oral midterm 1

7/29/2019 Oral Midterm 1

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Introduction Lecture

Definition:

Speciality of dentistry of which includes : DiagonsisSurgicaladjunctivetreatment of disease, injuries and defects involveing both functional andesthetic aspects of hard and soft tissues of the oral and maxillofacial region

(Head and Neck)Scope of Oral SurgeryGeneral Dentist: Provides common, usually lesscomplicated, surgical servicesin the office

Interests, Pt. Needs, Office schedule

Training/Experience, Skill level

Physical plant, Instruments, Assistant

Good assistant will have a greater influence

Pt. is more comfortable w/ assistant than the dentist

Specialist: Provides full scope of services including services requiringadjunctive anesthetic or hospital management

Availability of specialistGeographic proximity

Standard of care

Team approach to pt. care = referral is an important thing to keep line ofcommunication

Pain and Anxiety Control

Surgery is both Art and Science

Compassion/Kindness/Humanism/Attention to Detail are required to be anexcellent surgeon

Patient safety and well-being are the ultimate goals

---------------------------------------------------------------------------------------------------------------Principles of Surgery

1- Developing a surgical diagnosis

Gather data and evaluate before deciding the procedure to be performed

Evidence based therapy: Treatment is based on research and science, not

just good ideas

2- Developing the Diagnosis

Chief Complaint: A direct quote from the patient

History of Present Illness: The story of the patients Chief Complaint(this is NOT the Past Medical History)

Past Medical History (PMH): A summary of the patients medical status as

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it relates to dental care: Includes Dangers, Rxs, Allergies, Need forProphylaxis

Physical Examination:

Pertinent Extra-Oral Findings

Pertinent Intra-Oral Findings

Diagnostic Imaging:

PAs, Panorex, CBCT

Formulate a Differential Diagnosis: a list that definespotential diagnoses

Determine the Final Diagnosis: This may include more than one problemi.e.: Acute Irreversible Pulpitis

Acute Apical PeriodontitisGrossly Carious

Non- Restorable---------------------------------------------------------------------------------------------------------------Treatment OptionsDiscuss possible treatment alternatives with the patient:

RCT vs. ExtractionRCT with Crown vs. Bridge (FPD)vs. Implant

Review Financial Commitment by the Patient (cost)+++++++++++++++++++++++++++++++++++++++++++++

+++++++

Proposed Treatment

Determine an appropriate treatment option harmonizing the diagnosis with

patient needs

Discuss and Obtain Informed Consent

Document the Consent Discussion and add the Signed ConsentForm to the permanent record

Accomplish Treatment

Obtain profound anesthesia, employing adjunctive measures to aid patient

comfort and facilitate the procedure Accomplish the procedure with attention to avoiding, not creating,

complications

Instruct the patient for post operative care

Follow up check and treatment, as needed

Principles of Surgery1- Basic Necessities For Surgery

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Qualified Assistant A CRITICAL factor

Good Visibility of the Surgical Site

Access Retraction and Protection of Soft Tissue

Lighting Adjustable Light or Headlight

Clear Surgical Field Suctioning of debris/blood/saliva/irrigation

2- Principles of Surgery (safety measures)

Aseptic technique relative, minimize wound contamination by path.microbes

Sterile Instruments Avoiding Cross Contamination

Operatory Disinfection

Barrier techniques Sharps Protocol

Protection of Patient and Staff----------------------------------------

3- Principles of Surgery-- Incisions-Basic Principles

Sharp blade of proper size (# 15)

Firm, continuous stroke & LONG

Avoid anatomic structuresMental and IA Nerves

Perpendicular to surface

Place incision in proper location for closure and healing over intact

bony margins or attached Gingiva

Bone + Ligamentdull blade faster Buccal mucosadoesnt dull the blade as fast

------------------------------------------4- Flap design

Will discuss in detail with surgical extraction techniques

Base broader than free margin to allow adequate blood inflow

and outflow

Margin away from surgical site and located over sound bone

BE KIND TO THE SOFT TISSUE !

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-------------------------------5- Tissue handling

Gentle retraction

Careful suctioning

Avoid burns from drills labial commissure

Tissue forceps injury to patient or crush artifact for biopsy specimen

6- Hemostasis EXAM

Prevent excessive bleeding flap design

Preserve visibility to facilitate surgery

Prevent hematoma meticulous hemostasis prior to closure

Hematoma is a greater source of bacterial infection

Prevent Necrosis

Base wider than apex, unless major artery is found

Side should be parallel or .. Length shouldnt become more than 2 the base

Base should be free of any grasped that might damage blood vessel

Retard Wound breakdown and infection

Pressure

Packing

Place Drain, if needed

Closure watertight closure usually NOT Indicated

Obtaining Hemostasis:

Assisting natural hemostatic mechanism Use heat to fuse ends of a cut vessel

Suture ligation

Place a vasoconstrictor substance

Hemostasis

Thoroughly Debride Granulation Tissue

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Control Bleeding from Socket, Bone

Pressure Directly on wound or vessel Pack the Socket

Soft Tissue: ligation of vessel

Hemostasis

Burnishing of Bone crushing of bone to occlude vessel Cautery: Chemical, Electrocautery Caution re: IAN

Infiltrate LA with vasoconstrictor

Hemostatic agents: clot promoters (collagen plug, HemCon)

Debridement : the surgical excision of dead and devitalized tissue and

removal of all foreign matter from a wound

Bone spicules/granulation tissue/tooth fragments

Adequate irrigationLate infection is a quality of care measure

Antibiotics make a mediocre surgeon out of a really bad one.- Larry Peterson

---------------------------------------7- Control edemaEdema: is accumulation of fluid in the interstitial space bc of transduction fromdamaged vessels and lymphatic obstruction by fibrin

Normal response to surgical trauma

Careful tissue handling

Pressure dressing

Elevation of head Gravity Dependent

Ice? May or may not help - gives the patient something to do

Corticosteroids (must give before injury/surgery)

NSAIDS

Post-operative Mobilization !!!

Infection Control/Asepsis (summary - important):

Patient Care and Regulatory issues

Protects patient as well as dentist, staff and other patients

Often cited violation by State Dental Board

Indication of Commitment to Patient Care/ Professionalism

Normal Orla flora contain:

Aerobic G+ Cocci (Streph), actinomycte

Anearobic (Canada)

Total Number of Oral Organisms is held in check by:

Rapid epi. Turn over w/ desquamation

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IgA

Dilution by saliva flow

Competition btw oral organism for avalible nutrients and attachmentsites

Infection Control

Communicable Pathogenic Organisms Aseptic Technique and Standard (Universal) Precautions

Instrument sterilization/disinfection

Operatory disinfection

Surgical staff preparation

Staff Preparation: Clean Technique for Office Surgery

Non-sterile gown

Gloves Change as often as needed

Mask

Hair, shoe covers as needed

Instruments are sterile when opened

Used for most office based intra-oral procedures

Cross-contamination is a major problem

Emphasis must remain on avoiding touching of anycontaminated item - mask, glasses, charts, chair, etc.

!! EMPLOY BARRIER TECHNIQUES !!

Surgical Staff Preparation: Sterile Technique

Sterile Technique is practiced in OR even when operating intra-orally(Consistent Technique)

Necessary for uncontaminated wounds (extra-oral) such as skin biopsy,

TMJ, Salivary gland surgery where no oral contamination is present

Sterile gloves, gown, drapes with strict adherence to touching only sterileobjects (touch only what is blue)

Precise and formal surgical scrub, gloving, and gowning techniques

End of Lecture 1

Peri-Operative Management

Goals of Post-op Care

Minimize Discomfort and/ or the PERCEPTION of Discomfort

Regain pre-operative function

Return patient to normal activities of daily life

Avoid Infection

A General Rule Pt. should feel better after 3-4 days

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Avoid infectionPost-operative Instructions (POI)

Educate patients about anticipated/ expected post op events

Instruct patients how to care for themselves

Instruct patients how to avoid complications

Educate patients to recognize complications

Things that are normal.Not good, but normal.

Soreness

Swelling

Chapped lips

Bruising

Minor Bleeding

Post Operative Bleeding

Minor bleeding is normal and expected

First part of the healing process

Gauze pressure should be placed directly over the surgical site

Gauze pressure should be maintained for 30-60 minutes, prior toreplacing gauze

Bleeding must be well controlled before discharge from the office

Gauze pressure must be placed directly on the surgical site, not theocclusal plane

Do NOT change the gauze TOO often - acts like a dry sponge pulls clotfrom socket, causes bleeding to continue

Moistening the gauze pad may be of benefit

Minor bleeding may occur after meals or brushing the teeth

Mild oozing may occur for 24-36 hours post-op

NO SPITTING !

NO STRAWS!

NO SMOKING! if the patient must smoke, then draw very lightly on

the cigarette

Minimize negative pressure intra-orally

Avoid strenuous exercise for 12-24 hours post-op May have bleeding on pillow overnight

A little blood and a lot of saliva, looks like a lot of blood

Prolonged bleeding, bright red bleeding , and large (liver) clots may

indicate the need for a return visit

Initially, liver clots may be wiped from the socket, the area rinsed, and

gauze reapplied with biting pressure

If needed, office evaluation should be accomplished on a after-hours

basis

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Postoperative bleeding causes

Failure of POI - poor instructions, poor emphasis,poor compliance

Poor quality tissue

Suboptimal surgical technique

Very rarely due to undiagnosed coagulopathy

Edema

Edema is ALWAYS expected after surgery

Degree is dependent upon the extent of surgery and quality of tissue

Maximum edema at 48-72 hours post-op

Gravity dependent

Ice packs may be used for 24-36 hours to limit swelling. MAY or MAYNOT HELP LIMITEDEMA

20 minutes on and 20 minutes off during waking hours

Dry cloth interposed between cold and skin avoid frostbite

Allows patient to take an active role in their care

Edema is, in part, gravity dependent

Surgical site should be elevated above the heart

Resting in a recliner is a good position

Limited inter-Incisal opening

Trismus an inability to open the jaw due to inflammation associated withtrauma or infection, a spasm of the muscles of mastication

Guarding limited opening due to pain or anticipated pain

Post-op patient may have both

Trismus -Inflammation, trauma

Masseter, Temporalis insertion may be traumatized with removal oflower 3rds

Medial Pterygoid may be traumatized during local anesthetic injections

Masseter, Buccinator may be inflamed due to buccal hematoma

secondary to PSA injection, removal of maxillary 3rd molar

Limited Inter-Incisal Opening

Warn, advise patients for potential decreased IIO

Early mobilization of the mandible retards muscle stiffness, increases IIO

Advance to a regular diet in the early post op period

Ecchymosis

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A hemorrhagic spot in the skin or mucous membrane forming a non-

elevated, round or irregular, blue or purplish patch

Blood in the subcutaneous tissue

A bruise

May be quite extensive

More likely in older patients with decreased tissue tone, intracellularattachments

Red-heads > blonds > brunettes

Fairly complexioned > darkly complexioned persons

May be quite alarming to patients!! Reassure the patient.

Reportedly does not increase pain or chance of infection

Onset over 2-4 days post-op

Purple green/ brown yellow

Usually resolves at 7-10 days post-op

Control of Infection Careful surgical technique is the most important consideration

Topical antimicrobials (chlorhexidine) may be of benefit

Antibiotics may be appropriate for selected individuals i.e. depressedhost-defense responses, extensive surgery, violation of anatomic spaces

For NON-surgical pt. use penicillin

For Surgical pt. use ..

Diet

Pain, fear may discourage patients from eating

The more you eat and drink, the better you will feel. Anything you want to eat or drink is fine

Soft, cool foods until Novacaine is gone: Nothing scalding hot until

the Novacaine wears off

Best to avoid coarse foods chips, popcorn, nuts

High calorie diet

> 2 liter fluid volume during 1st 24 hours

Limit caffeine or any diuretics

Oral hygiene

Good hygiene promotes healing Gently brush in routine fashion 3X / day

Avoid the areas of surgery

Minor bleeding is to be expected particularly after meals or brushing the

teeth.

Gentle chlorhexidine gluconate or saline rinses may promote healing

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Retainers

Orthodontic retainers, appliances should be used in routine fashion,

beginning on the day of surgery

Place the retainer once the novacaine has worn off. Do NOT wait until

edema precludes appliance placement.

Post-operative contact Patient should be instructed to call early in the day for post-op questions

or concerns

Facilitates scheduling of post-op visits in the daily schedule

Patient should receive emergency contact numbers i.e. cell phone,

beeper, & home phone

Considerations for Sinus Communications

Anatomy: teeth develop in proximity to the maxillary sinus

The surgical approach often determines the extent and size of the

communication Uncontrollable factors: size, depth , location influence need for and

extent of surgical closure

Tissue available for closure may require extensive repositioning of softtissue

POI Sinus Communications

Maintain equal pressure between sinus and mouth to avoiddisplacement of the clot !!!

Do NOT blow the nose!

Do NOT play a wind instrument !

Do NOT use a straw!

Do NOT smoke!

If a cough or a sneeze is unavoidable, open the mouth, turn the head

toward the floor and direct

The Healing of the sinus depend on: location and communication

o the sneeze or cough toward the floor through your OPEN mouth!

Gently rinse the surgical sites as directed

Take all medications as prescribed. Prophylactic antibiotics such asamoxicillin or Augmentin are commonly employed

Use of a nasal decongestant drops, not spray, may be helpful (i.e. %Neosynephrine). Check with your physician if you have high blood pressure.

For one-sided communications, please rest or sleep with the involved

side tilted up . This will promote drainage from the affected side. (ostiumof the sinus is above the level of the floor)

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Some bleeding from the nose may occur. Blot the area. Do NOT blow the

nose

Postoperative pain

Pain - a sensation of discomfort, distress or agony resulting from the

stimulation of specialized nerve endings

Always anticipated postoperatively Perception and psyche are significant influences

Should be addressed pre-operatively

Sore, but not miserable

Pain medication will help

Patients past experience and perception are very important !!!

Different philosophies:

o Youll be fine with Tylenol vs. Everyone gets a prescription

What pain medication has worked well for you in the past?

NSAIDs coupled with a Class III or Class IV analgesic are a good

combination for most patients

Analgesic should be started BEFORE the local anesthetic effect hasdiminished delayed onset of p o Rx

Take with food buffers against nausea, GI distress

Excessive narcotic use may cause drowsiness

Constipation occurs rarely

Class III analgesics

Hydrocodone compounds (Vicodin , Lortab) Codeine compounds (Tylenol #3)

Dihydrocodeine compounds (Synalgos DC9)

Class II analgesics

Oxycodone compounds limited use (Percocet, Percodan, Tylox)

Other Class II analgesics - seldom, if ever , used (Demerol , Dilaudid,morphine)

End of Lecture 2

Armamentarium

Scalpel

Handle: number 3

Blades: #s 15 (most common),11 (incision and drainage) ,12,10 (largerversion of #15)

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Proper technique for loading/ unload

Always use an instrument

NEVER USE FINGERS!

Cut with belly of blade perpendicular to epithelium (mucosa, skin)

Firm, uniform cut uniform pressure

Cut to depth (usually through the periosteum to bone) in a single

stroke Single patient use - Disposable

Change as needed, if blade becomes dull

Proper grip (pen grasp)

Periosteal Elevator

For elevating muco-periosteum from bone

#9 Molt

Pry/push and roll/scrape

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Retractors

Fingers are NOT routinely used unless palpating underlying structuresExamples: Minnesota*, Mouth Mirror,Weider (tongue)* - see pictures

Hemostats NOT for Driving Needles

Commonly used to clamp bleeding vessels (general surgery

Curved, Straight

Employed to debride follicle, granulation tissue, deliver fragments of teeth,

alloy

NOT for Handling delicate tissue or biopsy specimens will create a crush

artifact rendering the specimen unreadable

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1. Instruments for Grasping Tissue

Tissue forceps

Russion large, for teeth

Adson: with and without teeth, for soft tissue

Stillies longer

Allis- clamping removing large pieces of tissue

Cotton plier2.Instruments for Removing Bone

Bur and handpiece

High torque, no venting into wound = rear exhaust or electrical toELIMINATE AIR EMPHYSEMA

DO NOT USE A CONVENTIAONAL HIGH SPEED HANDPIECE !!!

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Nitrogen (90-100psi) or Electrical (Caution: Overheating)

#8 round, #701, 703 fissure

Erupted teeth - consider a 45 mm bur

Impacted teeth - consider a 51 mm bur

# 701, 8, 703 Burs: 45 vs. 51 mm see picture

2. Instruments for Removing Bone

Rongeur

Combination of side and end cutting

Works like a hedge shears or nail nipper

File or Rasp

Dental Curette spoon

Small - Periapical curette to debride apical cyst

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Large Remove follicle of impacted tooth

Removes tissue from bony defect double ended

3. Instruments for Suturing

Needle

Various Sizes and Shapes

Cutting, reverse cutting, taper

Suture material

Size (0 to 000000 or 0 to 6-0) common to OMFS

Monofilament vs. braided

Resorbable vs. Non-Resorbable

Needle holder

Proper grip: thumb and ring finger with palm down

Scissors

Dean Scissors -Commonly used for sutures and soft tissue

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Other

Bite block

Suction

Irrigation

Tonsil Suction

Vacuums pharynx

Surgical Suction

Clears surgical field

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#8 Frazier Suction with Stylette see picture

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4. Instruments for Extracting Teeth

Elevators

screwdriver or chisel

Forceps

pliers

Dental Elevators

Components

Handle, shank and bladeMost of our elevators use same handle and shank with variation of blade

Basic types see pictures for these

Straight-luxate teeth.

Small straight-301, Large straight-34S

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Triangle or pennant-shape recover root from socket

usually paired

Broken root remnants

Cryer (aka East/West) are most common

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Potts Eleveators:

Maxillary 3rd Molars

Portion of impacted teeth

Elevates and rolls

Curved roll teeth out of socket i.e. maxillary 3rd molar

Maxillary 3rds molars

Portions of impacted teeth

Elevates and rolls

Pick small, straight elevator

Remove roots

Crane/Cogswell-heavy

Root-tip pick-thin and delicate Heidbrink or double ended

* Hu-Friedy Heidbrink Root Tip Picks - Handle design improvesleverage

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Extraction Forceps

Provides a HANDLE on the tooth

Improves the LEVER ARM Works in similar fashion to a VISE GRIPS pliers

Components:

Handles

Hinge: English vs. American

Horizontal=American

Vertical=English (i.e. Ash)

Beak: Greatest variation

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Adapts to the ROOT

NOT CROWN

Maxillary Forceps

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Universal: - #150

Site specific:

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Universal Molar (Note Offset or Bayonet Design)

Right molar (53R, 88R)

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Premolar (150-A)

Anterior (1-A)

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Left Molar (53L, 88L)

Several Pictures in this section.

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#88 Right and LeftUpper CowhornsMaxillary Anterior #1A

Mandibular Forceps

Universal: - #151 A Style beakSite specific:- Molar (17, 23) #23 also called [Cowhorn]- Premolar (151A)- Mandibular incisors, canines, premolars (Ash)

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Proper hand

position for

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Uncomplicated ExodontiaUncomplicated Exodontia

Baisc Principles

Clinical evaluation

Presurgical assessment

Radiographic evaluation Proper diagnosis/treatment plan - understand the indication for removing

the tooth/teeth

Informed consent

Surgeon and patient preparation Surgical assistant, instrumentation

Proper pain and anxiety control- Excellent Local Anesthesia

Access Chair position, soft tissue retraction, lighting

Extraction of tooth: closed or surgical

Post-op care of patient

Indications for Removal of Teeth Infection/ Acute Abscess Possible difficulty with local anesthesia, refer

for IV Sed or GA indicated, prior to attempting removal

Severe Caries

Pulpal Necrosis

Severe Periodontal Disease

Orthodontic Treatment

Indications for Removal of Teeth

Malopposed Teeth, non-functional teeth

Non-Restorable/ Cracked Teeth Pre-Prosthetic Extractions

Impacted Teeth

Supernumerary Teeth

Teeth Associated with Pathologic Lesions

Pre-Irradiation / Pre-Bisphosphonate Therapy

Teeth in the Line of Jaw Fractures

Aesthetics

Economics

Relative Contraindications for Removal of Teeth -Systemic Uncontrolled Metabolic Disease IDDM, ESR Failure, Hyper-thyroidism

Malignancy Leukemia, Lymphoma

Recent MI(b4 6 mo.), Unstable Angina, Uncontrolled HTN, CHF

Pregnancy

Immuno-compromise HIV/AIDS, Chemo/Radiation Therapy, Steroids

Bleeding Diatheses- Hemophilia/ Factor Deficiency, Platelet Disorder- ITP,

Anti-Coagualtion

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Medications that compromise hemostasis or ability to heal warfarin

(Coumadin), anti-resorbtive use (I.V. bisphosphonates, anti-resorbtivemedications) Have them check their INR

Relative Contraindications for Removal of Teeth - Local

Previous Head and Neck Irradiation osteo-radio-necrois (ORN)

Previous Systemic (I.V.) Bisphosphonate (Anti-resorbtive) Therapy ARONJ

(formerly BRONJ) Acute Pericoronitis increased likelihood of infection of major fascial spaces

( manage pericoronitis with local care, usual resolution in several days, thenextract)

Anatomic Considerations IAN, Sinus, Compromise of adjacent teeth,

Periodontal Defects

Potential for Pathologic Fracture

INFECTION / ACUTE ABSCESS IS NOT A CONTRAINDICATION TOEXTRACTION !!!!!

REFER FOR TREATMENT FOR SYSTEMIC SIGNS, SWELLING,

TRISMUS

Clinical Evaluation for Tooth Removal

Patient Attitude/ Ability to Cooperate

Access - MIO, Angles class, tongue size, gag reflex

Location and Position of the Tooth

Mobility Periodontal Involvement, Patient Age, Resiliency of Bone

Condition of the Crown, Previous Endo Tx

Condition of the Adjacent Teeth/ Restorations

Condition of Bone - Lack of Resiliency, Tori

Radiographic Evaluation for Tooth Removal

Proper Name/ Date (< 1 year old)

Proper exposure

Angulation

mas, kvp

developed properly - traditional films

enhancement of digital radiograph

Entire root visible

Relationship to vital structures

Sinus

IAN

Radiographic Evaluation for Tooth Removal

Configuration of roots

Length and morphology

Previous endodontic therapy, internal resorbtion

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Condition of surrounding bone

Density

PDL

Pathology

CAN YOU SEE WHAT YOU NEED TO SEE?

Prior To Procedure

PMH Verified? Previous Medical Hx

Proper diagnosis/treatment plan - understand the indication for removing

the tooth/teeth

Will the Proposed Procedure Obtain the Desired Result?

Will the Patient be Happy with the Result?

Informed consent: documented, signed, dated, witnessed

Surgeon and Patient Preparation Aseptic technique - relative

Personal protective equipment

Mask, gloves, gown, glasses - OSHA Compliant

Safety glasses for patient per clinic recommendations

Personal hygiene

Clothes, hair

Gauze throat screen

Chair and Operator Position for Dental Extractions

Access and visibility overhead light angulation and focal length

Stability

feet apart, weight distributed on balls of feet

Controlled force

Mechanical advantage

Surgeons health

chronic musculoskeletal strain (PROTECT YOUR BACK)

Patient comfort

Chair and Patient Position: Standing Surgeon Maxillary teeth

Maxillary plane >60 to floor

Maxillary arch level with surgeons elbow or below (elbow bent >90 )

Turn head so quadrant of extraction is easily visible

Lateral protrusive position of the mandible- moves coronoid processlaterally and away from the maxillary surgical site

Chair and Patient Position: Standing Surgeon

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Mandibular Teetho Chair Upright so that when mouth is open, occlusal plane is parallel to

floor, adjust headrest as neededo Bite block to support TMJ and Maintain IIO

o Lower Chair ( Elbow at >120 )

o Turn Head so that quadrant of extraction is easily visible

o Some prefer a Behind the Patient approach

Basic Principles

CONTROLLED FORCE

Mechanical Advantage, NOT Strength

NEVER USE EXCESSIVE FORCE !!!

RECOGNIZE WHEN YOU ARE NOT MAKING PROGRESS AND PROCEED TO A

SURGICAL APPROACH

Place finger/thumb on buccal plate to stabilize alveolus and evaluatedegree of force transmitted and tooth/mobility

DO NOT PULL THE TOOTH Intrude, Push, Rock, Rotate, Draw, and

Deliver

Simple Machines: Basis of Extraction Techniques

Lever

Wedge

Wheel and Axle

LEVER

Requires a FULCRUM

Lever-mechanism likely to break fragile elevators (root tip picks), teethand/or bone

Straight Elevator

Cryer elevators, Potts elevators

Cogswell, Crane, and others

Forceps are actually paired, opposing levers

WEDGE

SAFER with MORE CONTROL of FORCE

Straight elevators, root tip elevators

Direct along the axis of the root, in the periodontal ligament space,

between the tooth and the bone

Surgical blade is a form of a wedge

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WHEEL AND AXLE

Used to SCOOP tooth from socket

May generate EXCESSIVE FORCE

Purpose of ElevatorsPrimary:

Loosen teeth in preparation for extraction with forceps

Create space for forceps

May be primary mechanism for extraction, particularly for impactedteeth

Secondary

Remove parts of tooth or root

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Specific Elevators:Straight Elevators

Usually the initial instrument used during extraction

Primary use is for initial expansion of alveolus and loosening of tooth/PDL

(Lever and Wedge)

Often used incorrectly- DO NOT FULCRUM FROM THE ADJACENT TOOTH

FULCRUM ONLY FROM THE CRESTAL or INTERSEPTAL BONE

When used between teeth and only one tooth is to be extracted, care

must be used to avoid damage to adjacent tooth/restorations

Use with working end pointed from facial toward the lingual or apically

along the axis of the root

NEVER USE IN CROSS ARCH FASHIONbecause the elevator canpenetrate the cheek

Proper way to elevate

Elevator is used to force the tooth to expand the bone

Wedges the apical edge of the elevator against crestal,interseptal bone and

pushes the tooth

Avoids force on adjacent tooth

Straight Elevator When used to scoop the tooth out, significant force is placed on the

adjacent tooth. Dont do this routinely!

ACCEPTABLE TO USE THE ADJACENT TOOTH AS A FULCRUM ONLYWHEN

THAT TOOTH IS ALSO TO BE REMOVED !!!---------------------------

Cryer Elevators

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Lever, and/or wheel & axle forces

Careful as will fracture tooth, bone generates much force

Primary use is for removing residual roots of multi-rooted teeth, especiallyretained mandibular molar roots

Sharp tip removes inter-radicular bone providing access to the retained root

(two scoops)

Root Tip Elevators

Appearance seems to indicate they would be good lever for prying out

root tips. This will ruin the instrument.

FRAGILE - Prying forces will bend or break these instruments

Sole use is as wedge. Push fine tip apically to wedge root tip fromsocket or wedge tip into PDL to displace root

Wedging out a root tip with a straight elevator:1- Finger rest to control apical force2- Insert elevator within PDL3- Avoid pressure that will displace the root into the sinum

FORCEPS

Paired, opposing LEVERS

CLASS II LEVER: The load (tooth) is situated between the fulcrum (apical

bone) and the force (operator)

Primary force is initially in an apical direction to seat the forceps MOVES

FULCRUM TO APEX OF THE TOOTH

o Usethe root of the tooth to expand the alveoluso If you keep closing the forceps you can fracture the crown

Not for pulling teeth- use the forceps as a handle and lever comparable to a Vise Grips

Secondary force is buccal, lingual, and rotational to EXPAND THEALVEOLUS and release the tooth

Lastly, minimal tractioning force DRAW = DELIVER the tooth

Forceps movement produces significant wedging forces

The tooth is used as a wedge to expand the alveolar bone

o Use in lingual/buccal apical direction

Initial and greatest magnitude of force of apical. Secondary force is B/L.Expansion of the alveolar bone is the goal.

Non-Surgical ExtractionNo such thing as a simple extraction

Closed or Non-surgical is proper description

What makes it easy (or difficult) is the skill of the surgeon (or lack thereof)

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Step by Step Approach to Non-Surgical (Closed) Extraction:

Confirm profound anesthesia of soft, hard tissues, and pulp

Release soft tissue around tooth- Be Kind to the Soft Tissue

Elevate tooth with the elevator

Adapt forceps to the tooth: Luxate with forceps to expand the alveolar bone.

o Luxate: To throw out of place or out of join

Remove the tooth from the socket

Confirm that roots have been delivered in their entirety : Confirm normalroot anatomy, Check for cleavage planes and accessory roots: lookfor pdl fuz

Examine socket and debride soft tissue, debris, granulation tissue-curette

Compress socket (realign the labial cortical plate)

u dont want it narrow bc it iwill be diffic. For implant or ortho

treatment If you have undercut compress it a little

Place 2x2 gauze directly over socket and compress with occlusal force

Make sure you have good anesthesia, and Articane Shouldnt be used formandibular BlockLoosening of Soft Tissue Attachment

Sharp end of periosteal elevator (convex side toward periosteum): #9

Molt, curette, Woodson reflect to the crest

Also confirms soft tissue anesthesia

Allows forceps to be seated apically or elevator to be placedinterproximally

BE KIND TO THE SOFT TISSUE

Luxation of the Tooth with Dental Elevator

A straight elevator is commonly the first instrument employed

Perpendicular to interproximal space or parallel to the long axis of thetooth. DO NOT USE THE ADJACENT TOOTH AS A FULCRUM.

Luxate tooth

Tear, Disrupt PDL- bleeding into PDL hydraulic pressure facilitatingexpansion of the alveolus

Expands the bone

Avoid injury to adjacent teeth crowns, interproximal restorations

Confirms degree of mobility or establishes need for surgical extraction

If successful you can use forceps if not you go surgically

Never use Exccessive force or sth BAD is gonna happen

Fulcrum up the crest bone

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Adaptation of the Forceps to the Tooth

Choose forceps that has beaks that will adapt well to subgingival

morphology of tooth - engage intact cementumn

Confirm long axis of beaks clears adjacent teeth to avoid trauma.

Generally this requires the beaks to be parallel to the long axis of the tooth

We want to shorten the length of th root by placing the forceps more

apically on the tooth Seat with apical force (lingual/palatal before buccal)

Avoid pinching soft tissue place lingual or palatal beak first

Firm apical force

Moves fulcrum to apex

Moves center of rotation apically to retard root fracture

Expands alveolus and widens PDL space

If crown: Root ration is big

It is BAD for perio

It is Good for extraction

It is easier to see lingual/palatal

Luxation of the Tooth with the Forceps

Firm grip to hold forceps handles together in a stable position. Do NOTcontinuously squeeze the handles together as this will fracture the crown(exception is the mandibular #23 forceps = cowhorns)

Straight wrist with controlled force generated from shoulder andupper arm, not wrist

Firm, steady, sustained force hold, flex the bone to allow expansion of

the alveolus Initial force displaces the tooth apically

Lateral force is then applied buccally and then with less lingual/palatal

force

Rotate the tooth gently after initial mobilization

JUST LIKE WIGGLING A FENCE POST OUT OF THE GROUND oftencompared to a figure of 8 motion

Continue to re-seat the forceps apically as tooth mobilizes

DO NOT FRACTURE THE CROWN

It is hard mechanically to use forces. But

Pt. Postion + good mechanis = good extraction

***Opposite hand stabilizes alveolus and palpates for alveolar fracture ormovement of adjacent teeth. It protects adjacent tissue and prevents slipping thatcould harm the patient.***

Removal of the Tooth from the Socket

Slight traction, usually buccal is usually the final step to removal of a tooth

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Not a pulling motion

Traction = DRAWING motion

Draw: to cause (an unwanted element) to depart (as from the body or a

lesion)

Post-Extraction Care of the Socket

Remove Debris, if present

PA Lesion small curette

Calculus, Amalgam

Tooth Fragments

Realign Buccal Plate gently compress socket

Restore Pre-Extraction Anatomy

Do NOT collapse the B-L dimension of the alveolus, except for pre-prosthetic purposes

Debride Granulation Tissue from Gingival Sulcus

Smooth any Sharp Bone

Irrigate as needed

Control hemorrhage

Pressure with moist 2x2 gauze placed over the extraction space

Specific Forceps and Their Use: Technique for Extracting Specific Teeth

Universal Maxillary and Mandibular Forceps:150 and 151 and Variations

Seat beaks with firm and deliberate apical pressure

Moves center of rotation apically to decrease root fracture

Secures purchase on non-carious/sound tooth Further wedging force augments that already accomplished by elevator

Buccal-lingual force (primarily buccal) and rotation (single rooted teeth)

Figure-8 motion works well with multi-rooted teeth

Luxate as in removing a fence post

Maxillary Molar Forceps:53 and 88

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Off-set beaks may allow better access along vertical axis of the tooth

Less chance of damage to adjacent teeth

Beaks are designed to engage root morphology and improve apicalpurchase

Use with figure-8 movement

DO NOT use TOO much FORCE

DO NOT FRACTURE TUBEROSITYor BUCCAL PLATE

Low threshold for surgical extraction if only limited or no movement !!!

Mandibular Molar Forceps:Cowhorn #23

Designed to engage the furcation of lower molar

No crown required to engage the tooth may be better than Universal

forceps for broken down mandibular molar teeth

Must seat into furcation with pumping up and down action BEFORE

any buccal-lingual rotation

OK to squeeze the handles together, but anticipate a crown fracture or

rapid delivery of the tooth Works best for parallel = non-divergent roots

Seat on lingual first taking care not to injure soft tissue

Up and down motion with gentle pressure closing beaks together

squeezing handles together

Once seated, use water-pump handle, buccal-lingual motion, &/ or figure-

8 motion

Primary Teeth

If roots are not resorbed, long, divergent and fragile roots complicate

exodontia.

Likely to fail due to differential resorbtion caused by erupting permanentteeth especially premolars.

Bone is more flexible.

Care not to damage succedaneous tooth.

Post-Extraction Care of the Socket

Remove obvious PA pathology or socket debris.

Remove soft tissue pathology/granulation tissue

Realign Buccal Cortical Plate (Compress Socket) to restore pre-

extraction anatomy.

Moist gauze for pressure hemostasis.

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Complicated Exodontia

Complicated ExodontiaSurgical Extraction :

Delivery of the tooth requiring construction and elevation of a muco-

periosteal flap, removal of supporting/ impeding bone, and/ or delivery ofthe tooth in multiple pieces

MATHEMATICS OF EXTRACTION

FORCE + SURGERY = ( SURGERY + $ )

SURGERY + FORCE =

+ $

Complicated Exodontia

Flap design, construction, and elevation

Removal of supporting/ impeding bone

Sectioning (Dividing ) the tooth into smaller segments

Multiple extractions

CONCEPTS : NON- SURGICAL EXTRACTION

NON- SURGICAL = UNCOMPLICATED EXTRACTION:

Removal of a fence post

Push and wiggle side to side to expand the dirt and allow the post to

be drawn and removed

Concepts: Surgical Extraction

Goal: Expedite delivery of all tooth structure while maintaining necessary

alveolar contour

Create a path of withdrawal for the entire tooth or each individual

segment of the tooth Consider the shape/ contour of the remaining alveolar bone different

goals for implant, removable prosthesis, no prosthesis

Conditions Leading to Need for Surgical Extraction

Avoid Excessive Force !!! - fractures

Dense bone

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Exostoses, tori

Root morphology

Multi-rooted teeth

Dilacerations

Internal resorbtion

Age: Dense Bone vs. Ankylosis vs. Atrophic Periodontal Ligament ?

Body Build/ Genetic considerations- Race

Bruxism

Previous Endodontic therapy

Deep Caries

Adjacent Anatomic Structures: Sinus, IAN proximity

Compromised adjacent teeth crown, recurrent caries

Multiple extractions

Impactions

CONCEPTS

SURGICAL EXTRACTION:

Removal of a rock from the lawn

Push back the sod = expose the tooth by constructing and elevating afull thickness muco-periosteal flap

CONCEPTS

Options:

Remove a lot of dirt to remove the whole rock,

Or

Divide the rock into many smaller pieces,

Or

Remove some dirt and divide the rock into a few largepieces.

The initial plan for the approach to the tooth may be an uncomplicated or

closed extraction.

As the tooth is manipulated and more information as gained, the approach

may progress to a surgical approach. The approach to, and delivery of, the tooth is a dynamic process.

Flap Design: Development and Management

Design parameters

Types of muco-periosteal flaps

Technique for developing a muco- periosteal flap

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Design Parameters

BLOOD SUPPLY: Flap base MUST be broader than free margin

Allows inflow of arterial blood and outflow of venous blood. Lack ofadequate outflow leads to venous congestion and death of the tissue. -Nice picture slide #17

Adequate size: Big Flap = Big Surgeon

See what you are doing

Full thickness- Do NOT tear the flap

BE KIND TO THE SOFT TISSUE

Design Parameters

Incision over intact bone

Avoid injury to vital structures LINGUAL, MENTAL nerves Releasing Incision, if needed, to avoid tearing

Adequate Size: DONT work in a hole

Visualization: If you cant see it well, you cant do it well.Patient PositionLightingSuctioningAdequate Exposure of Surgical Site

Elevation of flap margins over intact bone Proper Instrumentation Retractors to displace and protect the soft tissue

Prevent tearing (sharp incision heals better than a tear)

If releasing incision required, extend at least one tooth anterior or/and one

tooth posterior flap margin must rest on sound bone

Common Flap Designs

Sulcular Incision

Envelope Flap No Vertical (Oblique) Releasing Incision

Envelope Flap with Releasing Incision

Posterior ( Distal ) Oblique Release May be Preferable Cosmetically

Release Tissue around the corner of the canine eminenceAnterior Vertical (Oblique) Release Incision

May Compromise Anterior Aesthetics try to avoid creating flaps

around anterior crowns which may expose the finish line andcompromise aesthetics

Probably Easier to design and work under an anterior release

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Around the Corner- Canine Eminence

Vertical (Oblique) Release Incision

Base is broader than free margin = loose edge of the flap

Cross gingival margin at the line angle of the tooth (May include tissue of

embrasure to facilitate suturing) Incision over intact bone, but not on an osseous prominence such as

the Canine Eminence tiger trap

Types of Muco-periosteal Flaps

Envelope

Sulcular incision in dentate patient

Crestal incision in edentulous area

Three cornered flap

Single vertical (oblique) release Posterior (distal) or Anterior (mesial)

release Four cornered flap

Anterior and posterior releasing incisions

Semi-lunar flap

apical to attached gingivae

periapical access retrograde endo

Y- flap

Palatal access for removal of tori

Pedicled flap

allows repositioning of tissue with its own blood supply closure of oral-antral communication

Developing the Flap

Sub-peri-osteal injection of LA - hydraulic force facilitates reflecting the

periosteum from the bone

Incision

Firmly, with scalpel blade contacting bone

Blade perpendicular to bone and soft tissue

A single stroke not multiple cuts

Developing the Flap

Reflection lift the periosteum and flap from the bone

Comparable to lifting up carpet or sod

Sharp end of periosteal elevator between periosteum and bone

Elevate along a broad front

Retraction protect the soft tissue

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Surgical Extraction of Single Rooted Tooth

Reflect the Flap

Determine Extent of bone removal, if any

Remove Bone Bur and COPIOUS IRRIGATION

Apical purchase of forceps on cementum

Irrigate well under depth of flap NO retained debris Elevate Flap and Gain Better Access Without Removing Bone

Deliver, Debride, Suture

Surgical Extraction of Multi- Rooted Tooth

Divide and Conquer Strategy

Identify furcation remove bone, if needed

Fissure bur (703,701) to section = divide tooth through pulpal floor intofurcation

Avoid violation of maxillary sinus floor Split tooth: divide root from root with straight elevator

Converts multi-rooted tooth into several single rooted pieces

Elevate or luxate and deliver root segments

Some options for divide and conquer:

Molar 2 Premolars

Molar Single rooted crown + root

Molar Roots 2 Roots

Max Molar 3 Roots

Fractured Roots

Some roots will fracture due to unfavorable curvature, or brittle nature

Thorough mobilization of the root prior to fracture facilitates delivery

Remove bone to create space into which the root can be elevated

Gently engage elevator into PDL space

Root Tip Elevators (Pick)

Fragile elevators

Appearance seems to indicate they would be good lever for prying out

root tips Easily damaged: use to wedge root tip from the socket

Prying forces will bend or break these instruments!

Only use is as a wedge. Push fine tip apically to wedge root tip from socket

or wedge tip into PDL and draw in a vertical vector to displace root tip ordisplace into created space

Root Tips:Tease or wiggle !!!Do NOT force apically !!!May displace root into sinus

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Remove Bone

Use bur to remove buccal or inter- radicular bone

Create a space into which the root can be elevated or expose adequate

tooth structure to engage with the forceps

Carefully Elevate the Root Tip! Gently elevate the root

If not mobilized, remove more bone

NEVER use excessive force !!!

May displace the root into sinus, submand space, FOM, or through the

buccal plate

Apical Window

Buccal bone overlying the apex is removed a window is created

Crestal, buccal bone is preserved

Root tip is elevated from apical area through window or into socket Do NOT violate sinus or IAN

Leaving Root Tips ? Indications:

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Evaluate at recall appointments

Multiple Extractions

Treatment planning

Sequencing

Technique

Multiple Extractions: Treatment Planning Replacing the Tooth you just pulled.

Replacement: Implant vs. Bridge

Implant: Maintain maximum volume of bone

Bridge: Favorable contours for pontic

Pre-prosthetic surgery: RPD vs. CD

Smooth alveolar contour

No prosthesis: May concentrate on delivering tooth expeditiously

Multiple Extractions: Sequencing

Maxillary first theory

Anesthesia obtained first and of shorter duration

Debris does not fall into lower ext sites

Mandibular first theory

Blood from maxilla does not obscure surgical field

Harder teeth first- surgeon is not fatigued

Multiple Extractions: Sequencing

Usually from posterior to anterior Recover all roots from one tooth before proceeding to the next tooth !!!!

Dense bone over 1st molar and cuspid

May elect to mobilize 1st molar and cuspid initially (loosen), extract

adjacent teeth, then extract 1st molar and cuspid

Hydraulic forces from sheared PDL may expand alveolus (?)

Treatment Plan: Implant ?

Preserve Bone height and width

If surgical approach, attempt to maintain

a 4-walled bony defect to allow osseous fill Consider grafting = socket preservation, if applicable

Treatment Planning: RPD or CD?

Maintain bone over canine eminences

Maintain buccal plate contour

Smooth osseous prominences

A take away process. Is this as smooth as I can make it ?, Will

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removing more bone make things worse ?

Palpate the alveolar contour through the soft tissue

oral midterm 1

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