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When should retreatment be completed?
- - Moiseiweitsch, Trope – RETX before SX
- - Lovdahl – Review article; RETX before SX
- - Allen, Newton, Brown – NSRCT RETX SX = 73% success; NSRCT SX = 60%; RETX before SX
How much blood loss during surgery?
o El Deeb, Messer – 9.5cc average blood loss (comparable to single tooth extraction)
How do we control the bleeding?
- o Buckley – 1:50K decreaed blood loss during PA surgery; 2X blood loss w/ 1:100K epi
- o Racellet pellets - #3 0.55 mg epi; #2 – 1.15 mg epi
- o Baumgartner - racellet pellets / racemin epi acts locally providing excellent hemostasis without any significant effect on systemic BP or pulse (no cardiovascular effects)
Does oral sedation help?
oHargreaves & Dionne – 0.25mg Triazolam appears safe, effective alternative to PO sedation with Valium; sublingual Triazolam results in greater anxiolytic activity and less pain perception than PO Triazolam due to greater plasma drug levels
What are we concerned about when it comes to the sinus?
Eberhardt – MB root of Max 2nd molar is closest to sinus 2mm average & farthest from buccal plate 4.5mm average; Max 1st PM is closest to buccal plate 1.6mm average & farthest from sinus 7mm average; 5% of apices protrude into sinus; As move from posterior to anterior, the roots become closer to buccal plate and further from sinus
Lin & Langeland – Use antihistamines ONLY if sinus perfed; Use Abx ONLY if symptoms develop, not prophylactically
Torabinejad – sinus perfs tend to repair, regardless of size w/ limited bony covering and fibrous scar; resorbable membranes DON’T improve repair
What are we concerned about when it comes to the mental foramen?
Moiseiwitsch – make a groove in the bone superior to mental foramen to prevent retractor slippage; average 16mm apical to 2nd molar CEJ
What are we concerned about when it comes to the IAVN?
- In the buccolingual dimension, the mandibular canal follows a curve from the buccal half of the mandible near the distal root of 2nd molar to the lingual half near the 1st molar, then curving back to the buccal near 2nd PM as it exits the mental foramen.
- The average distance from superior border of canal to distal root apex of 2nd molar in 3.5 mm; gradually increases to 6.2 mm at mesial root of 1st molar and 4.7 mm from 2nd PM
What kind of incision will you use?
- oVelvart – PBI allowed recession-free healing; full thickness sulcular flaps led to marked papilla loss; use PBI in esthetic areas to avoid opening interproximal space
- oVelvart & Peters – recommend suture removal after 3-5 days to promote rapid healing; can be removed after 48 hrs but no longer than 96 hrs.
- oKaminski – submarginal incision must have 3 mm btwn BASE of SULCUS and INCISION (so need more than 3 mm of attached gingival for this to work); will preserve gingival level in esthetic zone
How much of the root will you resect?
Kim, Pecora, Rubenstein – 3mm resection eliminates 98% of ramifications and 93% of lateral canals
What kind of material will you use?
- Tricalcium silicate
- Dicalcium silicate
- Tricalcium aluminate
- Bismuth oxide
- Tetra-calcium aluminoferrite (not in white MTA)
- Calcium sulfate hydrate (gypsum)
- Torabinejad – biocompatible; demonstrates the least leakage; ok with blood contamination; substrate for osseous and cementum growth
Why use ultrasonics for the retro-prep? Do ultrasonics cause cracks?
Baumgartner – 3mm prep with diamond coated ultrasonics; no crack seen and minimal bony crypt required
Does the entire lesion need to be curetted and removed for healing to occur?
Lin & Langland – No, but must remove all foreign objects
When is GTR indicated?
- o Percora – indications for GTR in endo sx
- Thru and thru lesion
- Large lesions
- Endo-Perio lesions
When would you remove sutures?
Kim- 2-3 days but no longer than 96hrs
What is the expected success of surgery?
o Wang (Toronto Study) – 74% healing over 4-8 yrs.
How do the tissues heal? (Incisional Wound)
- Healing of the incisional wound:
- 24 h – thin epithelial seal
- 24-48 h – multilayered epithelial seal
- 48-72 h – epithelial barrier; collegen fiber synthesis
- Preserve root attached tissue; submarginal & intrasulcular flaps performed equally
How do the tissues heal? (Osseous Wound)
- Healing of the osseous wound:
- Day 1-3 – fibrin clot
- Day 4 – granulation tissue replaces clot
- Day 14 – new periosteum forms; osteoblastic activity; new woven bone trabeculae occupy 80%
- Day 28 – maturing new trabecular bone
- Periosteum does not survive flap reflection; don’t curette cortical retained tissue; crestal bone levels will reduce following sx
What is success of intentional replantation?
o Bender, Kratchman & Koenig – intentional replant survival rate 85% up to 22 yrs.
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