oral surgery for general dentist

8/13/2019 Oral Surgery for General Dentist

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David B. Ettinger MD,DMD

Assistant Professor Oral and Maxillofacial

Surgery


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Caries

Periodontal Disease

Orthodontics

Tooth Fracture

Preprosthetic Preparation

Teeth Associated withPathologic Conditions

Chemotherapy and Radiation


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Involves minor alveolar bone expansion, separation of theperiodontal ligament, and simple coronal forceps delivery of thetooth

Use of appropriate specialized instrumentation Proper elevation of the tooth

Choosing the right forceps in order to be able to grasp the cervical portionof the tooth and position it as apically as possible to try to shift the centerof rotation toward the root

Avoid any traumatic extraction leading to further bone remodelingand ultimately more bone resorption


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Involves techniques to removeteeth other than by simple luxationof the tooth and forceps delivery

Elevation of a mucoperiosteal flap

Ostectomy

Sectioning of the tooth

Luxation and removal of roots Removal of radicular pathologic

condition when present

Debridement of the surgical fieldand removal of sharp bony edges

Wound closure


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Full thickness mucoperiosteal flap Allow for complete visualization of

the operative field Prevent unnecessary trauma to the

adjacent soft tissue whenremoving teeth

Provide an adequate working area

that will allow for the full removalof intrabony pathologic conditionswhen present


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Incisions should be placed overbone not planned for removal

The incision should be longenough to allow for a flapreflection without tearing

The base of the flap should bewider than the reflected free

margin Avoid placing incisions over vital

structures (mental foramen andlingual nerve)


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Sometimes it will be necessary to remove alveolar bone fromthe crown of the tooth or from the retained root to facilitateits removal

Constant irrigation

Must be as conservative as possible


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Active/chronic infection at site

Cyst formation

Tumors

Caries

Preparation for orthognathicsurgery

Preradiation therapy for head andneck cancer

Resorption of adjacent teeth

Tooth in line of fracture

Active periodontal disease arounddistal of adjacent teeth


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COMPLIC TION an additional problem thatarises following a procedure, treatment orillness and is secondary to it. A complicationcomplicates a situation.


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Removal of the wrong tooth Injuries to teeth and adjacent structures Residual root remnants Displacement of teeth or root tips Soft tissue injuries Oroantral communications Swallowing or aspiration of teeth, fragments of teeth, or restorations and

crowns Tissue emphysema Sensory nerve injuries Alveolar Osteitis (dry socket) Infection Trismus, swelling, or pain

Temporomandibular joint problems Hemorrhage Injuries to osseous structures


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Miscommunication betweenreferring dentist and officepersonnel with specialists office

Incorrectly labeled radiographs orreferral slips

Disagreement between dentist and

patient Inadvertent removal

If discovered at time of surgery,tooth should be implantedimmediately and stabilized

Patient should be informed


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Fractures and loosening adjacentteeth

Dislodging large restorations orcrowns

Careful evaluation of surroundingdentition and radiographs should

be done before institutingtreatment

Partially avulsed teeth should berepositioned and stabilized

Crowns should be recemented

Dislodged restorations temporized


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Dilacerated or divergent roots If remnant is 2-3 mm and in close proximity to a vital structure,

risks versus benefits should be considered

Usually small remnants will be of no consequence if not grosslyinfected

Post op radiograph Appropriate follow up


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DISPLACED ROOT TIP THROUGH THINLINGUAL PLATE


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Exposure of maxillary sinus Maxillary sinusitis or chronic

oraoantral fistula Widely divergent roots increase

the chance that the sinus floorcould be removed along with theroot

Less force should be used anddivision of roots should beconsidered if tooth roots in closeproximity with sinus floor


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Treatment dictated by size ofcommunication

Probing not advised

6mm communication must beclosed primarily using a flapprocedure; sinus precautions


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Laceration of the flap Burns

Abrasions

Puncture wounds Subcutaneous emphysema


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Seen less frequently since the useof rotary instruments such as theHall drill

Caused by the inclusion of airunder pressure into thesubcutaneous soft tissue duringremoval of bone or sectioning ofteeth with an air driven dentalhand piece

Rapid onset of swelling Tenderness Can be life threatening or result in

an infection leading to meningitisor mediastinitis

Tx: ice application, antibiotics, andclose monitoring


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Teeth or fragments of teeth,restorations, and crowns

Chest Xray for patients who haveswallowed/aspirated teeth tolocalize it

If aspirated during surgery and

lodged in trachea, methods usedin ACLS, abdominal thrusts, backslaps, Heimlich maneuver
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Can occur with the removal of teeth whose roots are close to theinferior alveolar, lingual, or mental nerve

Horizontally impacted 3rdmolars

Depth of impaction, presence of completely developed roots, use ofrotary instruments, and sectioning of teeth

Division of inferior alveolar nerve is infrequent but pressure and

compression can take place during removal of third molars Proper patient evaluation, correct flap placement, proper use of

rotary instruments, knowledge of anatomy, and informed consent


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One of the more common surgicalcomplications seen postoperatively

Smoking, oral contraceptives,mandibular teeth, experience ofsurgeon, complexity of extraction,

poor oral hygiene Dull throbbing pain on POD 3-5

with complaint of earache,headache, radiating pain, and norelief with analgesics

Malodorous

Extraction site devoid of clot


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Dry socket pastes containingeugenol, guaiacol, chlorobutanol,and balsam of peru are placed ona dressing and placed in thesocket

Dressings replaced every 2-5 daysprn

Obtain imaging if pain persistsbeyond 3 weeks


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Signs and symptoms typicallymanifest 5 days post op

Swelling,trismus,tenderness,erythema, fever, malaise, purulentdischarge

Flap elevation, bone removal, poorsurgical technique, poor oralhygiene, noncompliant patient,periodontal disease,immunocompromised patient

Tx: antibiotics, incision anddrainage, and acquisition ofcultures


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Pressure with a moistened tea bag or gauze pad Bone wax

Cautery

Absorbable gelatin sponges (Gelfoam)

Oxidized regenerated cellulose (Surgicel)

Microfibrillar collagen (Avitene) Absorbable collagen dressings (Collatape, CollaPlug)

Topical thrombin


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Due to lack of supportagainst lateral focesduring exodontia

Bite block

Other hand

Thorough history

Post op instructions


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Disocation of condyle


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oral surgery for general dentist

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