Oral Midterm 1
Transcript of Oral Midterm 1
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Introduction Lecture
Definition:
Speciality of dentistry of which includes : DiagonsisSurgicaladjunctivetreatment of disease, injuries and defects involveing both functional andesthetic aspects of hard and soft tissues of the oral and maxillofacial region
(Head and Neck)Scope of Oral SurgeryGeneral Dentist: Provides common, usually lesscomplicated, surgical servicesin the office
Interests, Pt. Needs, Office schedule
Training/Experience, Skill level
Physical plant, Instruments, Assistant
Good assistant will have a greater influence
Pt. is more comfortable w/ assistant than the dentist
Specialist: Provides full scope of services including services requiringadjunctive anesthetic or hospital management
Availability of specialistGeographic proximity
Standard of care
Team approach to pt. care = referral is an important thing to keep line ofcommunication
Pain and Anxiety Control
Surgery is both Art and Science
Compassion/Kindness/Humanism/Attention to Detail are required to be anexcellent surgeon
Patient safety and well-being are the ultimate goals
---------------------------------------------------------------------------------------------------------------Principles of Surgery
1- Developing a surgical diagnosis
Gather data and evaluate before deciding the procedure to be performed
Evidence based therapy: Treatment is based on research and science, not
just good ideas
2- Developing the Diagnosis
Chief Complaint: A direct quote from the patient
History of Present Illness: The story of the patients Chief Complaint(this is NOT the Past Medical History)
Past Medical History (PMH): A summary of the patients medical status as
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it relates to dental care: Includes Dangers, Rxs, Allergies, Need forProphylaxis
Physical Examination:
Pertinent Extra-Oral Findings
Pertinent Intra-Oral Findings
Diagnostic Imaging:
PAs, Panorex, CBCT
Formulate a Differential Diagnosis: a list that definespotential diagnoses
Determine the Final Diagnosis: This may include more than one problemi.e.: Acute Irreversible Pulpitis
Acute Apical PeriodontitisGrossly Carious
Non- Restorable---------------------------------------------------------------------------------------------------------------Treatment OptionsDiscuss possible treatment alternatives with the patient:
RCT vs. ExtractionRCT with Crown vs. Bridge (FPD)vs. Implant
Review Financial Commitment by the Patient (cost)+++++++++++++++++++++++++++++++++++++++++++++
+++++++
Proposed Treatment
Determine an appropriate treatment option harmonizing the diagnosis with
patient needs
Discuss and Obtain Informed Consent
Document the Consent Discussion and add the Signed ConsentForm to the permanent record
Accomplish Treatment
Obtain profound anesthesia, employing adjunctive measures to aid patient
comfort and facilitate the procedure Accomplish the procedure with attention to avoiding, not creating,
complications
Instruct the patient for post operative care
Follow up check and treatment, as needed
Principles of Surgery1- Basic Necessities For Surgery
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Qualified Assistant A CRITICAL factor
Good Visibility of the Surgical Site
Access Retraction and Protection of Soft Tissue
Lighting Adjustable Light or Headlight
Clear Surgical Field Suctioning of debris/blood/saliva/irrigation
2- Principles of Surgery (safety measures)
Aseptic technique relative, minimize wound contamination by path.microbes
Sterile Instruments Avoiding Cross Contamination
Operatory Disinfection
Barrier techniques Sharps Protocol
Protection of Patient and Staff----------------------------------------
3- Principles of Surgery-- Incisions-Basic Principles
Sharp blade of proper size (# 15)
Firm, continuous stroke & LONG
Avoid anatomic structuresMental and IA Nerves
Perpendicular to surface
Place incision in proper location for closure and healing over intact
bony margins or attached Gingiva
Bone + Ligamentdull blade faster Buccal mucosadoesnt dull the blade as fast
------------------------------------------4- Flap design
Will discuss in detail with surgical extraction techniques
Base broader than free margin to allow adequate blood inflow
and outflow
Margin away from surgical site and located over sound bone
BE KIND TO THE SOFT TISSUE !
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-------------------------------5- Tissue handling
Gentle retraction
Careful suctioning
Avoid burns from drills labial commissure
Tissue forceps injury to patient or crush artifact for biopsy specimen
6- Hemostasis EXAM
Prevent excessive bleeding flap design
Preserve visibility to facilitate surgery
Prevent hematoma meticulous hemostasis prior to closure
Hematoma is a greater source of bacterial infection
Prevent Necrosis
Base wider than apex, unless major artery is found
Side should be parallel or .. Length shouldnt become more than 2 the base
Base should be free of any grasped that might damage blood vessel
Retard Wound breakdown and infection
Pressure
Packing
Place Drain, if needed
Closure watertight closure usually NOT Indicated
Obtaining Hemostasis:
Assisting natural hemostatic mechanism Use heat to fuse ends of a cut vessel
Suture ligation
Place a vasoconstrictor substance
Hemostasis
Thoroughly Debride Granulation Tissue
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Control Bleeding from Socket, Bone
Pressure Directly on wound or vessel Pack the Socket
Soft Tissue: ligation of vessel
Hemostasis
Burnishing of Bone crushing of bone to occlude vessel Cautery: Chemical, Electrocautery Caution re: IAN
Infiltrate LA with vasoconstrictor
Hemostatic agents: clot promoters (collagen plug, HemCon)
Debridement : the surgical excision of dead and devitalized tissue and
removal of all foreign matter from a wound
Bone spicules/granulation tissue/tooth fragments
Adequate irrigationLate infection is a quality of care measure
Antibiotics make a mediocre surgeon out of a really bad one.- Larry Peterson
---------------------------------------7- Control edemaEdema: is accumulation of fluid in the interstitial space bc of transduction fromdamaged vessels and lymphatic obstruction by fibrin
Normal response to surgical trauma
Careful tissue handling
Pressure dressing
Elevation of head Gravity Dependent
Ice? May or may not help - gives the patient something to do
Corticosteroids (must give before injury/surgery)
NSAIDS
Post-operative Mobilization !!!
Infection Control/Asepsis (summary - important):
Patient Care and Regulatory issues
Protects patient as well as dentist, staff and other patients
Often cited violation by State Dental Board
Indication of Commitment to Patient Care/ Professionalism
Normal Orla flora contain:
Aerobic G+ Cocci (Streph), actinomycte
Anearobic (Canada)
Total Number of Oral Organisms is held in check by:
Rapid epi. Turn over w/ desquamation
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IgA
Dilution by saliva flow
Competition btw oral organism for avalible nutrients and attachmentsites
Infection Control
Communicable Pathogenic Organisms Aseptic Technique and Standard (Universal) Precautions
Instrument sterilization/disinfection
Operatory disinfection
Surgical staff preparation
Staff Preparation: Clean Technique for Office Surgery
Non-sterile gown
Gloves Change as often as needed
Mask
Hair, shoe covers as needed
Instruments are sterile when opened
Used for most office based intra-oral procedures
Cross-contamination is a major problem
Emphasis must remain on avoiding touching of anycontaminated item - mask, glasses, charts, chair, etc.
!! EMPLOY BARRIER TECHNIQUES !!
Surgical Staff Preparation: Sterile Technique
Sterile Technique is practiced in OR even when operating intra-orally(Consistent Technique)
Necessary for uncontaminated wounds (extra-oral) such as skin biopsy,
TMJ, Salivary gland surgery where no oral contamination is present
Sterile gloves, gown, drapes with strict adherence to touching only sterileobjects (touch only what is blue)
Precise and formal surgical scrub, gloving, and gowning techniques
End of Lecture 1
Peri-Operative Management
Goals of Post-op Care
Minimize Discomfort and/ or the PERCEPTION of Discomfort
Regain pre-operative function
Return patient to normal activities of daily life
Avoid Infection
A General Rule Pt. should feel better after 3-4 days
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Avoid infectionPost-operative Instructions (POI)
Educate patients about anticipated/ expected post op events
Instruct patients how to care for themselves
Instruct patients how to avoid complications
Educate patients to recognize complications
Things that are normal.Not good, but normal.
Soreness
Swelling
Chapped lips
Bruising
Minor Bleeding
Post Operative Bleeding
Minor bleeding is normal and expected
First part of the healing process
Gauze pressure should be placed directly over the surgical site
Gauze pressure should be maintained for 30-60 minutes, prior toreplacing gauze
Bleeding must be well controlled before discharge from the office
Gauze pressure must be placed directly on the surgical site, not theocclusal plane
Do NOT change the gauze TOO often - acts like a dry sponge pulls clotfrom socket, causes bleeding to continue
Moistening the gauze pad may be of benefit
Minor bleeding may occur after meals or brushing the teeth
Mild oozing may occur for 24-36 hours post-op
NO SPITTING !
NO STRAWS!
NO SMOKING! if the patient must smoke, then draw very lightly on
the cigarette
Minimize negative pressure intra-orally
Avoid strenuous exercise for 12-24 hours post-op May have bleeding on pillow overnight
A little blood and a lot of saliva, looks like a lot of blood
Prolonged bleeding, bright red bleeding , and large (liver) clots may
indicate the need for a return visit
Initially, liver clots may be wiped from the socket, the area rinsed, and
gauze reapplied with biting pressure
If needed, office evaluation should be accomplished on a after-hours
basis
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Postoperative bleeding causes
Failure of POI - poor instructions, poor emphasis,poor compliance
Poor quality tissue
Suboptimal surgical technique
Very rarely due to undiagnosed coagulopathy
Edema
Edema is ALWAYS expected after surgery
Degree is dependent upon the extent of surgery and quality of tissue
Maximum edema at 48-72 hours post-op
Gravity dependent
Ice packs may be used for 24-36 hours to limit swelling. MAY or MAYNOT HELP LIMITEDEMA
20 minutes on and 20 minutes off during waking hours
Dry cloth interposed between cold and skin avoid frostbite
Allows patient to take an active role in their care
Edema is, in part, gravity dependent
Surgical site should be elevated above the heart
Resting in a recliner is a good position
Limited inter-Incisal opening
Trismus an inability to open the jaw due to inflammation associated withtrauma or infection, a spasm of the muscles of mastication
Guarding limited opening due to pain or anticipated pain
Post-op patient may have both
Trismus -Inflammation, trauma
Masseter, Temporalis insertion may be traumatized with removal oflower 3rds
Medial Pterygoid may be traumatized during local anesthetic injections
Masseter, Buccinator may be inflamed due to buccal hematoma
secondary to PSA injection, removal of maxillary 3rd molar
Limited Inter-Incisal Opening
Warn, advise patients for potential decreased IIO
Early mobilization of the mandible retards muscle stiffness, increases IIO
Advance to a regular diet in the early post op period
Ecchymosis
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A hemorrhagic spot in the skin or mucous membrane forming a non-
elevated, round or irregular, blue or purplish patch
Blood in the subcutaneous tissue
A bruise
May be quite extensive
More likely in older patients with decreased tissue tone, intracellularattachments
Red-heads > blonds > brunettes
Fairly complexioned > darkly complexioned persons
May be quite alarming to patients!! Reassure the patient.
Reportedly does not increase pain or chance of infection
Onset over 2-4 days post-op
Purple green/ brown yellow
Usually resolves at 7-10 days post-op
Control of Infection Careful surgical technique is the most important consideration
Topical antimicrobials (chlorhexidine) may be of benefit
Antibiotics may be appropriate for selected individuals i.e. depressedhost-defense responses, extensive surgery, violation of anatomic spaces
For NON-surgical pt. use penicillin
For Surgical pt. use ..
Diet
Pain, fear may discourage patients from eating
The more you eat and drink, the better you will feel. Anything you want to eat or drink is fine
Soft, cool foods until Novacaine is gone: Nothing scalding hot until
the Novacaine wears off
Best to avoid coarse foods chips, popcorn, nuts
High calorie diet
> 2 liter fluid volume during 1st 24 hours
Limit caffeine or any diuretics
Oral hygiene
Good hygiene promotes healing Gently brush in routine fashion 3X / day
Avoid the areas of surgery
Minor bleeding is to be expected particularly after meals or brushing the
teeth.
Gentle chlorhexidine gluconate or saline rinses may promote healing
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Retainers
Orthodontic retainers, appliances should be used in routine fashion,
beginning on the day of surgery
Place the retainer once the novacaine has worn off. Do NOT wait until
edema precludes appliance placement.
Post-operative contact Patient should be instructed to call early in the day for post-op questions
or concerns
Facilitates scheduling of post-op visits in the daily schedule
Patient should receive emergency contact numbers i.e. cell phone,
beeper, & home phone
Considerations for Sinus Communications
Anatomy: teeth develop in proximity to the maxillary sinus
The surgical approach often determines the extent and size of the
communication Uncontrollable factors: size, depth , location influence need for and
extent of surgical closure
Tissue available for closure may require extensive repositioning of softtissue
POI Sinus Communications
Maintain equal pressure between sinus and mouth to avoiddisplacement of the clot !!!
Do NOT blow the nose!
Do NOT play a wind instrument !
Do NOT use a straw!
Do NOT smoke!
If a cough or a sneeze is unavoidable, open the mouth, turn the head
toward the floor and direct
The Healing of the sinus depend on: location and communication
o the sneeze or cough toward the floor through your OPEN mouth!
Gently rinse the surgical sites as directed
Take all medications as prescribed. Prophylactic antibiotics such asamoxicillin or Augmentin are commonly employed
Use of a nasal decongestant drops, not spray, may be helpful (i.e. %Neosynephrine). Check with your physician if you have high blood pressure.
For one-sided communications, please rest or sleep with the involved
side tilted up . This will promote drainage from the affected side. (ostiumof the sinus is above the level of the floor)
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Some bleeding from the nose may occur. Blot the area. Do NOT blow the
nose
Postoperative pain
Pain - a sensation of discomfort, distress or agony resulting from the
stimulation of specialized nerve endings
Always anticipated postoperatively Perception and psyche are significant influences
Should be addressed pre-operatively
Sore, but not miserable
Pain medication will help
Patients past experience and perception are very important !!!
Different philosophies:
o Youll be fine with Tylenol vs. Everyone gets a prescription
What pain medication has worked well for you in the past?
NSAIDs coupled with a Class III or Class IV analgesic are a good
combination for most patients
Analgesic should be started BEFORE the local anesthetic effect hasdiminished delayed onset of p o Rx
Take with food buffers against nausea, GI distress
Excessive narcotic use may cause drowsiness
Constipation occurs rarely
Class III analgesics
Hydrocodone compounds (Vicodin , Lortab) Codeine compounds (Tylenol #3)
Dihydrocodeine compounds (Synalgos DC9)
Class II analgesics
Oxycodone compounds limited use (Percocet, Percodan, Tylox)
Other Class II analgesics - seldom, if ever , used (Demerol , Dilaudid,morphine)
End of Lecture 2
Armamentarium
Scalpel
Handle: number 3
Blades: #s 15 (most common),11 (incision and drainage) ,12,10 (largerversion of #15)
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Proper technique for loading/ unload
Always use an instrument
NEVER USE FINGERS!
Cut with belly of blade perpendicular to epithelium (mucosa, skin)
Firm, uniform cut uniform pressure
Cut to depth (usually through the periosteum to bone) in a single
stroke Single patient use - Disposable
Change as needed, if blade becomes dull
Proper grip (pen grasp)
Periosteal Elevator
For elevating muco-periosteum from bone
#9 Molt
Pry/push and roll/scrape
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Retractors
Fingers are NOT routinely used unless palpating underlying structuresExamples: Minnesota*, Mouth Mirror,Weider (tongue)* - see pictures
Hemostats NOT for Driving Needles
Commonly used to clamp bleeding vessels (general surgery
Curved, Straight
Employed to debride follicle, granulation tissue, deliver fragments of teeth,
alloy
NOT for Handling delicate tissue or biopsy specimens will create a crush
artifact rendering the specimen unreadable
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1. Instruments for Grasping Tissue
Tissue forceps
Russion large, for teeth
Adson: with and without teeth, for soft tissue
Stillies longer
Allis- clamping removing large pieces of tissue
Cotton plier2.Instruments for Removing Bone
Bur and handpiece
High torque, no venting into wound = rear exhaust or electrical toELIMINATE AIR EMPHYSEMA
DO NOT USE A CONVENTIAONAL HIGH SPEED HANDPIECE !!!
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Nitrogen (90-100psi) or Electrical (Caution: Overheating)
#8 round, #701, 703 fissure
Erupted teeth - consider a 45 mm bur
Impacted teeth - consider a 51 mm bur
# 701, 8, 703 Burs: 45 vs. 51 mm see picture
2. Instruments for Removing Bone
Rongeur
Combination of side and end cutting
Works like a hedge shears or nail nipper
File or Rasp
Dental Curette spoon
Small - Periapical curette to debride apical cyst
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Large Remove follicle of impacted tooth
Removes tissue from bony defect double ended
3. Instruments for Suturing
Needle
Various Sizes and Shapes
Cutting, reverse cutting, taper
Suture material
Size (0 to 000000 or 0 to 6-0) common to OMFS
Monofilament vs. braided
Resorbable vs. Non-Resorbable
Needle holder
Proper grip: thumb and ring finger with palm down
Scissors
Dean Scissors -Commonly used for sutures and soft tissue
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Other
Bite block
Suction
Irrigation
Tonsil Suction
Vacuums pharynx
Surgical Suction
Clears surgical field
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#8 Frazier Suction with Stylette see picture
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4. Instruments for Extracting Teeth
Elevators
screwdriver or chisel
Forceps
pliers
Dental Elevators
Components
Handle, shank and bladeMost of our elevators use same handle and shank with variation of blade
Basic types see pictures for these
Straight-luxate teeth.
Small straight-301, Large straight-34S
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Triangle or pennant-shape recover root from socket
usually paired
Broken root remnants
Cryer (aka East/West) are most common
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Potts Eleveators:
Maxillary 3rd Molars
Portion of impacted teeth
Elevates and rolls
Curved roll teeth out of socket i.e. maxillary 3rd molar
Maxillary 3rds molars
Portions of impacted teeth
Elevates and rolls
Pick small, straight elevator
Remove roots
Crane/Cogswell-heavy
Root-tip pick-thin and delicate Heidbrink or double ended
* Hu-Friedy Heidbrink Root Tip Picks - Handle design improvesleverage
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Extraction Forceps
Provides a HANDLE on the tooth
Improves the LEVER ARM Works in similar fashion to a VISE GRIPS pliers
Components:
Handles
Hinge: English vs. American
Horizontal=American
Vertical=English (i.e. Ash)
Beak: Greatest variation
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Adapts to the ROOT
NOT CROWN
Maxillary Forceps
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Universal: - #150
Site specific:
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Universal Molar (Note Offset or Bayonet Design)
Right molar (53R, 88R)
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Premolar (150-A)
Anterior (1-A)
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Left Molar (53L, 88L)
Several Pictures in this section.
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#88 Right and LeftUpper CowhornsMaxillary Anterior #1A
Mandibular Forceps
Universal: - #151 A Style beakSite specific:- Molar (17, 23) #23 also called [Cowhorn]- Premolar (151A)- Mandibular incisors, canines, premolars (Ash)
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Proper hand
position for
maxillaryforceps
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Uncomplicated ExodontiaUncomplicated Exodontia
Baisc Principles
Clinical evaluation
Presurgical assessment
Radiographic evaluation Proper diagnosis/treatment plan - understand the indication for removing
the tooth/teeth
Informed consent
Surgeon and patient preparation Surgical assistant, instrumentation
Proper pain and anxiety control- Excellent Local Anesthesia
Access Chair position, soft tissue retraction, lighting
Extraction of tooth: closed or surgical
Post-op care of patient
Indications for Removal of Teeth Infection/ Acute Abscess Possible difficulty with local anesthesia, refer
for IV Sed or GA indicated, prior to attempting removal
Severe Caries
Pulpal Necrosis
Severe Periodontal Disease
Orthodontic Treatment
Indications for Removal of Teeth
Malopposed Teeth, non-functional teeth
Non-Restorable/ Cracked Teeth Pre-Prosthetic Extractions
Impacted Teeth
Supernumerary Teeth
Teeth Associated with Pathologic Lesions
Pre-Irradiation / Pre-Bisphosphonate Therapy
Teeth in the Line of Jaw Fractures
Aesthetics
Economics
Relative Contraindications for Removal of Teeth -Systemic Uncontrolled Metabolic Disease IDDM, ESR Failure, Hyper-thyroidism
Malignancy Leukemia, Lymphoma
Recent MI(b4 6 mo.), Unstable Angina, Uncontrolled HTN, CHF
Pregnancy
Immuno-compromise HIV/AIDS, Chemo/Radiation Therapy, Steroids
Bleeding Diatheses- Hemophilia/ Factor Deficiency, Platelet Disorder- ITP,
Anti-Coagualtion
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Medications that compromise hemostasis or ability to heal warfarin
(Coumadin), anti-resorbtive use (I.V. bisphosphonates, anti-resorbtivemedications) Have them check their INR
Relative Contraindications for Removal of Teeth - Local
Previous Head and Neck Irradiation osteo-radio-necrois (ORN)
Previous Systemic (I.V.) Bisphosphonate (Anti-resorbtive) Therapy ARONJ
(formerly BRONJ) Acute Pericoronitis increased likelihood of infection of major fascial spaces
( manage pericoronitis with local care, usual resolution in several days, thenextract)
Anatomic Considerations IAN, Sinus, Compromise of adjacent teeth,
Periodontal Defects
Potential for Pathologic Fracture
INFECTION / ACUTE ABSCESS IS NOT A CONTRAINDICATION TOEXTRACTION !!!!!
REFER FOR TREATMENT FOR SYSTEMIC SIGNS, SWELLING,
TRISMUS
Clinical Evaluation for Tooth Removal
Patient Attitude/ Ability to Cooperate
Access - MIO, Angles class, tongue size, gag reflex
Location and Position of the Tooth
Mobility Periodontal Involvement, Patient Age, Resiliency of Bone
Condition of the Crown, Previous Endo Tx
Condition of the Adjacent Teeth/ Restorations
Condition of Bone - Lack of Resiliency, Tori
Radiographic Evaluation for Tooth Removal
Proper Name/ Date (< 1 year old)
Proper exposure
Angulation
mas, kvp
developed properly - traditional films
enhancement of digital radiograph
Entire root visible
Relationship to vital structures
Sinus
IAN
Radiographic Evaluation for Tooth Removal
Configuration of roots
Length and morphology
Previous endodontic therapy, internal resorbtion
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Condition of surrounding bone
Density
PDL
Pathology
CAN YOU SEE WHAT YOU NEED TO SEE?
Prior To Procedure
PMH Verified? Previous Medical Hx
Proper diagnosis/treatment plan - understand the indication for removing
the tooth/teeth
Will the Proposed Procedure Obtain the Desired Result?
Will the Patient be Happy with the Result?
Informed consent: documented, signed, dated, witnessed
Surgeon and Patient Preparation Aseptic technique - relative
Personal protective equipment
Mask, gloves, gown, glasses - OSHA Compliant
Safety glasses for patient per clinic recommendations
Personal hygiene
Clothes, hair
Gauze throat screen
Chair and Operator Position for Dental Extractions
Access and visibility overhead light angulation and focal length
Stability
feet apart, weight distributed on balls of feet
Controlled force
Mechanical advantage
Surgeons health
chronic musculoskeletal strain (PROTECT YOUR BACK)
Patient comfort
Chair and Patient Position: Standing Surgeon Maxillary teeth
Maxillary plane >60 to floor
Maxillary arch level with surgeons elbow or below (elbow bent >90 )
Turn head so quadrant of extraction is easily visible
Lateral protrusive position of the mandible- moves coronoid processlaterally and away from the maxillary surgical site
Chair and Patient Position: Standing Surgeon
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Mandibular Teetho Chair Upright so that when mouth is open, occlusal plane is parallel to
floor, adjust headrest as neededo Bite block to support TMJ and Maintain IIO
o Lower Chair ( Elbow at >120 )
o Turn Head so that quadrant of extraction is easily visible
o Some prefer a Behind the Patient approach
Basic Principles
CONTROLLED FORCE
Mechanical Advantage, NOT Strength
NEVER USE EXCESSIVE FORCE !!!
RECOGNIZE WHEN YOU ARE NOT MAKING PROGRESS AND PROCEED TO A
SURGICAL APPROACH
Place finger/thumb on buccal plate to stabilize alveolus and evaluatedegree of force transmitted and tooth/mobility
DO NOT PULL THE TOOTH Intrude, Push, Rock, Rotate, Draw, and
Deliver
Simple Machines: Basis of Extraction Techniques
Lever
Wedge
Wheel and Axle
LEVER
Requires a FULCRUM
Lever-mechanism likely to break fragile elevators (root tip picks), teethand/or bone
Straight Elevator
Cryer elevators, Potts elevators
Cogswell, Crane, and others
Forceps are actually paired, opposing levers
WEDGE
SAFER with MORE CONTROL of FORCE
Straight elevators, root tip elevators
Direct along the axis of the root, in the periodontal ligament space,
between the tooth and the bone
Surgical blade is a form of a wedge
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WHEEL AND AXLE
Used to SCOOP tooth from socket
May generate EXCESSIVE FORCE
Purpose of ElevatorsPrimary:
Loosen teeth in preparation for extraction with forceps
Create space for forceps
May be primary mechanism for extraction, particularly for impactedteeth
Secondary
Remove parts of tooth or root
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Specific Elevators:Straight Elevators
Usually the initial instrument used during extraction
Primary use is for initial expansion of alveolus and loosening of tooth/PDL
(Lever and Wedge)
Often used incorrectly- DO NOT FULCRUM FROM THE ADJACENT TOOTH
FULCRUM ONLY FROM THE CRESTAL or INTERSEPTAL BONE
When used between teeth and only one tooth is to be extracted, care
must be used to avoid damage to adjacent tooth/restorations
Use with working end pointed from facial toward the lingual or apically
along the axis of the root
NEVER USE IN CROSS ARCH FASHIONbecause the elevator canpenetrate the cheek
Proper way to elevate
Elevator is used to force the tooth to expand the bone
Wedges the apical edge of the elevator against crestal,interseptal bone and
pushes the tooth
Avoids force on adjacent tooth
Straight Elevator When used to scoop the tooth out, significant force is placed on the
adjacent tooth. Dont do this routinely!
ACCEPTABLE TO USE THE ADJACENT TOOTH AS A FULCRUM ONLYWHEN
THAT TOOTH IS ALSO TO BE REMOVED !!!---------------------------
Cryer Elevators
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Lever, and/or wheel & axle forces
Careful as will fracture tooth, bone generates much force
Primary use is for removing residual roots of multi-rooted teeth, especiallyretained mandibular molar roots
Sharp tip removes inter-radicular bone providing access to the retained root
(two scoops)
Root Tip Elevators
Appearance seems to indicate they would be good lever for prying out
root tips. This will ruin the instrument.
FRAGILE - Prying forces will bend or break these instruments
Sole use is as wedge. Push fine tip apically to wedge root tip fromsocket or wedge tip into PDL to displace root
Wedging out a root tip with a straight elevator:1- Finger rest to control apical force2- Insert elevator within PDL3- Avoid pressure that will displace the root into the sinum
FORCEPS
Paired, opposing LEVERS
CLASS II LEVER: The load (tooth) is situated between the fulcrum (apical
bone) and the force (operator)
Primary force is initially in an apical direction to seat the forceps MOVES
FULCRUM TO APEX OF THE TOOTH
o Usethe root of the tooth to expand the alveoluso If you keep closing the forceps you can fracture the crown
Not for pulling teeth- use the forceps as a handle and lever comparable to a Vise Grips
Secondary force is buccal, lingual, and rotational to EXPAND THEALVEOLUS and release the tooth
Lastly, minimal tractioning force DRAW = DELIVER the tooth
Forceps movement produces significant wedging forces
The tooth is used as a wedge to expand the alveolar bone
o Use in lingual/buccal apical direction
Initial and greatest magnitude of force of apical. Secondary force is B/L.Expansion of the alveolar bone is the goal.
Non-Surgical ExtractionNo such thing as a simple extraction
Closed or Non-surgical is proper description
What makes it easy (or difficult) is the skill of the surgeon (or lack thereof)
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Step by Step Approach to Non-Surgical (Closed) Extraction:
Confirm profound anesthesia of soft, hard tissues, and pulp
Release soft tissue around tooth- Be Kind to the Soft Tissue
Elevate tooth with the elevator
Adapt forceps to the tooth: Luxate with forceps to expand the alveolar bone.
o Luxate: To throw out of place or out of join
Remove the tooth from the socket
Confirm that roots have been delivered in their entirety : Confirm normalroot anatomy, Check for cleavage planes and accessory roots: lookfor pdl fuz
Examine socket and debride soft tissue, debris, granulation tissue-curette
Compress socket (realign the labial cortical plate)
u dont want it narrow bc it iwill be diffic. For implant or ortho
treatment If you have undercut compress it a little
Place 2x2 gauze directly over socket and compress with occlusal force
Make sure you have good anesthesia, and Articane Shouldnt be used formandibular BlockLoosening of Soft Tissue Attachment
Sharp end of periosteal elevator (convex side toward periosteum): #9
Molt, curette, Woodson reflect to the crest
Also confirms soft tissue anesthesia
Allows forceps to be seated apically or elevator to be placedinterproximally
BE KIND TO THE SOFT TISSUE
Luxation of the Tooth with Dental Elevator
A straight elevator is commonly the first instrument employed
Perpendicular to interproximal space or parallel to the long axis of thetooth. DO NOT USE THE ADJACENT TOOTH AS A FULCRUM.
Luxate tooth
Tear, Disrupt PDL- bleeding into PDL hydraulic pressure facilitatingexpansion of the alveolus
Expands the bone
Avoid injury to adjacent teeth crowns, interproximal restorations
Confirms degree of mobility or establishes need for surgical extraction
If successful you can use forceps if not you go surgically
Never use Exccessive force or sth BAD is gonna happen
Fulcrum up the crest bone
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Adaptation of the Forceps to the Tooth
Choose forceps that has beaks that will adapt well to subgingival
morphology of tooth - engage intact cementumn
Confirm long axis of beaks clears adjacent teeth to avoid trauma.
Generally this requires the beaks to be parallel to the long axis of the tooth
We want to shorten the length of th root by placing the forceps more
apically on the tooth Seat with apical force (lingual/palatal before buccal)
Avoid pinching soft tissue place lingual or palatal beak first
Firm apical force
Moves fulcrum to apex
Moves center of rotation apically to retard root fracture
Expands alveolus and widens PDL space
If crown: Root ration is big
It is BAD for perio
It is Good for extraction
It is easier to see lingual/palatal
Luxation of the Tooth with the Forceps
Firm grip to hold forceps handles together in a stable position. Do NOTcontinuously squeeze the handles together as this will fracture the crown(exception is the mandibular #23 forceps = cowhorns)
Straight wrist with controlled force generated from shoulder andupper arm, not wrist
Firm, steady, sustained force hold, flex the bone to allow expansion of
the alveolus Initial force displaces the tooth apically
Lateral force is then applied buccally and then with less lingual/palatal
force
Rotate the tooth gently after initial mobilization
JUST LIKE WIGGLING A FENCE POST OUT OF THE GROUND oftencompared to a figure of 8 motion
Continue to re-seat the forceps apically as tooth mobilizes
DO NOT FRACTURE THE CROWN
It is hard mechanically to use forces. But
Pt. Postion + good mechanis = good extraction
***Opposite hand stabilizes alveolus and palpates for alveolar fracture ormovement of adjacent teeth. It protects adjacent tissue and prevents slipping thatcould harm the patient.***
Removal of the Tooth from the Socket
Slight traction, usually buccal is usually the final step to removal of a tooth
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Not a pulling motion
Traction = DRAWING motion
Draw: to cause (an unwanted element) to depart (as from the body or a
lesion)
Post-Extraction Care of the Socket
Remove Debris, if present
PA Lesion small curette
Calculus, Amalgam
Tooth Fragments
Realign Buccal Plate gently compress socket
Restore Pre-Extraction Anatomy
Do NOT collapse the B-L dimension of the alveolus, except for pre-prosthetic purposes
Debride Granulation Tissue from Gingival Sulcus
Smooth any Sharp Bone
Irrigate as needed
Control hemorrhage
Pressure with moist 2x2 gauze placed over the extraction space
Specific Forceps and Their Use: Technique for Extracting Specific Teeth
Universal Maxillary and Mandibular Forceps:150 and 151 and Variations
Seat beaks with firm and deliberate apical pressure
Moves center of rotation apically to decrease root fracture
Secures purchase on non-carious/sound tooth Further wedging force augments that already accomplished by elevator
Buccal-lingual force (primarily buccal) and rotation (single rooted teeth)
Figure-8 motion works well with multi-rooted teeth
Luxate as in removing a fence post
Maxillary Molar Forceps:53 and 88
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Off-set beaks may allow better access along vertical axis of the tooth
Less chance of damage to adjacent teeth
Beaks are designed to engage root morphology and improve apicalpurchase
Use with figure-8 movement
DO NOT use TOO much FORCE
DO NOT FRACTURE TUBEROSITYor BUCCAL PLATE
Low threshold for surgical extraction if only limited or no movement !!!
Mandibular Molar Forceps:Cowhorn #23
Designed to engage the furcation of lower molar
No crown required to engage the tooth may be better than Universal
forceps for broken down mandibular molar teeth
Must seat into furcation with pumping up and down action BEFORE
any buccal-lingual rotation
OK to squeeze the handles together, but anticipate a crown fracture or
rapid delivery of the tooth Works best for parallel = non-divergent roots
Seat on lingual first taking care not to injure soft tissue
Up and down motion with gentle pressure closing beaks together
squeezing handles together
Once seated, use water-pump handle, buccal-lingual motion, &/ or figure-
8 motion
Primary Teeth
If roots are not resorbed, long, divergent and fragile roots complicate
exodontia.
Likely to fail due to differential resorbtion caused by erupting permanentteeth especially premolars.
Bone is more flexible.
Care not to damage succedaneous tooth.
Post-Extraction Care of the Socket
Remove obvious PA pathology or socket debris.
Remove soft tissue pathology/granulation tissue
Realign Buccal Cortical Plate (Compress Socket) to restore pre-
extraction anatomy.
Moist gauze for pressure hemostasis.
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Complicated Exodontia
Complicated ExodontiaSurgical Extraction :
Delivery of the tooth requiring construction and elevation of a muco-
periosteal flap, removal of supporting/ impeding bone, and/ or delivery ofthe tooth in multiple pieces
MATHEMATICS OF EXTRACTION
FORCE + SURGERY = ( SURGERY + $ )
SURGERY + FORCE =
+ $
Complicated Exodontia
Flap design, construction, and elevation
Removal of supporting/ impeding bone
Sectioning (Dividing ) the tooth into smaller segments
Multiple extractions
CONCEPTS : NON- SURGICAL EXTRACTION
NON- SURGICAL = UNCOMPLICATED EXTRACTION:
Removal of a fence post
Push and wiggle side to side to expand the dirt and allow the post to
be drawn and removed
Concepts: Surgical Extraction
Goal: Expedite delivery of all tooth structure while maintaining necessary
alveolar contour
Create a path of withdrawal for the entire tooth or each individual
segment of the tooth Consider the shape/ contour of the remaining alveolar bone different
goals for implant, removable prosthesis, no prosthesis
Conditions Leading to Need for Surgical Extraction
Avoid Excessive Force !!! - fractures
Dense bone
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Exostoses, tori
Root morphology
Multi-rooted teeth
Dilacerations
Internal resorbtion
Age: Dense Bone vs. Ankylosis vs. Atrophic Periodontal Ligament ?
Body Build/ Genetic considerations- Race
Bruxism
Previous Endodontic therapy
Deep Caries
Adjacent Anatomic Structures: Sinus, IAN proximity
Compromised adjacent teeth crown, recurrent caries
Multiple extractions
Impactions
CONCEPTS
SURGICAL EXTRACTION:
Removal of a rock from the lawn
Push back the sod = expose the tooth by constructing and elevating afull thickness muco-periosteal flap
CONCEPTS
Options:
Remove a lot of dirt to remove the whole rock,
Or
Divide the rock into many smaller pieces,
Or
Remove some dirt and divide the rock into a few largepieces.
The initial plan for the approach to the tooth may be an uncomplicated or
closed extraction.
As the tooth is manipulated and more information as gained, the approach
may progress to a surgical approach. The approach to, and delivery of, the tooth is a dynamic process.
Flap Design: Development and Management
Design parameters
Types of muco-periosteal flaps
Technique for developing a muco- periosteal flap
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Design Parameters
BLOOD SUPPLY: Flap base MUST be broader than free margin
Allows inflow of arterial blood and outflow of venous blood. Lack ofadequate outflow leads to venous congestion and death of the tissue. -Nice picture slide #17
Adequate size: Big Flap = Big Surgeon
See what you are doing
Full thickness- Do NOT tear the flap
BE KIND TO THE SOFT TISSUE
Design Parameters
Incision over intact bone
Avoid injury to vital structures LINGUAL, MENTAL nerves Releasing Incision, if needed, to avoid tearing
Adequate Size: DONT work in a hole
Visualization: If you cant see it well, you cant do it well.Patient PositionLightingSuctioningAdequate Exposure of Surgical Site
Elevation of flap margins over intact bone Proper Instrumentation Retractors to displace and protect the soft tissue
Prevent tearing (sharp incision heals better than a tear)
If releasing incision required, extend at least one tooth anterior or/and one
tooth posterior flap margin must rest on sound bone
Common Flap Designs
Sulcular Incision
Envelope Flap No Vertical (Oblique) Releasing Incision
Envelope Flap with Releasing Incision
Posterior ( Distal ) Oblique Release May be Preferable Cosmetically
Release Tissue around the corner of the canine eminenceAnterior Vertical (Oblique) Release Incision
May Compromise Anterior Aesthetics try to avoid creating flaps
around anterior crowns which may expose the finish line andcompromise aesthetics
Probably Easier to design and work under an anterior release
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Around the Corner- Canine Eminence
Vertical (Oblique) Release Incision
Base is broader than free margin = loose edge of the flap
Cross gingival margin at the line angle of the tooth (May include tissue of
embrasure to facilitate suturing) Incision over intact bone, but not on an osseous prominence such as
the Canine Eminence tiger trap
Types of Muco-periosteal Flaps
Envelope
Sulcular incision in dentate patient
Crestal incision in edentulous area
Three cornered flap
Single vertical (oblique) release Posterior (distal) or Anterior (mesial)
release Four cornered flap
Anterior and posterior releasing incisions
Semi-lunar flap
apical to attached gingivae
periapical access retrograde endo
Y- flap
Palatal access for removal of tori
Pedicled flap
allows repositioning of tissue with its own blood supply closure of oral-antral communication
Developing the Flap
Sub-peri-osteal injection of LA - hydraulic force facilitates reflecting the
periosteum from the bone
Incision
Firmly, with scalpel blade contacting bone
Blade perpendicular to bone and soft tissue
A single stroke not multiple cuts
Developing the Flap
Reflection lift the periosteum and flap from the bone
Comparable to lifting up carpet or sod
Sharp end of periosteal elevator between periosteum and bone
Elevate along a broad front
Retraction protect the soft tissue
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Surgical Extraction of Single Rooted Tooth
Reflect the Flap
Determine Extent of bone removal, if any
Remove Bone Bur and COPIOUS IRRIGATION
Apical purchase of forceps on cementum
Irrigate well under depth of flap NO retained debris Elevate Flap and Gain Better Access Without Removing Bone
Deliver, Debride, Suture
Surgical Extraction of Multi- Rooted Tooth
Divide and Conquer Strategy
Identify furcation remove bone, if needed
Fissure bur (703,701) to section = divide tooth through pulpal floor intofurcation
Avoid violation of maxillary sinus floor Split tooth: divide root from root with straight elevator
Converts multi-rooted tooth into several single rooted pieces
Elevate or luxate and deliver root segments
Some options for divide and conquer:
Molar 2 Premolars
Molar Single rooted crown + root
Molar Roots 2 Roots
Max Molar 3 Roots
Fractured Roots
Some roots will fracture due to unfavorable curvature, or brittle nature
Thorough mobilization of the root prior to fracture facilitates delivery
Remove bone to create space into which the root can be elevated
Gently engage elevator into PDL space
Root Tip Elevators (Pick)
Fragile elevators
Appearance seems to indicate they would be good lever for prying out
root tips Easily damaged: use to wedge root tip from the socket
Prying forces will bend or break these instruments!
Only use is as a wedge. Push fine tip apically to wedge root tip from socket
or wedge tip into PDL and draw in a vertical vector to displace root tip ordisplace into created space
Root Tips:Tease or wiggle !!!Do NOT force apically !!!May displace root into sinus
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Remove Bone
Use bur to remove buccal or inter- radicular bone
Create a space into which the root can be elevated or expose adequate
tooth structure to engage with the forceps
Carefully Elevate the Root Tip! Gently elevate the root
If not mobilized, remove more bone
NEVER use excessive force !!!
May displace the root into sinus, submand space, FOM, or through the
buccal plate
Apical Window
Buccal bone overlying the apex is removed a window is created
Crestal, buccal bone is preserved
Root tip is elevated from apical area through window or into socket Do NOT violate sinus or IAN
Leaving Root Tips ? Indications:
Small piece-
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Evaluate at recall appointments
Multiple Extractions
Treatment planning
Sequencing
Technique
Multiple Extractions: Treatment Planning Replacing the Tooth you just pulled.
Replacement: Implant vs. Bridge
Implant: Maintain maximum volume of bone
Bridge: Favorable contours for pontic
Pre-prosthetic surgery: RPD vs. CD
Smooth alveolar contour
No prosthesis: May concentrate on delivering tooth expeditiously
Multiple Extractions: Sequencing
Maxillary first theory
Anesthesia obtained first and of shorter duration
Debris does not fall into lower ext sites
Mandibular first theory
Blood from maxilla does not obscure surgical field
Harder teeth first- surgeon is not fatigued
Multiple Extractions: Sequencing
Usually from posterior to anterior Recover all roots from one tooth before proceeding to the next tooth !!!!
Dense bone over 1st molar and cuspid
May elect to mobilize 1st molar and cuspid initially (loosen), extract
adjacent teeth, then extract 1st molar and cuspid
Hydraulic forces from sheared PDL may expand alveolus (?)
Treatment Plan: Implant ?
Preserve Bone height and width
If surgical approach, attempt to maintain
a 4-walled bony defect to allow osseous fill Consider grafting = socket preservation, if applicable
Treatment Planning: RPD or CD?
Maintain bone over canine eminences
Maintain buccal plate contour
Smooth osseous prominences
A take away process. Is this as smooth as I can make it ?, Will
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removing more bone make things worse ?
Palpate the alveolar contour through the soft tissue