luis bruzual oral surgery day for cesrc

www.centralenglandreferrals.co.uk

Sharing knowledge and stimulating conversation

between dental professionals.

Follow Central England Specialist Referral Centre

online and join in the conversation.Mr.LuisMBruzual,BOdont(Ven)Cert(OMFS)BLACIBU

SpecialistinOralSurgery

WelcometoCESRC’S

OralSurgeryday

June7,14and28,2017ThePavilionsShirley

BRUZUAL CESRC

www.centralenglandreferrals.co.uk

Sharing knowledge and stimulating conversation

between dental professionals.

Follow Central England Specialist Referral Centre

online and join in the conversation.Mr.LuisMBruzual,BOdont(Ven)Cert(OMFS)BLACIBU

SpecialistinOralSurgery

UpdateonOralSurgeryforthe

GeneralPractitioner

June7,14and28,2017ThePavilionsShirley

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Basic surgical needs

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1.Visibility

2.Control of haemostasis

3.Appropriate assistance

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1.Visibility• Adequate lighting

• Improve visualisation of surgical field

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2.Controlofhaemostasis

• Good Local Anaesthesia (vaso constrictor)

• Patient comfort (anaesthesia < anxiety)

• Suction (surgical suction)

• Instruments - exposure to structures

• Diathermy (bipolar or monopolar)

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3. Appropriate assistance

• Assistants have to be familiarised with surgical instruments and surgical procedures

• Circulating nurse - trained in oral surgery to assist outside of sterile field

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HandpiecesforOS

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Instruments

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Forceps

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Elevators

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Surgical retractors

Minnesota retractor

Rake retractor

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Minnesota retractor

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Minnesota retractor

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Periosteal elevators

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Suturing instruments

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Suturing instruments

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Surgical blades

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Surgical blades

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Surgical technique

• Provide minimal sufficient exposure of surgical field

• Preserve biological structures (Periosteum, Keratinised tissues, vascular and nerve structures)

• Allow appropriate closure of surgical wound

Flapproperties

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Surgical technique

• Use of appropriate instruments

• Avoid over-stretching, over-pressure and use care handling

• Preserve blood supply

TissueManagement

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Surgical technique

FlapdesignLocal flap

• Outlined by a surgical incision

• Carries its own blood supply

• Allows surgical access to underlying tissues

• Can be replaced in its original position

• Can be maintained with sutures and is expected to heal

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Surgical technique

Flapdesign

Properties

• Base > free margin

• Preserve an adequate blood supply

• Unless there is a large artery in the base

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Surgical technique

Flapdesign

Properties

• Axial blood supply in the base

• Flap must be held with retractor resting on intact bone to prevent tension

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Surgical technique

Flapdesign

Preventing complications

• Incision must be made over intact bone

• If a defect exists in the underlying bone, incision must be made at least 8 mm away on top of intact bone and 6 mm if the defect is created by surgery

• Always treat flap gently

• Don't stretch flap or place excessive pressure on itBRUZUAL CESRC

Surgical technique

Flapdesign

Incision must be made away (6 mm) away from the expected created surgical defect

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Surgical technique

Width of Base always > Length of flapBRUZUAL CESRC

Surgical technique

Envelope / sulcular flap

Envelope flap with one releasing incision

(Three corner flap)

Envelope flap with two releasing incision

(four corner flap)

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Surgical technique

Envelope / sulcular flap no releasing incisions

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Surgical technique

Envelope flap with one releasing incision

(Three corner flap)

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Surgical technique

Envelope flap with two releasing incision (four corner flap)

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Surgical technique

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Surgical technique

Semilunar flap

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Surgical technique

Semilunar flap

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Surgical technique

Semilunar flap

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Surgical technique

Semilunar flap

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Surgical technique

Semilunar flap

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Surgical technique

• Flap dehiscence

• Flap tearing

• Injury to local structures

• Flap necrosis

Flapcomplications

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Alternative surgical technique to conventional surgical extraction of impacted third molars

(other impacted teeth)

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Coronectomies

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Coronectomies

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CBCT planning

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Coronectomies

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Coronectomy + enucleation of cyst

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Coronectomies

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Coronectomies

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Coronectomies

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Coronectomy + enucleation of cyst

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Coronectomies

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Coronectomies

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Coronectomies

Preop 3 months postBRUZUAL CESRC

Coronectomies

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Coronectomies

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Simple SuturesSuturing needles

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Suturing needles

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Tear created by normal cutting

needle

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Suturing techniques

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Simple sutures

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Horizontal continuous mattress sutures Simple sutures

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Horizontal continuous mattress sutures Simple sutures

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Simple sutures

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Continuous simple sutures

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8 shaped suture

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Continous blocked suture

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Horizontal individual mattress sutures

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Horizontal individual mattress sutures

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Horizontal continuous mattress sutures

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Removing Sutures

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• What constitutes the ideal suture?

• Easy to handle

• Easy to knot

• Minimal tissue reaction

• Maintain tensile strength until tissue has healed

• Narrow diameter to minimise tissue damage and scarring

• Unfavourable surface for bacterial colonisation

• Cost

Sutures

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Learning outcomes: • Understand the different complications that

can arise from dental extractions• Preventing and anticipating complications

related to dental extractions• Manage complications related to dental

extractions• Management of patients taking NOAC

other blood thinning drugs

Complications related to dental extractions

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•Haemorrhage•Dry Socket (Local alveolar osteitis)•Oro-antral communications (OAC) / Oro-antral fistulas (OAF)

Other conditions •MRONJs - ORNJs•Temporo-Mandibular Joint (TMJ)•Displaced tooth or tooth segment to other anatomical spaced•Tooth deglution and bronco aspiration

Complications related to dental extractions

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Aspirin Clopidrogel

WarfarinNovel anticoagulants - NOACs

Heparins

Atrial Fibrillation - other arrhythmiaSeptal defects

Pulmonary embolismDeep vein thrombosis

Cerebro-vascular accidentsRecent Myocardial infarction

Post extraction haemorrhage secondary to anticoagulation

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•Preventable •Most common of complications•Immediate or delayed•Alarming •Related to traumatic procedure (poor technique)•Related to anti platelet, anticoagulation meds or systemic conditions •Anticipated

Haemorrhage

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Post extraction haemorrhage secondary to anticoagulation

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Traumatic extractionTuberosity fracture

Lingual plate fractureDental fusionAge - Race

Post extraction haemorrhage secondary to traumatic extraction

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1. Irrigate the area with isotonic solution and remove excessive clots 2. Patient is then instructed to bite on the gauze pack until the general condition has

been evaluated.3. Patient’s blood pressure and pulse rate should be checked.4. Administer local anaesthetic just enough to achieve anaesthesia in desired area.

(Lidocaine 2% 1:80.000 adrenaline) Avoid giving large amounts of LA that will temporarily stop the bleeding but then will result in bleeding later on.

5. Once anaesthesia is obtained, the extraction wound is examined to determine the source of bleeding. Determine whether the bleeding is from the soft tissues (gingiva), the alveolus’ bone or both.

6. Bone bleeding: pack local haemostat into socket7. Secure haemostat with sutures8. Soft tissue bleeding - local haemostasis - diathermy or silver nitrate

Management of post extraction haemorrhage

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In addition to serving as a mechanical obstruction to bleeding, these materials affect the coagulation process. In contact with blood, collagen causes aggregation of platelets, which bind in large numbers to the collagen fibrils. The aggregated platelets degranulate, releasing factors such as thromboxane A2 that assist in the formation of a clot. The sponge also provides a 3-D matrix for strengthening the blood clot.

Haemostatic Collagen These products (eg, CollaPlug, CollaTape, and Helistat [Integra LifeSciences]) are soft, white, pliable, nonfriable, coherent, sponge-like structures.

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Cellulose (eg, Surgicel, ActCel)Surgicel (Johnson & Johnson) is a resorbable oxidized cellulose material.

Expensive but useful option in oral surgery. It is prepared as a sterile fabric meshwork.

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Secure haemostat

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Soft tissue bleeding

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Patient that can be treated in practice

Management of patients in anticoagulation

Warfarin - INR < 3.0 (4.0) not more than 72 hours

Aspirin and Clopidogrel - Can be discontinued 4-7 days before the

procedure

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Novel Anticoagulants (NOAC)

• Praxada® Dabigatran • Xarelto® Rivaroxaban • Eliquis® Apixaban

Advantages - do not require regular blood test

Disadvantages - Effect cannot be easily quantified

Praxada® - Stop drug 24 hrs prior to an invasive surgical procedure in patient with normal renal function I.e. creatinine clearance >80ml/min

If creatinine clearance 50-80ml/min -increase time to 48 hours If creatinine clearance 30-50ml/min -increase time to 72 hours

Xarelto® and Eliquis® - Stop drug 24 hrs prior to an invasive surgical procedure Both drugs should be started asap after haemostasis is achieved Risk vs benefit (discuss with the prescribing doctor) BRUZUAL C

NICE - for extraction of up to 3 teeth, periodontal surgery and implant placement:

• Procedure should be done just before the next dose or 18-24 hours after the last dose given

• 5% Tranexamic acid mouthwash 5 days post-operative

* As long as no earlier than 4 hours after haemostasis has been achieved

Simplified dose schedule - Scottish Dental Clinical Effectiveness Programme

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NOAC Usual drug scheduledMorning dose

(pre-treatment) Post-treatment dose

Apixanban or Dabigatran

Twice a day Miss morning dose Usual time in evening *

Rivaroxaban Once a day; Morning Delay morning dose4 hours after

haemostasis has been achieved

Once a day; Evening Not aplicable Usual time of the evening*

* As long as no earlier than 4 hours after haemostasis has been achieved

Simplified dose schedule - Scottish Dental Clinical Effectiveness Programme

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•Associated with extraction of postero-superior teeth: second premolars and molars (Tuberosity fractures)

ORO-ANTRAL COMMUNICATION (OAC)ORO-ANTRAL FISTULA

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ORO-ANTRAL COMMUNICATION (OAC)

Immediate after extraction

Signs: Trans-alveolar visualisation of maxillary sinus membrane tearor communication

Symptoms: • Passage of air from the maxillary sinus to the oral cavity• Passage of fluid from the oral cavity to the maxillary sinus• Post extraction epistaxis

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ORO-ANTRAL COMMUNICATION (OAC)

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Management of oro-antral communication

<5 mm Communication • Never probe the defect• Never test by nose blowing• The gingival margins around the socket should be approximated as close as possible• Gently pack physical agents placed in the socket to stop excess bleeding, (Surgicel,

Spongostan or Haemocollagene)• Antibiotics should be prescribe Amoxicillin, Metronidazole or Clyndamicin)• Nasal decongestants can be beneficial (Ephedrine nasal drops, Oxymetazoline)• Antiseptic mouth-wash should be used (Chlorhexidine) after 24 hours• Consider use of a cover plate (extra precaution should be taken if taking an impression)• Carefully follow the patient 1, 2, 3 and 4 weeks and advise to avoid straining the area (no

holding back sneezes, no smoking, no use of straws, no pressure on the sinus). BRUZUAL CESRC

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>5 mm Communication Do not attempt to pack haemostats (gelatine sponges, etc)

Surgical management

• Immediate surgical repair• Antibiotics, nasal decongestants• Carefully follow the patient after 2 and 4 weeks and advise to avoid straining the area (no

holding back sneezes, no smoking, no use of straws, no pressure on the sinus).

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Surgical management of oro-antral communication

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Delayed

Signs: Delayed healing in previous extraction siteIntra oral visual communication to maxillary sinus cavityAssociated or not with maxillary sinus discharge

Symptoms: Passage of fluid from the oral cavity to the maxillary sinusSinusitis symptoms - Infection

ORO-ANTRAL FISTULA (OAF)

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Diagnostic imaging:•OPG•Periapicals•OM views•CT or CBCT

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Surgical management of oro-antral fistula

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Surgical management of oro-antral fistula

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Synonyms: •Alveolitis sicca dolorosa•Localised alveolar osteitis•Fibrinolytic osteitis

DRY SOCKET

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Pathophysiology: Blood clot disintegration - no granulation tissue

Incidence: For routine dental extractions, 0.5% to 5% After extraction of mandibular third molars 1% to 37.5%

Surgical extractions result in about 10 times higher incidence of AO

DRY SOCKET

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• Onset after 1 - 3 days of extraction• Severe pain inside and around the extraction

site - radiate to ear• Disintegration of the blood clot• Foul smell (Necrotic Odour) • Not an infection (No suppuration)

• Higher incidence • Smokers• Female : Male Ratio 3:2 • Oral Contraceptive• Physical dislodgment of clot

DRY SOCKET

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DRY SOCKET

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DRY SOCKET

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Emergencies

DRY SOCKET

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Clinical features - Pain

Alveolar Osteitis (AO) (DRY SOCKET)

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ALVOGYL

100 g the following active ingredients : 25.70 g of butamben, 15.80 g of iodoform 13.70 g of eugenol

TREATMENT Localised Alveolar Osteitis (LAO) (DRY SOCKET)

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Treatment: •LA (Avoid Lidocaine)•Wash area•Stimulate bleeding•Treat symptoms (pain) Recommendations•Rinses•Chlorhexidine MW•Review visit - advise that might need several visits

TREATMENT Localised Alveolar Osteitis (LAO) (DRY SOCKET)

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I. Temporo-mandibular joint I. Prolonged extractions

I. Trismus (masseter muscle) II. Dental anaesthetic injection - ID Block

I. Mandibular hypo-mobility < than 2 cm III. TMJ subluxation or true luxation

Temporo-Mandibular Joint complications

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TMJ true luxation

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TMJ true luxation

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TMJ true luxation

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TMJ true luxation

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TMJ true luxation

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BisphosphonatesInhibit osteoclastic function - essential enzymes

RANKL Inhibitors (Receptor Activator Nuclear Factor kB Ligant)

Inhibit osteoclastic function - humanised monoclonal antibody

Anti-angionegic drugsTarget the process of new blood vessel formation - restrict tumour vascularisation

Medically related osteonecrosis of the jaws (MRONJ)

AAOMS position paper, on medication related osteonecrosis of the jaw, 2014BRUZUAL CESRC

Patients may be considered to have MRONJ if all of the following characteristics are present:

1. Current or previous treatment with anti-resorptive or antiangiogenic agents

2. Exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region that has persisted for more than eight weeks

3. No history of radiation therapy to the jaws or obvious metastatic disease to the jaws.

AAOMS position paper, on medication related osteonecrosis of the jaw, 2014BRUZUAL CESRC

MRONJ is comparatively uncommon following dental extractions

• 0.04 - 0.5% incidence in patients on ORAL BP

• 1.15% - 14.8% incidence in patient on IV BP

• There are an estimated 8.2-12.8 cases / million / year or 508 - 793 patients newly diagnosed each year in the UK

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Clinical features: • Exposed bone• Pain• Persistent fistula• Osteonecrosis• Infection

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Low Risk High Risk

If any of the following is present If any of the following is present

• Patients being treated for osteoporosis or other non-malignant disease of bone (e.g. Paget’s disease) with oral bisphosphonates for less than 5 years who are not currently being treated with systemic steroids

• Patients being treated for osteoporosis or other non-malignant disease of bone (e.g. Paget’s disease) with oral bisphosphonates or quarterly or yearly infusions of intravenous bisphosphonates for more than 5 years

• Patients being treated for osteoporosis or other non-malignant disease of bone with quarterly or yearly infusions of intravenous bisphosphonates for less than 5 years who are not currently being treated with systemic steroids

• Patients being treated for osteoporosis or other non-malignant disease of bone with bisphosphonates or denosumab for any length of time who are currently being treated with systemic steroids

• Patients being treated for osteoporosis or other non-malignant disease of bone with denosumab who are not being treated with systemic steroids

• Patients being treated with anti-resorptive or anti-angiogenic drugs (or both) as part of the management of cancer

• Patients with a previous diagnosis of MRONJ

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Has the pat had previous dx MRONJ

Is the patient being treated with anti-resorptive or anti-angiogenic drugs for the management of cancer?

Is the patient currently taking a bisphosphonate drug or have taken them in the past?

Is the patient currently taking denosumab or have taken it in the last 9 months

No Yes

How long have they taken/did they take the bisphosphonate drug for?

Is the patient being currently treated with systemic steroids

< 5 years > 5 years

NO RISK LOW RISK HIGH RISK

No YesBRUZUAL CESRC

Bisphosphonate > 4 years OralSuspend medication for 2 months prior

to extractions

Bisphosphonate + other risk factors (Smoking, Steroids, anti-cancer drugs)

> 4 years OralSuspend medication for 2 months prior

to extractions

Anti-RANKL Denosumab

Given every 6 months

Sub Cutaneous

Suspend medication 3 months prior to extractions

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Recommendations

• Healthy diet and reducing sugary snacks and drinks • Maintain excellent oral hygiene • Use of fluoride tooth paste • Stop smoking • Limiting alcohol intake • Reporting any symptoms such as: loose teeth, numbness or altered sensation,

pain or swelling ASAP • Monitoring:

• Regular clinical check up • Consider imaging if suspected changes or symptoms • If any surgical procedure has been done monitor area until it has completely

healed (minimum 8 weeks or until area has healed)

If patient develops MRONJ - refer to specialistBRUZUAL CESRC

Medically related osteonecrosis of the jaws (MRONJ) Antibiotics therapy for high risk patients

Recommended antibiotic prophylaxis (patients with high risk of MROJN) - (IV bisphosophonates)

• 1g Amoxicillin TDS starting 3 days prior to surgery • 1g Amoxicillin + Clavulanic Acid starting TDS 2 days prior to surgery • If allergic to penicillin

• Clindamycin 600 mg TDS 2 days prior to surgery • Metronidazole 400 mg TDS 2 days prior to surgery

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PRGF Platelet Rich Growth Factors

PRF / L-PRF/ AL-PRF

Luis M Bruzual, B Odont(Ven), Cert (OMFS)

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Platelets produce growth factors for > 7 days

• PDGF-AB /Platelet derived growth factor

• TGF β-1 / Transforming growth factor β

• VEGF / Vascular endothelial growth factor

• TSP-1 / Thrombospondin - 1

What are PRGF benefits?

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Applications in Dental/Oral and Maxillofacial Surgery

• Bone defects (congenital, post cystic, post-traumatic, etc.)

• Alveolar preservation for implant placement

• Sinus and alveolar ridge augmentation

• Implant placement

• Periodontal defects

• Prevention of MRONJ and ORN

• Treatment of MRONJ and ORNBRUZUAL CESRC

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PRGF PreparationPRGF Preparation

Blood collection Centrifugation Preparations

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PRGF Preparation

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PRGF Preparation

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Why Leukocytes • Cytokines production

• Anti-inflamatory effects

• Anti-infectious effects

• Promote angiogenesis VEGF

PRF is also rich in Leukocytes

Leukocytes produce cytokines**

• 3 pro-inflamatory cytokines

• IL-6 / Interleukin 6

• IL-1β / Interleukin 1B

• TNF - α / Tissue Necrotic Factor alpha

• 1 retro-inflammatory Cytokine

• IL-4 / Interleukin 4

PRF is also rich in Leukocytes

One of the most powerful promoter of the VEGF

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info@centralenglandreferrals.co.uk

luis.bruzual@nhs.net

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luis bruzual oral surgery day for cesrc

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