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DMD Oral-Surgery-Study-Review
DMD Oral-Surgery-Study-Review
PRINCIPLES OF BIOPSY 2
PRE-CANCER SCREENING 3
COMPLICATIONS IN EXODONTIA 3
PREVENTION 3
SOME ISSUES 4
EXTRACTION COMPLICATIONS 4
MUCOPERIOSTEAL FLAPS 8
TYPES OF SUTURES 9
REMOVING ROOTS 10
MULTIROOTED TEETH 11
INSTRUMENTS 12
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Principles of Biopsy
Biopsy = Taking of living tissue for Lab examination
2 Main Types:
Technique
1. LA
- Infiltrations will ↓ local bleeding 😊 But it it is too close to the site, LA might contaminate the sample
2. Select Representative tissue
- Adjacent to “normal” tissue, include some normal tissue for comparison
3. Incise Tissue
- Use elliptical shape -> this allows you to suture the wound closed without weird “dog ears” at the ends
- For highly vascular areas that are difficult to cut (FOM), can use a CO2 laser
- Consider local anatomy! Vessels, Nerves, Salivary ducts in the area
4. Remove biopsy
- To avoid issues, in general practice we will usually biopsy benign lesions <1cm. Anything iffy just refer
- Can add a single suture tied to 1 side to help lab orient the tissue (“This side up”)
5. Close wound
6. Send sample to pathology lab (Within 2 days)
- Lay the sample with epithelium upward on a piece of paper or cardboard
- Place this in 10x its volume of 10% formaldehyde/saline in a clearly labelled specimen transport container
and specimen bag
7. Await Results
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Special Techniques
Receiving lab must give you warning before you prepare the sample so you know what to do.
- Frozen Sections
o Ordered in the OR when a lesion is suspected of being malignant -> If it is found to be malignant, surgery happens right away
- Immunostaining
o DON’T place these sample in Formaldehyde, use Michelle’s Medium instead so the staining will work
Pre-Cancer Screening
A few methods exist
OroScreen
Velscope
- Hand-held device, adjunct screening for early detection of soft tissue dysplasia
- Pretty sensitive (if you know how to use it), but not at all specific: Cancer looks the same as Candidiasis etc
- Dr. Matthew hates it
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Complications in Exodontia
Peri-Operative Post-Operative
- Primary hemorrhage (Can’t stop bleeding initially) - Osteonecrosis
- Tooth Fracture - Osteoradionecrosis
- Tooth Aspiration - Secondary Hemorrhage (Bleeds again once a clot was already
- Tooth Displacement into anatomical space (sinus etc) formed at appointment)
- Jaw Fracture (too much force, especially with extracting 8’s)
Prevention
- Better than a cure! -> Finesse, not force
- Ensure a thorough pre-operative assessment and Tx plan -> Know your limits, surgery within in
- If you need to refer, do so OVER TELEPHONE rather than by letter
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Final Checks before Extraction
Some issues
Local Anesthesia Problems - Double check expiry date of LA
- Use your landmarks, make sure you are injecting in the proper stop
- Aspirate!
- Inject slowly
Soft Tissue Injuries Almost always due to
- ↓ attention to mucosal delicacy
- Rushing
- Use of excessive force
Tear of mucosal flap Most common soft tissue injury during oral surg.
- Often from inadequately sized envelope flap -> forcibly retracted = tearing at 1 end of incision
Avoid by:
- Creating adequately sized flap
- Controlling retraction force
- Create releasing incisions
Management
- Stop procedure and ↑ length of incision to gain better access
- Reposition carefully after surgery
- Can result in poor and delayed healing
Puncture Wound When sharp instruments (elevators usually) slip from surgical field
- Typically from uncontrolled force
- Use finger rest or support from other hand!
Management
- Apply direct pressure to wound if there is bleeding
- Leave would open and unsutured
Stretch, Burn or Abrasion Abrasions or burns can happen from shank of a bur rubbing on soft tissue or sharp edges of metal retractor
- Cannot really Tx this. Just keep it clean
- Heals in 4-7 days without scarring -> Rub salt water on wound multiple times a day
Management: 5-10 days for skin abrasions -> Cover with antibiotic ointment
Extraction Complications
Root Fracture Most common problem with extractions
- Preventable if you have good technique or use an open technique (remove bone)
- Remove the root tips asap
What if the roots are curved, divergent, dilacerated or hyper-cementosed?
- Use a surgical transalveolar approach
Root Displacement into Maxillary Caused by uncontrolled upwards pressure from extraction forceps or elevators
Sinus - Most often w/ conical single rooted premolars, and palatal roots of molars
- #1 root is the Palatal root from Max. 1st Molar
Remove displaced roots/teeth in sinus ASAP (otherwise give antibiotics until you can do it)
- Maxillary molar root is the most common to be displaced
<2mm = no Tx -> ensure a good blood clot and take sinus precautions
- Precautions ↓ changes in sinus air pressure that would dislodge the clot (no blowing nose, sneezing, sucking,
smoking
2-6mm -> Figure of 8 suture to hold retention of Surgicel, Gelfoam or PRF. Sinus Precautions, Antibiotics for 5 days
Management:
- Identify the size of root lost -> Take radiograph to determine position and size (ideally 2 radiographs 90o to each
other)
- Assess if there is an infection of the tooth or periapical tissues
- Assess pre-operative condition of the sinus
If the frag. Is small (2-3mm) and there is no pre-existing sinus condition:
- Irrigate through small opening with saline rinse at the apex of socket -> Then suction the irrigating solution. This
might flush the root apex through the socket
- Confirm radiologically that the tip has been removed
- If this doesn’t work, you can leave the root tip in the sinus. If it isn’t infected, probably wont cause a problem
Oroantral Communication Close the extraction site with a figure 8 suture over the socket
Provide antibiotics and nasal spray to prevent infection
- Find Hx of Sinusitis -> can cause poor healing, or a chronic communication leading to fistula
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Sinus Precautions for 10-14 days:
= Aim is to prevent changes in maxillary sinus air pressure that would dislodge the clot
- Open mouth w/ sneezing
- No sucking (straws or cigarettes)
- Avoid nose blowing
- If a smoker can’t stop -> small puffs
- See Pt at 48-72 hour intervals
Rx:
- Penicillin (or other antibiotic)
- Systemic decongestant for 7-10 days
- No antihistamines! They dry our the mucosa
Tooth displacement into Tissue Unerupted Upper 3rd Molars when elevated can slip behind maxillary tuberosity into infratemporal space (Maye migrates
space into neck even)
- Make sure you always place instruments behind upper 3M and have direct vision to
prevent this -> Laster Retractor
Mandibular 3Ms can have their roots pushed through thin lingual plate and into FOM
- Refer to oral surgeon for removal
Tooth Displacement into Inferior If roots fracture -> Lift out of the socket
Alveolar Canal Create channel of bone adjacent and under to the retained root with a fine diamond bur
Take Radiographs in 2 planes
Aspirated Root/Tooth Protect the airway with 4/4 Gauze or C-Sponge -> stop the issue before it even happens
If the tooth is inhaled:
- Usually in the R. Main bronchus (Larger and steeper)
- Send to Emerge for an X-Ray
- Refer via Telephone (more instant)
Fractured/Damaged teeth DON’T USE AN ADJACENT TOOTH AS A FULCRUM
- So easy to damage teeth or resto’s
Broken Resto’s = Most common Adjacent tooth injury
- Warn Pt pre-operatively of the risk to adjacent teeth/resto’s
- Careful with angulation of elevators
- Use controlled and appropriate forces with forceps etc
*If break off a resto -> Repair the resto BEFORE you finish the extraction*
- Blood will contaminate the prep if you keep going. AND the resto material can contaminate the open socket
Dry Socket = Delayed healing not associated with infection
- Caused by excess fibrinolytic activity (Lysis of blood clot and exposure of bone)
Add medicated gauze to cleaned out wound -> Ingredients: Eugenol (obtunds pain from bone), Topical LA
Extracting wrong tooth Avoid! Double check before you pull it out!
If you fuck up… IMMEDIATELY replace the tooth into the socket (before the tooth dries out)
- If its mobile, use ortho bonding/straight wire for 4 weeks
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**Weird trivia note: Phillipinos typically have 3 roots with their mandibular 1st molars -> Straanggee
Elevators Straight
- Coupland
- No. 301
Triangular Patterns
- Warwaick-James elevators
- Cryer Elevators
- Teeth are attached to bone through a Gomphosis joint -> Fibrous attachment of periodontal fibers from alveolar bone to the tooth root
o Periodontal fiber groups:
▪ Alveolar Crest fibers
▪ Horizontal Fibers
▪ Apical fibers
▪ Oblique Fibers
▪ Inter-Radicular fibers
- The Whole purpose of extraction is the dislocate this fibrous joint
- Obviously pulling teeth will hurt -> Ensure profound analgesia to prevent
traumatic experience
o Pt Anxiety can ↑ the perception of pain. Be Calm and confident!
- May consider Conscious sedation if the patient is particularly anxious
o Triazolam is ideal for our procedures -> ½ life is only 2-3hrs 😊
o Lorazepam is NOT ideal -> ½ life is 2-3 days, effects lasting way
too long for what we are doing
- Nitrous Oxide or IV Sedation are options also
3 Orchestral movements:
1. Grasp tooth -> Grasp the whole crown and 1-2mm of root beyond CEJ to ↓ chance of fracture
2. Expansion of bony socket -> Apply buccal and lingual force (mostly buccal) to expand the alveolar plate
3. Delivery -> Use a lateral traction force to remove the tooth! If you pull upward, you risk smashing the opposing
arch. Control the force
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Forces
Apical Pressure Breaks the periodontal seal -> Helps your forceps grasp below the CEJ
Forces to Break Perio fibers Buccal Force -> Expand the buccal plate of bone
Lingual Force -> Expand lingual crest of bone
Rotational Force -> Overall expansion of socket
Traction Force -> Delivers the tooth
Forces for teeth
Max. Teeth Bucco-Palatal forces
Mand. Teeth
Buccal + Lingual Forces
Figure of 8 movement
- Examine Tooth morphology -> Make sure all roots are present, check for rough spots on roots
- Compress alveolar bone -> brings it back to normal after all the dilation you did
- Place bite pack -> 2x2 gauze for 30 mins or until bleeding has stopped
- Give Post op instructions
- Ensure haemostasis
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Indications to leave retained roots - ↑ risk of displacing the root (into Max. antrum or Inferior Alveolar Canal)
- ↑ risk of damaging adjacent nerve or vessels
- Patient is soooo over it
Indications to remove the roots - Could compromise ortho or pros. Tx
- Irreversible Pulpitis
- You have good access
- Patient is compliant
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- Need for excessive force to extract tooth (Crowding, Dense bone, Jaw Fracture, Brittle tooth)
- Inability to remove a tooth with forceps -> Leading to uncontrolled force
o Reflect soft tissue flap, remove some bone, section the tooth/roots and extract in sections
- Thick Dense bone
o If cannot expand the buccal cortical plate -> ↑ chance of root fracture
- Hypercementosis
o Cementum continued to deposit on tooth = large bulbous root that is hard to pull out of socket opening
- Short Clinical Crown + Signs of severe attrition (bruxism)
o ↑ chance that tooth is surrounded by dense heavily bone
Patient Assessment
- Med Hx
- Suitability for Extraction (Level of Co-Operation, Previous Experience, Apprehension and confidence in you)
- Surgical Access (Small Mouth? Trismus?)
- Radiographs -> PA or Pan, or CBCT to see adjacent structures (like the IAN, or Max. sinus)
- Analgesia -> Do you do a block or infiltration?
Mucoperiosteal Flaps
Envelope Flap Just a simple horizontal incision, peeled off from the periosteum
- Edentulous Pt: Envelope made along the scar at the crest of the ridge
-> Limited vital structures here, so the incision can be long AF
- If they have been edent. For a while, the mental nerve may have migrated into the area =
Caution still
Envelope + 1 Releasing Place a vertical incision from one end of the horizontal envelope
Incision - Functions to ↓ the stress on the envelop and ↓ risk of tearing
(3 Corner Flap) - ↑ access and visibility for deeper regions in the envelope
Envelope + 2 Releasing Vertical releasing incision made at either end of the envelope incision
incision - ↑ assess and visualization
(4 Corner Flap) Ensure it is narrower at the Coronal portion of the flap vs the base
-> Ensures good blood supply to the flap
Semilunar Incision Avoids marginal attached gingiva when working on the root apex
- Most useful when you only need a limited amount of access
Takes a long time to heal -> Will look terrible at first, but after some time will heal very
well
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Y-incision Useful on palate -> Removal of palatal tori
- 2 Anterior limbs function as releasing incisions for ↑ access
- Avoid nasopalatine nerve + Greater Palatine nerve
Pedicled Flap Indicated to keep good blood supply to the socket and promote healing
- Heavy Smokers who have ↓ healing response
- The denuded bone of the palate will look terrible until soft tissues grows back over it
DO THIS 😊 NOPE -> Risk papilla necrosis NOPE -> Risk Recession
Types of Sutures
Single interrupted This is the principle technique. Used most frequently for the suturing we will do
Horizontal mattress Helps to appose displaced mucosa post extraction
Helps apply tension to mucosa after an extraction that lead to gingival bleeding
Figure of 8 Horizontal This is used to secure haemostatic agents placed within a socket post
Mattress extraction
Vertical Mattress Brings together underlying surface of oral mucosa (for deep incisions)
Continuous Lock Placed after multiple tooth extractions instead of placing many single interrupted
sutures
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Removing Roots
Bone Removal - Helps to mobilize tooth
- Use bone cutting bur after reflecting flap-> FG 70-02 OS
- Bone removed ½-2/3rd the length of the tooth root
DON’T use a regular high-speed turbine that you would use for Resto’s -> Risk of surgical
emphysema if air enters tissues
DON’T let the bone overheat (denatures alkaline phosphatase enzyme needed for bone
healing) -> Denatures at 55o
Sometimes you just need to remove bone to create a purchase point for your elevator between the
root and the alveolar bone
Luxation Delivers tooth
- When enough bone is removed, straight elevator can be used down the palatal aspect of the tooth to pop
it out buccally
- MAKE SURE you have a solid finger rest -> or you might slip and put the elevator
through their FOM (which would be both bad and embarrassing, and would take up
your lunch hour)
Delivery w/ forceps Once the bone is removed, and the tooth root luxated buccaly -> Use forceps to remove the root
- If you use a bone rauncher to elevate the tooth Dr. Matthew will kill you
Wound Debridement This is the final cleaning and tidying of the operating site before wound closure
- Not necessary for simple extractions unless debris is present
- Remove all loose bone, soft tissue, done dust, other debris and irrigate with sterile fluid
Can use:
- Elevator
- Bur
- Mosquito artery forceps
- Sterile saline irrigation
Wound Closure 2 main categories of sutures
- Resorbable and Non-Resorbable
- Typically we use “gut” sutures intraorally -> This is resorbable, but can be immersed in chromic acid to ↑
handling and ↓ resorption rate
Suture gauge
- 12/0 -> Fine suturing of microvasculature
- 3/0 or 4/0 -> Typical for intraoral use
- 0/0 -> THICCCC for suturing abdominal wall
Resorbable vs non-resorbable
- Pt typically prefer resorbable (don’t need to come back etc), but sometimes its better to place a non-
resorbable to ensure they come back for you to assess healing
Resorbable Non-Resorbable
- Can be left to resorb over several weeks - Made of silk most often
- Gut is the resorbable material of choice - Remove after 7-10 days
(plain is hard to handle, so we use chromic - These encourage plaque retention, which ↓
gut) wound healing
- Gore-tex sutures don’t encourage plaque
retention, but are $$$$
Sequence of Knots
1. 1st knot always repositions the flap -> Specifically the position of the interdental papilla
2. Additional sutures ensure the flap stays in place -> Suture from buccal to lingual
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Multirooted Teeth
Can divide up the tooth with a bur to convert a multirooted tooth into 2 or 3 single rooted teeth
Mandibular
OR
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Instruments
Name Picture/Use Name Picture/Use
Periosteal Elevator Detach Periosteum from bone/neck of tooth Straight Elevator Loosen tooth or root from bony socket
– Molt #9 (301, 1, 34)
Angular Elevators Loosen tooth or root from bony socket Root Tip Picks Loosen Small root fragments from bony socket
(Cryer, Potts, Crane) (Angled or Straight)
-> Cryer -> Angled
-> Crane
Surgical Curettes Remove tissue or debris from bony sockets Hemostat Securely hold small items, clamp
(Angular, Molt) blood vessels, remove small pieces of
-> Angled tooth/bone
-> Molt
Needle Drivers Hold Suture Needle -> Like Suture Resorbable -> Plain/Chromic gut, Polyglycolic Acid
hemostat, but with concave area Non-resorbable -> Silk, Polyester, Nylon, Polypropylene
inside each beak
Sizes in Dentistry: 3-0, 4-0, 5-0 -> Smaller # = wider diameter
Scalpel Rongeurs Cut and contour bone -> Remove sharp edges of alveolar crest and
(Side Cutting, remove exostoses
-> #11 -> #12 End Cutting)
Side Cutting
-> #15
Bone File Smooth bone for better contour of alveolar ridge (after rongeur) Tissue Scissors Cut and Remove excess or diseased soft tissue
(Straight or cross cut or (Dean, Iris, Kelly)
curved) -> Dean -> Iris
-> Kelly
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Towel Clamps Scary looking tool used only to hold Tissue Retractor Deflect and retract periosteum from bone
surgical drapes and secure tubing to (Austin, Senn, Selden
drapes -> Austin
- Randomly also used to
remove metal temporary -> Senn
crowns
->Selden
Tongue and Cheek Hold back tongue and cheek away from surgical site Surgical Aspirating Maintain clear working field by removing saliva, blood, debris
Retractor Tips
(Minnesota, Shuman, -> Minnesota (Byrd Self Cleaning, -> Byrd Self Cleaning
Weider) Cogswell, Frazier,
Yankeur Tonsil -> Cogswell
-> Shuman Aspirator)
-> Frazier
-> Allison
#103
(Man. Anteriors and #101 #103
Premolars)
#150 Universal (R +L) #151 (Universal R+L)
(Max. Anteriors and Premolars (Man. Anteriors +
Premolars)
#18R / L + #53 R/L Round Beak contours #15 + #17 *#17 has straight handle
(Right Max. 1st and 2nd Molar) lingual root (Man 1st + 2nd Molars)
Pointed back contours
bifurcation of buccal roots
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#88R/L Bayonet Beak #16 / #23– Cowhorn
(Max. 1st and 2nd molar) Beak w/2 projections (Ma. 1st + 2nd molars)
contours lingual root
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