5. surgery overview
DESCRIPTION
Surgery Luc Vrielinck Afdeling Mond-,Kaak- en Aangezichtsheelkunde Ziekenhuis Oost-Limburg, Genk Overview Anesthesy techniques Surgery Postoperative care NB 30 min before surgery glucocorticoid IM or IV Local anesthesy Loco-regional Loco-regional + sedation General anesthesy Anesthesy techniques Local anesthesy Loco-regional Loco-regional + sedation General anesthesyTRANSCRIPT
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Surgery
Luc Vrielinck
Afdeling Mond-,Kaak- en Aangezichtsheelkunde
Ziekenhuis Oost-Limburg, Genk
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Overview
Anesthesy techniques
Surgery
Postoperative care
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Anesthesy techniques
Local anesthesy
Loco-regional
Loco-regional + sedation
General anesthesy
NB 30 min before surgery glucocorticoid IM
or IV
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Anesthesy techniques
Local anesthesy
Loco-regional
Loco-regional + sedation
General anesthesy
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Local anesthesy
Buccally up to
infraorbital nerve
Palatal infiltration
incl. palatine nerve
and incisal canal
Externally: zygomatic
region
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Anesthesy techniques
Local anesthesy
Loco-regional
Loco-regional + sedation
General anesthesy
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Regional anesthesy
Maxillary nerve block = Pterygopalatine
block
Necessary for pterygoid implants
Techniques:
Intraorally
Externally
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Pterygoid block intraorally
Needle 8-10 cm
Needle in line with the
pupil
In lateral view midpoint of
the zygomatic arch
Insert until contact with
roof of infratemporal
fossa
Tilt the point upwards
for 30° and inject 5 ml
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Pterygoid block intraorally
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Pterygoid block extraorally
Coronoid notch
Mouth half-opened
Perpendicular insertion
At 5 cm depth contact
with lateral pterygoid
plate
Tilt 30° anterior and insert
1 cm deeper before
injecting 5 ml
Neural blockade in clinical anesthesia and management of pain by Michael J. Cousins, Phillip O. Bridenbaugh
Edition: 3, published by Lippincott Williams & Wilkins, 1998 ISBN 0397511590, 9780397511594
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Pterygoid block
Possible complications:
Hematoma
Temporal hematoma:
Branches of facial artery
Through inferior orbital
fissure: black eye
Trismus by hematoma in
pterygoid muscles
Temporary blindness by
spread to optical nerve
Treatment: conservative:
resolves in a few days
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Anesthesy techniques
Local anesthesy
Loco-regional
Loco-regional + sedation
General anesthesy
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Loco-regional anesthesy +
sedation
IV access
Monitoring
Pulse-oximeter
ECG
Bloodpressure
monitoring
Recovery room 2h
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Medication
Benzodiazepines
Anxiolytic
Sedation
Anticonvulsant
Muscle relaxation
Retrograde amnesia
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Benzodiazepines
Very short: midazolam(Dormicum®0.5-2.5mg)
Short: lorazepam (Temesta® 1–2.5 mg)
Long: nitrazepam (Mogadon® 2.5 mg)
Anxiolytic: alprazolam (Xanax Retard 1-2 mg)
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Anesthesy techniques
Local anesthesy
Loco-regional
Loco-regional + sedation
General anesthesy
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Anesthesy technique
General anesthesia: day-clinic
Classic operation room setting
Preoperative screening (>40 year or ASA
score >1)
ASA Score
A normal healthy patient.
A patient with mild systemic disease.
A patient with severe systemic disease.
A patient with severe systemic disease that is a constant threat to life.
A moribund patient who is not expected to survive without the operation.
A declared brain-dead patient whose organs are being removed for donor purposes.
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Overview
Anesthesy techniques
Surgery
Postoperative care
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Zygoma implant Surgery
Incision
Lefort I
Crestal
10 mm palatal
Distal relieving incision
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Zygoma Implant Surgery
Prelevation of buccal flap
Up to the infraorbital nerve
Distally up the inferolateral border (try to avoid Bichat fat)
Laterally up to the zygomatic bone
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Zygoma Implant Surgery
Prelevation of
palatal flap
sometimes section
of the incisal nerve
Palatal entry point
for the drill must be
visible
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Zygoma Implant Surgery
Anterior maxillary antrotomy (10 x 5 mm)
Far enough laterally and cranially
Maxillary surface of the zygomatic bone must be visible
Ideally Schneiderian membrane kept intact
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Zygoma Implant Surgery
Handpiece zygoma
20:1
Max 2000 r/min
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Zygoma Implant Surgery
Select entry point
Close to the dento-
alveolar border
2 mm round drill
Select emergence
point on the zygoma
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Zygoma Implant Surgery
Check intended
drilling direction
using a special
retractor
Implant follows
inferolateral border
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Zygoma Implant Surgery
Mark drill
Round
Ø 2,9 mm
Protect overlying soft
tissues
Recheck drilling
position
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Zygoma Implant Surgery
Twist drill Ø 2,9 mm
Pilot drill Ø 3,5 mm
Twist drill Ø 3,5 mm
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Zygoma Implant Surgery
Depth gauge to select
correct implant length
Implant lengths:
30 35 40 42,5 45 47,5 50 52,5
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Zygoma Implant Surgery
Machined zygoma
TiUnite zygoma
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Zygoma Implant Surgery
Installation of implants
3 important points:
Insert implant following
drilled trajectory
If drilling unit blocks
before reaching depth: consider redrilling
Consider rotation of the implant head
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Zygoma Implant Surgery
Connection to
handpiece
Engage the implant
and bring it
intraorally
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Zygoma Implant Surgery
Use slow speed
drilling to engage
the implant
Continue with
manual insertion
with the handle
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Zygoma Implant Surgery
Connect handle
with adapter to the
implant
Rotate manually
clockwise
Do no apply
bending forces
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Zygoma Implant Surgery
Check correct
implant head position
Remove implant
mount
Place cover screw
with hexagonal driver
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Zygoma Implant Surgery
Suturing
Vicryl 4/00 resorbable sutures
Single and matrass sutures
Abutments connection
After 6 months
Two lengths of zygoma abutments
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Overview
Anesthesy techniques
Surgery
Postoperative care
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Postoperative care
Cold pack application
Pain killer: Dafalgan®, paracetamol /6h
Nasal decongestive: Vibrocyl® spray 3/d
Antihistaminic: dexchloorfeniramine
Polaramine® repetab 1 x / d
Antibiotics: Clindamycin DalacinC 300 mg
3X/day
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Postoperative care
No prosthesis wearing until postoperative
swelling has disapeared (10-14 days)
Prothesis is released on implantation sites
Aplication of soft relining in the prothesis
eg CoeSoft (GC) to be repeated until
definitive relining
Inadequate adaptation of the prothesis
may cause rotation of the implants !!
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Where can we place long
implants? Zygoma
Pterygoid/Sphenoid
Skull base
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Zygomatic bone
Maximum 4
Pterygoid
Maximum 2
Sphenoid
Maximum 2
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Where can we place long
implants? Zygoma
Intrasinusal Brånemark
Perforating ant maxillary wall Stella
Extramaxillary Miglioranca / Malo
External sinus lifting Hinze/ Vrielinck
Quad zygoma
Pterygoid Vrielinck
Skull base bone Vrielinck
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Intrasinusal zygoma
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Where can we place long
implants? Zygoma
Intrasinusal Brånemark
Perforating ant maxillary wall Stella
Extramaxillary Miglioranca / Malo
External sinus lifting Hinze/ Vrielinck
Quad zygoma
Pterygoid Vrielinck
Skull base bone Vrielinck
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Anterior slot technique
Stella
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Where can we place long
implants? Zygoma
Intrasinusal Brånemark
Perforating ant maxillary wall Stella
Extramaxillary Miglioranca / Malo
External sinus lifting Hinze/ Vrielinck
Quad zygoma
Pterygoid Vrielinck
Skull base bone Vrielinck
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Extramaxillary
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Where can we place long
implants? Zygoma
Intrasinusal Brånemark
Perforating ant maxillary wall Stella
Extramaxillary Miglioranca / Malo
External sinus lifting Hinze/ Vrielinck
Quad zygoma
Pterygoid Vrielinck
Skull base bone Vrielinck
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External sinus lifting
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Where can we place long
implants? Zygoma
Intrasinusal Brånemark
Perforating ant maxillary wall Stella
Extramaxillary Miglioranca / Malo
External sinus lifting Hinze/ Vrielinck
Quad zygoma
Pterygoid Vrielinck
Skull base bone Vrielinck
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Quad zygoma
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Where can we place long
implants? Zygoma
Intrasinusal Brånemark
Perforating ant maxillary wall Stella
Extramaxillary Miglioranca / Malo
External sinus lifting Hinze/ Vrielinck
Quad zygoma
Pterygoid Vrielinck
Skull base bone Vrielinck
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Pterygoid / Sphenoid
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Where can we place long
implants? Zygoma
Intrasinusal Brånemark
Perforating ant maxillary wall Stella
Extramaxillary Miglioranca / Malo
External sinus lifting Hinze/ Vrielinck
Quad zygoma
Pterygoid Vrielinck
Skull base bone Vrielinck
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Skull base