SAS 5 FACTORS FOR PROPER BONE HEALING

PRINCIPLES OF INCISION  Vascularity: if not enough, cartilage forms instead of bone

1. Use sharp blades for clean cuts & less trauma
2. Use long, continuous stokes
o Repeated strokes increase tissue damage
3. Avoid cutting through vital structures
4. Incisions should be made w/ blade perpendicular
5. Place incisions over healthy bone for better healing
PRINCIPLES OF FLAP DESIGN
1. Prevention of flap necrosis
o Ensure enough blood supply to the flap
o Base of flap should be wider
o Length of flap should be no more than twice the width
of base
o Axial blood supply should be included in base of flap
o Base of flap should not be excessively twisted
2. Prevention of flap dehiscence
o Approximate edges of flap
o Not placing flap under tension
3. Prevention of flap tearing
o Create large flaps
o If necessary, use vertical releasing incisions
TISSUE HANDLING
 Avoid pinching when using tissue forceps
 Avoid exaggerated pulling
 Always irrigate
 Frequently moisten to avoid desiccation
 Avoid caustic substance from touching tissues
MEANS OF PROMOTING WOUND HEMOSTASIS
 Place pressure on bleeding vessel
 Ligation of bleeding vessel
 Thermal coagulation to fuse ends of cut vessels
 Place epinephrine, thrombin, collagen
 Immobility: promotes wound infection if fracture is contaminated
2 BRANCHES OF TRIGEMINAL NERVE COMMONLY INJURED
1. IAN 2. LINGUAL NERVE
TYPES OF NERVE INJURIES
1. Neurapraxia: contusion of nerve, continuity is maintained
2. Axonotmesis: axon’s continuity is disrupted
3. Neurotmesis: complete loss of nerve continuity (gunshot wounds)
TYPES OF NERVE HEALING
1. DEGENERATION 2. REGENERATION
SAS 19
POST OPERATIVE INSTRUCTIONS
 Hemorrhage: place moistened gauze/ tea bag (tannic acid) 30 mins
 Pain: peak 2-3 days after EXO -> Ibuprofen/ Acetaminophen
 Diet: soft, cool food high in calorie for 12-24 hrs after EXO
 Oral hygiene: resume normal hygiene 3-4 days after EXO
 Edema: peak 36-48 hrs after EXO
o 1st 24 hrs -> ice pack for 20 mins
o 2nd day -> neither ice nor hot pack
o 3rd day -> heat pack
 Trismus: medial pterygoid muscle -> affected during IAN block
 Ecchymosis: presence of blood in submucosal & subcutaneous
tissue; seen in older px due to
o Decreased tissue tone
o Increased capillary fragility
o Weak intercellular attachments
 Infection: antibiotic prophylaxis in immunocompromised px
SAS 20
SOFT TISSUE INJURY
 Tear of mucosal flap: most common
 Puncture wound
 Stretch/ abrasion injury: always moisten (Vaseline)

MEANS TO ELIMINATE DEAD SPACE: area devoid of tissue PROBLEMS ASSOCIATED W/ EXO
 Suture tissue planes together  Root fracture: most common complication associated w/ EXO
 Place pressure dressing  Root displacement
 Place iodoform packing o Maxillary molars: displaced in maxillary sinus
 Use of drains to drain remaining fluid or exudates  Perform Caldwell-Luc procedure
o Mandibular molars: displaced in submandibular space
DECONTAMINATION: constant irrigation of wound using NSS  Place lingual pressure to force tooth back up
DEBRIDEMENT: removal of necrotic & severely ischemic tissue the socket
EDEMA: accumulation of fluid in interstitial space because of transudation  Tooth lost into oropharynx
from damage vessels & lymphatic obstruction by fibrin
SAS 6 INJURIES TO ADJACENT TEETH
CAUSES OF TISSUE DAMAGE  Fracture: most common
PHYSICAL CHEMICAL  Luxation
Incision/ crushing, extremes of Unphysiologic pH/ toxicity,  EXO of wrong tooth: splint & stabilize tooth into socket
temp/ irradiation, dessication, those that disrupt protein
obstruction of arterial inflow/ integrity, those that cause OROANTRAL COMMUNICATIONS: maxillary molar EXO
venous outflow ischemia  Check if sinus was perforated
o Valsalva maneuver/ nose blowing test: note bubbles
STAGES OF WOUND HEALING  Tx for 2-6 mm perforation
1. INFLAMMATORY STAGE (lag phase) o Gelfoam (gelatin sponge) & figure-of-eight suture
o Lasts for 3-5 days  Sinus precautions
o Two phases: vascular & cellular phase o Avoid blowing nose, sneezing violently
o FIBRIN: principal material holding wound together o Avoid sucking on straws
o 5 cardinal signs of inflammation o Avoid smoking
2. FIBROPLASTIC STAGE
o Lasts for 2-3 weeks DELAYED HEALING
o Strands of fibrin crisscross forming latticework  Infection: most common cause of delayed healing
o Wound will be stiff & erythematous  Wound dehiscence: suture w/out tension
3. REMODELING STAGE (wound maturation)  Dry socket: iodoform gauze which contains
o Final stage that continues indefinitely o Eugenol, Benzocaine, Balsam of Peru (carrying vehicle)
o WOUND CONTRACTION: edges of wound migrate SAS 10
towards each other (3rd degree burn) ANXIETY CONTROL
 Local anesthesia -> BUPIVACAINE: longest-acting
FACTORS THAT IMPAIR WOUND HEALING (FINT)  Sedation
 FOREIGN MATERIAL o DIAZEPAM: given the night before surgery
 ISCHEMIA o LORAZEPAM: given on the morning of surgery
 NECROTIC TISSUE: act as a niche for bacteria
 TENSION INDICATIONS FOR EXO
 Caries  Malposed teeth
BASIC METHODS OF WOUND HEALING  Pulpal necrosis  Impacted teeth
1. Primary intention: no tissue loss, minimal scar formation  Periodontal disease  Cracked teeth
2. Secondary intention: tissue loss; EXO socket, deep ulcers  Orthodontic reasons  Supernumerary teeth
3. Tertiary intention: use of grafts to cover large wounds  Radiation therapy  Financial issues
SYSTEMIC CONTRAINDICATIONS FOR EXO TYPES OF SUTURING TECHNIQUES
 Pregnant px in their 1st or 3rd trimester 1. Simple interrupted suture: most commonly used in dentistry
 Hemophilia 2. Horizontal mattress suture: compresses wound together; used for
 Px taking a variety of meds soft tissue wounds
3. Continuous simple suture: used in long-span incisions; watertight
LOCAL CONTRAINDICATIONS FOR EXO SAS 14
 History of therapeutic radiation for cancer INDICATIONS FOR OPEN EXO
o Might lead to osteoradionecrosis  If excessive force is needed to extract tooth
 Teeth located w/in area of tumor  After initial attempts at forceps extraction failed
 Severe pericoronitis  If preoperative assessment reveals px has thick/dense bone
 Acute dentoalveolar abscess  Teeth has severe attrition due to bruxism
 Teeth w/ hypercementosis: radiopaque, apical root bulbous
CLINICAL EVALUATION OF TEETH FOR EXO  Teeth that have widely divergent roots/ dilacerated roots
1. Access to tooth  Close approximation to maxillary sinus
2. Mobility of tooth  Teeth w/ large amalgam restoration, carious crown, root caries
3. Condition of crown
TECHNIQUE FOR OPEN EXO OF SINGLE-ROOTED TEETH
RADIOGRAPHIC EXAMINATION OF TOOTH FOR EXO  Provide adequate visualization & access
1. Relationship to vital structures  Determine the need for bone removal
2. Configuration of roots  If bone removal is not enough, create a purchase point on tooth
3. Condition of surrounding bone o Use crane pick elevator to elevate tooth
SAS 11  Bone edges should be smoothened using bone file
CHAIR POSITION FOR EXO  Entire surgical field must be irrigated frequently using NSS
MAXILLARY MANDIBULAR  Flap is sutured back using 3-0 black silk or chromic sutures
Reclined at 60 degrees Occlusal plane parallel to the
Mouth is at or below surgeon’s elbow floor TECHNIQUE FOR OPEN EXO OF MULTIROOTED TEETH
 Reflection of adequately sized flap
MECHANICAL PRINCIPLES INVOLVED IN TOOTH EXO  Tooth is sectioned
LEVERS: elevators WHEEL & AXLE: cryer elevator o Use no. 8 round bur/ No. 703 or 557 straight fissure bur
o Mandibular molars are sectioned buccolingually
5 MAJOR MOTIONS APPLIED BY DENTAL FORCEPS o Maxillary molars: separate palatal root
1. Apical pressure: to minimize root fracture  Divided roots are elevated using No. 301 or Cryer
2. Buccal force: maxillary teeth SAS 15
3. Lingual pressure: mandibular molars Open-window technique: remove bone only at apical portion of root
4. Rotation pressure: maxillary incisors & mandibular premolars o Three-corned flap: preferred flap for this technique
5. Tractional force
SAS 12 Conditions that indicate root tip safe to be left in place
3 key differences between closed (routine) & open (flap) technique 1. Root tip must be small, no more than 4-5 mm in length
1. Incision 2. Flap 3. Suture 2. Root tip must be deeply embedded in bone & not superficial
3. Tooth must not be infected & no radiolucency in apex
Lingual beak: adapted first in adapting the forceps to the tooth
Thumb & index: fingers used to support alveolar process when extracting a Risk of removing root fragments
maxillary anterior tooth 1. Cause excessive damage to surrounding tissues
Maxillary canines: fracture of labial cortical bone 2. Endanger vital structures like IAN & mental nerve
Maxillary first premolars: most commonly fractured (bifurcation at apical 3rd) 3. Displace into other tissue spaces like maxillary sinus &
Maxillary 3rd molars: No. 210s Mandibular 3rd molars: No. 222 submandibular space

What to do after EXO? (CCSI) 3 fates of root fragments

1. Compress 2. Curette 3. Smoothen 4. Irrigate
SAS 13
DESIGN PARAMETERS FOR SOFT TISSUE FLAPS
 Base of flap must be broader to allow adequate blood supply
 Flap should be full-thickness
 Incisions must be made over intact bone. It should be placed 6-8
mm away from bony defect
 Flap should avoid injury to local vital structures
 Vertical-releasing incisions are not necessary. It must avoid bony
prominences. It should cross the free gingival margin at line angle
of tooth & not directly on facial aspect of tooth
TYPES OF MUCOPERIOSTEAL FLAPS
1. Envelope flap: create sulcular incisions
2. Three-corned flap: envelope flap w/ vertical releasing incisions
3. Four-cornered flap: w/ 2 vertical releasing incisions
4. Semi-lunar incision: used to approach only the root apex
5. Y incision: for removal of palatal torus
PURPOSE OF SUTURES
 Hold flap in position & approximate wound edges
 Aid in hemostasis acting as tamponade
 Help hold soft tissue flap over bone
 Aid maintaining blood clot in socket
1. Will eventually get ankylosed or fused w/ surrounding bone
2. Potentially infected especially if wound is not properly cared for
3. Resorb & move root tip superficially
Techniques on multiple EXO
 Avoid removing excess bone to support implant.
 Remaining alveolar ridge must be free from bony undercuts &
sharp bony spicules for placement of dentures.
 Maxillary teeth are extracted first before mandibular teeth.
 Removal should be from the most posterior teeth first. Canines are
the most difficult to extract thus, the last ones to be removed.
SAS 16
Most commonly impacted teeth
1. Maxillary & mandibular 3rd molars
2. Maxillary canines
3. Mandibular 2nd premolars
Ideal time for removal of impacted tooth: 17-20 yrs old
o When roots are 1/3 formed
Contraindications for removal of impacted teeth
1. Extremes of age
2. Compromised medical status
3. Excessive damage to adjacent structures

PRINCIPLES OF SUTURING
 Should be placed in papilla not above empty socket
 Needles are passed 1st w/ mobile tissue (facial tissue)
 Needle should enter at right angle
 Flap should not be tied too tight
 Placed 3-4 mm away from other sutures
 Knot should be positioned away from incision line
 SAS 17
Accessibility: primary factor determining difficulty of removal of impaction

CLASSIFICATION SYSTEMS FOR MANDIBULAR 3RD MOLAR

Based on angulation
1. Mesioangular: tilted towards 2nd molar in mesial direction
2. Horizontal: long axis perpendicular
3. Vertical: long axis parallel; most common in upper 3rd molars
4. Distoangular: lower 3rd molar is tilted toward ramus

Based on relationship w/ anterior border of ramus

1. Pell & Gregory Class 1
2. Class 2: 1/2 of MD diameter of crown covered w/ramus
3. Class 3: completely embedded in bone of ramus

Based on relationship w/ occlusal plane (OP)

1. Pell & Gregory Class A: OP is at the same level
2. Class B: between OP & cervical line of 2nd molar
3. Class C: below cervical line of 2nd molar

BASED ON EASIEST TO REMOVE DIFFICULT TO REMOVE

Angulation Mesioangular Distoangular
Anterior border of Class 1 Class 3
ramus
Relationship w/OP Class A Class C
Size of follicular sac Large Narrow
Root morphology Fused, conical roots Divergent, curved roots
Bone density Less dense (radiolucent) Denser (radiopaque)

SAS 18
Differences of surgical removal of erupted & impacted tooth
1. More bone is removed in impacted tooth
2. Impacted tooth needs to be sectioned

5 basic steps for surgical removal of impacted teeth

1. Reflect adequately-sized flap
2. Remove overlying bone
3. Section tooth
4. Delivery of sectioned tooth
5. Suture

Ditching: this maneuver gives access for elevators to gain purchase points