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- 1. Sharp blade
- 2. Firm, continuous stroke
- 3. avoid vital structures
- 4. blade held perpendicular =squared wound edge
- 5. placed on attached gingiva and over healthy bone
- Incision for extraction incision on gingival sulcus
- 1) Flap necrosis
- 2) Dehiscence
- 3) Tearing
Prevention of flap necrosis: 4 principles (FIGURE 3-2!!!)
- 1. Apex (tip) of flap is never wider than the base, unless major artery is present in the base
- 2. Length of flap should be no more than 2X the width of base
- Less critical in oral cavity but still the length of flap never exceed the width
- 3. Axial blood supply should be included in base of flap whenever possible
- 4. Base of flaps should not be excessively twisted, stretched, or grasped with anything that might damage vessels
- which will feeding and draining of pulp.
Prevention of flap dehiscence (separation)
- 1. Prevented by approximating the edges of flap over healthy bone (gentle handling of flap’s edges)
- 2. Expose underlying bone pain, bone loss and scarring
Prevention of flap tearing
1. Flap tearing occurs frequently in surgeons trying to create flap without tearing/interrupting surgery
promoting wound hemostasis: 5 ways
- 1. Assisting natural hemostatic mechanisms: either fabric sponge for pressure OR hemostat on a vessel stasis of
- blood in vessels promote coagulation (small: 20-30 sec & large: 5-10minutes)
- NOTE: dab (not wipe) the wound!
- 2. Use of heat to cuase the ends of cut vessels to fuse closed (thermal coagulation) via electrical current
- 1) Pt must be grounded current entering the body
- 2) Cautery tip can ONLY touch pt at the bleeding site
- 3) Removal of blood or fluid accumulated around the vessel to be cauterized
- 3. Suture ligation: grasped with hemostat and ties a nonresorbable suture around the vessel
- 4. Placing pressure dressing over the wound pressure on small vessels that were cut promoting coagulation
- NOTE: MOST DENTOALVEOLAR CAN BE CONTROLLED BY PRESSURE!
- 5. Vasocontrictive substances (ex. Epinephrine) OR procoagulatns (ex. commercial thrombin or collagen)
Dead space mgt
- 1) Suturing tissue planes together to minimize post-operative wound
- 2) Pressure over the repaired wound
- 3) Packing into void until bleeding stopped then remove packing
- a. used when can’t tack tissue together ex. in bone cavity
- b. packing usually impregnated with antibacterial to infection
- 4) Use of drains no hematoma (may be with pressure drains) either suction or non-suction drains
- positioning (head above heart)
Releasing incision guidelines
- Avoid releasing over bony prominences
- Avoid splitting papilla
- Anterior release tends to provide better visualization and access
- soft tissue.
- rounded and produce the smallest hole,
- minimizing trauma
- skin repair.
- triangular shaped
- puncturing tough tissue
- produce a larger
- hole than tapered tips.
- Regular cutting tips: edge is on the inner curvature.
- Reverse cutting tips: edge is on the outer curvature
MOST COMMON USED suture in ORAL CAVITY
3-0 black silk
- – Gut
- – Chromic gut
- – Vicryl (polyglactin)
- – Silk, braided
- – Nylon, monofilament
- Each stitch is tied separately.
- May be used in skin or underlying tissue layers.
- More exact approximation of wound edges can be achieved with this technique than with the running stitch.
Running, or Continuous Stitch
- close tissue layers which require close approximation, such as the peritoneum.
- May also be used in skin or blood vessels.
- Advantages: speed of execution, and accommodation of edema during the wound healing process
- parallel (horizontal mattress)
- perpendicular (vertical mattress) to the wound edge. strength of closure;
- each stitch penetrates each side of the wound twice, and is inserted deep into the tissue.
How much xylocaine is in a 2% solution?
- • % = grams/100 cc
- • 1% = 1 gram/100 cc
- • 1% = 1000 mg/100 cc
- • 1% = 10 mg/cc
- • 2% = 20 mg/cc
How much epinephrine is in a 1:100,000 solution?
- • 1:1000 = 1 gram/ 1000 cc
- • 1:100,000 = 1 gram/ 100,000 cc
- • 1:100,000 = 1000 mg/ 100,000 cc
- • 1:100,000 = 0.01 mg/ cc
- • 1:200,000 = 0.005 mg/cc
A carpule contains
- 1.8 cc
- • 2% lidocaine ( 20 mg/cc) = 36 mg
- • 1:100,000 epinephrine ( 0.01/cc) = 0.018 mg
- • Lidocaine- 5 mg/ kg or 300 mg total
- • Lidocaine with epinephrine- 7 mg/ kg
- • Healthy patients- 10 carpules
- • Cardiac patients- 2 carpules
- – epinephrine increases cardiac sensitivity to
- predispose to dysrhythmias
Systemic extraction Contraindications
- • Severe uncontrolled metabolic disease
- – Diabetes, Leukemia, Lymphoma, Cardiac,
- recent MI, uncontrolled HTN
- • Pregnancy- first and last trimesters
- • Bleeding diatheses
- – Hemophilia, platelet disorders
- • Drugs
- – Steroids, chemo, immunosuppressives
- • Psychiatric
Local extraction Contraindications
- • Radiation
- • Teeth in area of tumor
- • ? Severe pericoronitis
- – Antibiotics, extraction of impinging
- maxillary tooth, operculectomy
- • ? Acute dentoalveolar abscess
- – Antibiotics, incision and drainage, trismus,
- difficulty anesthetizing
Indications for surgical extractions
- Type 1/dense bone
- Short clinical crowns (attrition)
- Hypercementosis & bulbous roots (older patients)
- Widely divergent or dilacerated roots
- Extensive caries (root caries)
- Large restorations
- Retained roots
- Close approximation of maxillary
- Unsuccessful “closed” (forceps)
- delivery Not so easy
Envelope flap size
- - extends 2 teeth anterior and 1 tooth posterior to the area of the surgery
- 3-cornered: 1 ant, 1 post
3-cornered flap with releasing incision size
- extends 1 tooth anterior and 1 tooth posterior to
- the area of the surgery
- envelope: 2 ant, 1 post
2 most important vital structures that can be damaged during extraction
- both located in the mandible:
- lingual nerve
- mental nerve
optimal Location of margins
- Solid bone is best
- 6-8 mm from bony defect
- Prevents wound dehiscence
After the flap steps:
- Reseat the forceps
- Subgingival grasp
- Use of straight elevator
- Buccal bone removal (trough)
- Split the tooth (divide and conquer)
- Envelope flap to expose crestal bone
- Teeth luxated with straight elevator
- Forceps delivery
- Buccal and lingual plate compression
- Removal of bone spicules & undercuts
- Reposition soft tissue
- Keep tissue in place
- Approximate wound edges
- Does not typically aid in maintaining a blood clot in socket
Hep B diseases
- acute/chronic hepatitis
- primary hepato-cellular carcinoma
Infective Hep B risk related to ___
HBV can survive ___
dry for 7 days
Heptavax (3 shot series)
Most common blood borne infection in US?
- acute/chronic hepatitis, cirrhosis, primary hepatocellular carcinoma
- No vaccine
chronic vs acute HCV
- acute: syptoms, HCV RNA and ALT spike
- anti-HCV ab's increase both
- chronic: Alt inconsistent spikes, HCV RNA gaps
- 85% acute, 20-50% chronic
- cirrhosis -> 20% hepatic failure, 20% HCC (30 years)
etiology of most US AIDS
What decreases HIV risk?
Post exposure prophylaxis
What % of HIV+ are coinfected with HCV?
infection risk factors
- exposure type
- amount of inoculum
- amt in pt blood at exposure
Virii relative infectivity
- HCV 1.8%
- HIV 0.3%
- HBV 37-62% HBsAg and HBeAg+ -> 22-31 clinical hepatits
- 23-27% HBsAg+ and HBeAg- (1-6% clinical hepatitis)
mucosal tear mgt
care/plan flaps, suture
direct pressure, leave open(secondary intention)
vaseline, ointment, scar mgt
antibiotic ointment (5-10 days)
crush injuries mgt
herniated fat pad mgt
- cause: excessive retration
- NO turbine drills, H2O2 rinses
- prevention: tight wound closure
- mgt: antibiotics, surgery if mediastinal involved
mandibular extraction complications
submandibular displacement: place finger over lingual plate when sectioning or removing tip, don't push apically. Try to manipulate root back into socket w finger
How avoid aspiration or swallowing?
- turn pt head to side of delivery
- aspiratioin: O2, broncoscopy, check right main-stem bronchus
- swallowing: high cellulose diet (bananas, sauerkraut
- follow tooth movement
If aspirated where is most likely location?
right main-stem bronchus
partial avulsion mgt:
stabilize w/ wire/acrylic splint, plan endo
wrong tooth extraction:
replace, stabilize, endo. consult ortho
alveolar fracture mgt
- small: remove
- large: equilibrate tooth, splint, allow bone to heal
maxillary tuberosity fracture:
- plan: beware isolated super-erupted posterior tooth
- mgt: if bone attached to periosteum: do not lay flap, stop, splint and defer 6-8 weeks, extract open surgical tech
- bone separated: smooth jagged edges, position and suture soft tissue to cover exposed bones or antral openings.
bone expansion should not be relied upon where?
mandibular molar areas, especially 3rds to reduce fracture risk
oroantral communication mgt
- non-epithelialized, 2mm or less: no closure, no suction, smoking, nose-blowing
- non-epithelialized, >2mm: surgical flap for primary closure , prescribe antibiotics. Recommend decongestant, nasal spray for involved side.
- epithelialized: refer
TMJ trauma mgt:
- soft diet, heat, analgesics
- dislocation: relocate, barrel bandage
intraoperative bleeding mgt:
- Blood vessels - clamp, tie or
- Tissue - tight suture
- Nutrient canal/bone - gently
- burnish bone; insert oxidized
- cellulose into socket and suture wound
prolonged post-op bleeding
- Remove all granulation tissue.
- Do not tear or crush tissue.
- Avoid damaging major vessels.
- Have patient bite on gauze for 15 minutes following surgery before leaving the office.
- Apply pressure with gauze.
- Tie off bleeding vessels.
- Burnish bone where bleeding.
- Apply Gelfoam® or Surgicel® to socket.
postop bruising (ecchymosis)
observation, moist heat packs
- Warm saline rinses, antiinflammatory medication, rule out hematoma.
- - if it worsens after day 5, suspect infection and refer to OMF surgeon.
- ("Dry Socket")
- Inform patient of risk if removing mandibular 3rd
- molars (the incidence of osteitis following removal of mandibular 3rd molars is greater than 5%).
- Use nerve blocks.
- Carefully debride the wound.
- Minimize trauma.
- Irrigate the socket with warm sterile saline.
- Place medicated dressing.
- Repeat daily for 1-2 weeks.
- Administer strong analgesics for the first few days.
- Utilize long acting anesthetics.
- failed to fully erupt into the oral cavity within its expected developmental time period
- no longer reasonably be expected to do so
- eruption is prevented by adjacent teeth, dense overlying bone, or excessive soft tissue
- most often become impacted because of
- inadequate dental arch length and space in which
- to erupt
- retained for lifetime unless removed surgically
- proactive: removal should be considered as soon as
- diagnosis is made AND treatment can be safely performed
most commonly impacted teeth
- 1. third molars (“wisdom teeth”)
- 2. maxillary canines
- 3. mandibular premolars
3rd molar avg eruption age
3rd molar development
- begins horizontal, mesioangular, vertical
- failure of rotation is mcc of impaction, then inadequate space anterior to anterior ramus
3rd molar extraction contraindications
- fully erupted
- at occlusal plane
- in function
- adequate keratinized gingiva
- no evidence of cheek biting
- no periodontal pockets
- no caries
- extremes of age
- compromised medical status
- damage to adjacent structures
- “first do no harm”
ideal time for 3rd molar extraction
- 1/3 -2/3 root formed
- late teenage (16-18), recover easier
- if root not formed, spins in bony socket->multiple sections
- Class 1 = 0% ramus coverage of impacted
- Class 2 = 50% ramus coverage
- Class 3 = 100% ramus coverage
- Class A = impaction same as 2nd molar
- Class B = bet. occlusal plane & cervical line
- Class C = below cervical line of 2nd molar
easy mandibular 3rd molars
- mesioangular (horizontal?)
- ¡ Class 1, A
- ¡ roots partially formed
- ¡ wide PDL
- ¡ wide follicular space
- ¡ elastic bone
- ¡ distance from 2nd & nerve
- ¡ soft tissue impaction
- ¡ young patient
Most likely places fracture
- B over maxillary C and molars (esp 1M)
- Floor of maxillary sinus associated with maxillary molars
- Maxillary tuberosity
- Labial on mandibular incisors
Lingual nerve precautions
- a. Located directly against the lingual aspect of mandible in retromolar pad region
- b. Lingual nerve rarely regenerates make incision well buccal!
Trigeminal nerve branch precautions
- 1)Mental nerve: esp during surgical removal of mandibular PM roots or impacted PM and periapical Sx
- a. Result in temporary/permanent anesthesia/paresthesia of lip and chin
- b. If 3-cornered flap in area of mental nerve: vertical releasing incision far anterior to avoid severing of
- mental nerve (NOT at interdental papilla between canine and 1PM)
- 2) Lingual nerve
- a. Located directly against the lingual aspect of mandible in retromolar pad region
- b. Lingual nerve rarely regenerates make incision well buccal!
- 3) Buccal nerve
- 4) Nasopalatine nerve
- NOTE: Buccal and nasopalatine nerves: damage during flaps for removal of impacted teeth, but since the area of innervation is
- small and rapidly reinnervated without sequelae or complications
- 5) Inferior alveolar nerve
- a. Most common place of injury: area of mandibular 3M during extraction
- b. Common enough that must inform pt of possibility
- International Normalized Ratio (INR): takes prothrombin time (TP) and control
- Normal: 2-3
- Okay to do extraction when INR of 2.5 or less without reducing anticoagulant dose
Common area of exposed bone after tooth extraction:
- internal oblique ridge after extraction of 1/2M
- Lingual flap stretches over internal oblique
- bone perforates
- sharp projection of bone in area
- 1) Leave projection alone: exposed bone will slough off in 2-4 wks method of choice if no sharp bone
- 2) Smooth it with bone file without flap (because flap will amt of exposed bone)
- Require anesthesia
- Only for sharp bone!
dry socket proposed cause
- levels of fibrinolytic activity lysis of blood clot and subsequent exposure
- of bone
- fibrinolytic activity: maybe result of subclinical infection, inflammation of marrow space or others…
- 3. Incidence:
- After routine extraction: 2%
- Removal of impacted 3M: 20%
- 4. Prevention
- Minimize trauma and bacterial contamination of area of surgery
- with preoperative and postoperative rinses with antimicrobial mouth rinses (chlorhexidine) up to 50%
- 5. Tx: relieving pain during healing
- Gentle irrigation and insertion of medicated dressing
candida preventive factors
- ① Rapid epithelial turnover with desquamation
- ② Host immunologic factors (ex. IgA)
- ③ Dilution by salivary flow
- ④ Competition between oral organisms for available nutrients and attachment sites
Nasal/paranasal antimicrobial factors
- ① Ciliated respiratory epithelium
- ② Secretory immunoglobulins
- ③ Epithelial desquamation
Universal precaution terms
- 1. Sepsis: breakdown of living tissue by action of microorganisms and is usually accompanied by inflammation
- Not mere presence of microorganism!
- 2. Asepsis: avoidance of sepsis
- 3. Medical asepsis: attempt to keep pts, staff, objects as free as possible of agents that cause infection
- 4. Surgical asepsis: attempt to prevent microbes from access to traumatic surgically created wounds
- 5. Antiseptic: substance applied to living tissue that prevent multiplication of infectious microbe
- 6. Disinfectant: substance applied to inanimate object that prevent multiplication of infectious microbe
- 7. Sterility: NO/free of viable microbe
- 8. Sanitization: reduction of # of viable microbe to safe public health standards
- 9. Decontamination: reduction of # of viable microbe (not associated with public health standards)
Sterilization with heat (either dry or moist)
- Oldest method used by Pasteur and Koch
- Monitor by endospore: Bacillus stearothermophilus (tests hospital and dental offices’ sterilization)
- 6 months after sterilization possibility of organism entering sterilization bags label with expiration date
- Dry Heat:
- 1) Sterilize glassware and bulky items that can withstand heat but rusts!
- 2) Success by attaining temperature and sufficient duration of time!
- 3) Advantage: relative ease of use and unlikelihood of damaging heat-resistant instruments
- 4) Disadvantage: time and potential damage to heat-sensitive instruments
- Moist Heat:
- 1) More efficient because require lower temperature less time because
- a. Water is better at transferring heat than air
- b. Takes about 7X much heat to convert boiling water to steam than to turn room temp to boil storage of
- heat in steam
- c. Saturated steam under pressure (autoclave) is more effective because pressure boiling point
- superheated steam
- NOTE: instruments must be bagged!
- 2) Advantage: effectiveness, speed and relative availability of equipment
- 3) Disadvantage: moisture dulls and rusts instruments & cost of autoclave!
- 2. Gaseous sterilization: destroys enzyme and vital biochemical structures
- 1) ethylene oxide gas: most common
- 2) highly flammable gas with CO2 or nitrogen safe
- 3) Advantage: effectiveness for sterilizing porous material, large equipment and material sensitive to heat/moisture
- 4) Disadvantage: need of special equipment and time required for sterilization and aeration to toxicity