adjacent second removed molar Impacted teeth associated with cyst require removal of Position B – Highest convexity of the impacted third molar pathology as well is below the occlusal but above the CEJ of the adjacent o Pre-surgical diagnosis second molar o Cyst and tumors Position C – Highest convexity of the impacted third molar o May be more prone to jaw fracture is below the CEJ of the adjacent second molar o May need major surgical intervention depending on degree of invasiveness MAXILLARY THIRD MOLARS Density or surrounding bone Class A – Impacted maxillary third molar is at the same o Dense bone will make removal more difficult level as occlusal surface of adjacent second molar o Osteoporosis (low bone mass) may make removal Class B – Impacted maxillary third molar is above the easier but mor prone to jaw fracture occlusal surface of adjacent second molar bit below the CEJ MOUTH OPENING Class C – Impacted maxillary third molar is equal to or Mouth opening is not only related to the normal inter-incisal higher than the CEJ of the adjacent second molar distance Muscle activity plays a factor WINTER’S CLASSIFICATION ACCORDING TO AXIAL o Muscle weakness’ ORIENTATION: o Muscle tension Vertical Some procedure do not require the mouth to be wide open Distoverted o Removal of maxillary impacted teeth Mesioverted o Better half open and shifted to side of surgery Horizontal Buccoverted PREMEDICATION Lingoverted Analgesics/NSAID Inverted o Generally prescribed Torsiverted o Consider loading dose o Proper timing PROXIMITY TO VITAL STRUCTURES o Minimal effect on swelling Proximity to maxillary sinus o Consider pre-existing systemic problems NSA No sinus approximation. More than 2mm away from sinus Steroids SA Sinus approximation. 2mm or less distance from sinus o Effective for reducing swelling Antibiotics? RELATIONSHIP OF LINGUAL NERVE TO LINGUAL PLATE AND o Not an SOP CREST o Existing acute infection Approximately 2 mm. medial to the lingual plate o Medical conditions Approximately 4 mm. the lingual crest o Extent of surgery 14% are located above the level of the crest Antihemorrhagic drug 22% are in direct contact with the lingual plate o Not an SOP o While crating a flap on the lingual side mis not o Tranexamic acid – prevent clot dissolution’ contraindicated considerations of these relationships o Vitamin K – clot promoter should be made o Thrombin – clot promoter (intra-op) o Only horizontal flaps are allowed on the lingual side o Careful retraction should be done to minimize trauma SURGICAL PROCEDURE to lingual nerve The ease of the surgical procedure depends on careful planning based on assessment of diagnostic information ROOT MORPHOLOGY, STAGE OF DEVELOPMENT AND SIZE OF CROWN PAIN CONTROL Variations in root anatomy Technique of anesthesia o Fused conical roots are easier to remove o Local anesthesia alone o Divergent roots are more difficult o Local anesthesia with sedation o Hypercementosis and ankylosis o General anesthesia Stage of development o Easiest to remove when 1/3 to 2/3 root development THIRD MOLAR ODONTECTOMY o Germectomy may result in less post operative Incision and Flap Design complications Horizontal flap Size of the crown Triangular flap o The size of the crown may require multiple sectioning o Crown anomalies such as gemination KARMIR | ROMANS 8:18 14  DMD – ORAL SURGERY 2 – SURIGICAL MANAGEMENT OF IMPACTED TEETH ANATOMICAL CONSIDERATION DURING INCISION IMPACTED CANINES, SUPERNUMERARY AND OTHER TEETH The mandible flares as outward at the posterior end of the body ARCHER’S CLASSIFICATION OF IMPACTED CANINES DIRECTION OF INCISION Class I – palatal impaction (Horizontal, Vertical, Semi-vertical) Class II – labial or buccal impaction (Horizontal, Vertical, Semi- Using the occlusal grooves as a guide for incision may vertical) result in lingual nerve damage Class III – palato-labial impaction Incision is carried out laterally following the flare of the Class IV – impaction between lateral incisor and premolar ramus of the mandible between the internal and external Class V– impacted canine in edentulous arch oblique ridges The decision on how much bone to remove and number of ADDITIONAL CONSIDERATION IN NON-THIRD MOLAR IMPACTED tooth sections depends on the case at hand TEETH In some cases tooth can be delivered with minimal bone removal and tooth sectioning Involvement of other anatomic structures Palatal flap may necessitate cutting nasopalatine Some cases may require only bone removal neurovascular bundle o Collateral blood supply from greater palatine nerve GERMECTOMY o Minimal deficit is experienced Removal of the tooth that has not fully developed is sometimes Greater palatine neurovascular bundle should never be cut preformed particularly in cases when there is a predicted lack of o Maintain sulcular incision only (horizontal flap) space o Damage may result in flap necrosis No vertical incisions in the lingual side of mandible ODONTECTOMY OF MANDIBULAR THIRD MOLARS MAY HAVE o Avoid possible damage to lingual nerve and artery THE RISK OF: o Sulcular/ horizontal incisions only Risk of nerve damage Consider location of infraorbital neurovascular bundle o IAN : 1-5% o Especially true for high impacted canines o Lingual : 0.4-1.5% o Usually injured due to injudicious retraction Nerve deficit may result Consider location of mental nerve o Lip o May be affected in impacted mandibular canines, o Cheek premolars or supernumerary teeth o Teeth Consider possible involvement of maxillary sinus in o Gingiva maxillary posterior impacted teeth o Tongue o Oro-antral fistula o Taste o Root forces into the sinus Patient must be informed IMAGING Nerves do not have to be severed to manifest a problem Localize the impacted tooth Determine orientation of impacted tooth RECOVERY FROM NERVE INJURY Determine root anatomy of impacted tooth At least 50 percent of cases recover spontaneously Determine proximity to vital structures Standard objective evaluation of nerve injuries have been Detect associated pathologic conditions unsuccessful. CBCT is superior to routine radiographs Nerve surgery carried out between 4.5and 7 months, over *CBCT – Cone Beam Computerized Tomography 50 percent of patients probably show improvement. Most lingual nerve damage will recover tactile senses but PANORAMIC RADIOGRAPH not taste It is possible that in some cases there may be some OCCLUSAL VIEW recovery of taste in the case of lingual nerve repair Occlusal view may be beneficial in localizing mandibula teeth because tube can be place directly below the CORONECTOMY mandible Partial tooth removal, partial odontectomy or intentional root Maxillary occlusal views may be confusing and may lead to retention. misinterpretation Considerations Third molar is indicated for removal TUBE SHIFTING AND SLOB RULE Third molar ins in intimate relation to IAN SLOB stands for: same lingual, opposite buccal No standards of care regarding