oral surgery exam 1

8/13/2019 Oral Surgery Exam 1

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$nstrument Disinfe%tion

- ;lutaraldehyde )0idex+

o #ost commonly used for disinfection

- %odophores )


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iodophor compounds )


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- one end and side of towel

o dry both hands and one arm well progress up from hand to elbow

- other end and side of towel

o other arm

- don9t let towel touch non-sterile items

o scrubso surgical tables

Principles of Surgery*rin%iples of surgery

- 7ollowing surgical incison3excision8 surgeon maximies the opportunity for

healing and restoration of function to occur without complications- general principles

o apply to all aspects of surgery

- specific principles

o apply to certain areas like cancer surgery etcE

- ? main principleso perioperative assessment

%D diseases that may complicate anesthesia

e,g, 0F disease8 etcE

%D diseases that may compromise surgery or healing

e,g, diabetes8 A%DS8 hemophelia8 pts who have undergone

radiation treatment8 etcE

%D social habits that may complicate surgery

e,g, smoking8 alcoholism8 cocaine use etcE

elective surgery

optimie existing conditions )heart disease8 diabetes)BbAc value+8 chronic renal failure etc,,+

non-elective surgery

not always possible to optimie existing conditions

so complications are much higher )trauma8 acute infection8

obstetrics+

T"e a&ility to "eal %an affe%t t"e surgery ire%tly/t"ese

potential pro&lems nee to &e ientifie early on

o a%%ess

to ade(uately visualie problem

to preserve important structures

to allow for handling of complications )bleeding8 etcE+

)also a major problem with restorative dentistry+

if access isn9t ade(uate8 stop what you9re doing and make

necessary adjustmentsG

retraction

good assistance

light

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7lap3%ncision

o #ust be large enough for good visualiation

o $n skin use resting tension or Canger9s lines

o Avoid important structures,

o


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o !emove foreign bodies


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Dog -ite to 7"il


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o re(uire antibiotics

- antibiotic cover for surgery

o principle high peri-operative blood level of antibiotics during period of

bacteremia

o dose %F ?5 min pre-op

o . doses %F at 1-J hr intervalso I days of antibiotics are :$& indicated leads to bacterial resistance

Hemostasis

- primary

o occurs at time of sx

o pressure8 vasoconstrictors8 ties or clips

- reactionary

o 1-J hrs later

o after local wears off vasodilation

- secondary

o *-5 days after

o due to infection @liver clot

- Drains may be useful in large wounds with gross dead space to @suck the tissues

together and also to prevent the formation of hematoma

o :eed to have good oral closure with suction drains to prevent salivary

contamination

Ex%essive Healing

- despite good would closure8 healing may become excessive due to

o

low grade irritation infection

foreign body

mobility )bone callus in inade(uately fixated fracture

genetic 3 racial factors- "ypertrop"i% s%ars

o example on slide 24

o scar hasn9t grown out of its initial boundary but it9s raised and larger than

it should be

- ,eloi s%ars

o example on slides I5 > I

o grow beyond the initial boundary of the incisiono common in African-Americans

o can inject steroids into them to attempt to reduce volume

o small ones can be excised and followed with low-dose radiation but in

general8 nothing can be done

o 2elois are typi%ally on people of ar,er s,in

J


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Hypertrop"i% s%ar "as more volume of s%ar tissue+ &ut oes not

gro4 outsie area of in'ury

2elois gro4 4ell outsie of t"e area t"ey starte in

Inflammation and Wound Repair

7auses*at"ologi% surgeon has little control over this type of tissue damage

- caused by bacteria8 malignant processes8 metabolic processes etcE

Traumati% surgeon can do a lot to either favorably or unfavorably alter this type of

tissue damage

- B"S%0AC

o incision8 crushing

o extremes of temperature

o irradiation

o desiccation

o obstruction of arterial inflow or venous outflow

- 0B'#%0ACo non-physiologic pB or tonicity

o disruption of protein integrity

o ischemia due to vascular constriction or thrombosis

;oun Healing

- T"e p"ases signifi%antly overlap an ea%" p"ase is epenent on t"e

pre%eing one to o%%ur

- three phases

o %:7CA##A&$!" BAS'

o !$C%7'!A&%F' BAS'

o #A&H!A&%$: A:D !'#$D'C%:; BAS'

o !'S&$!A&%$: $7 7H:0&%$:

$nflammatory *"ase

- main function remove amage tissues an eliminate any invaing organisms

an e&risvia phagocytosis

- release of factors that cause migration and division of cells )proliferative phase+

*roliferative *"ase

- divided into 2 major processes

o angiogenesis

restoration of blood supply to tissues in the wound

new vessels grow from endothelial cells

o granulation tissue formation

fibroblasts grow and form a new '0# by excreting collagen and

fibronectin

must have a good bed of granulation to allow the new epithelialcells to move in

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o epit"elialization

epithelial cells proliferate and migrate along '0# until continuity

is reestablished

mucosa is replaced on internal surfacesK skin on external surfaces

o 4oun %ontra%tion

myoepithelial cells induce wound contracture to bring the woundedges closer together

extremely important in reducing the sie of the wound- :o restoration of blood flow prevents the next stage

- roliferation of cells into wound )endothelial and fibroblasts+

o !eplace blood vessels and '0# respectively

- 0overing of wound with mucosa3skin

o !e(uires granulation tissue to build upon

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o serotonin8 bradykinin8 prostaglandins8 prostacyclins8

thromboxanes8 histamine

increase cell proliferation and migration intoinjured area

cause vasodilation and increase capillary

permeabilityedema L entry ofleukocytes

leukocytes debride wound and neutralie

any foreign factors etcE

o &


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- begins .-? days after wounding even before inflammatory phase ends under the

influence of ;7s

- fibroblasts and endothelial cells enter wound and begin laying down new '0#and blood vessels

o endothelial cells enter first because a blood supply is needed before

anything elseo then fibroblasts migrate and proliferate along fibrinogen and fibronectin

)can9t migrate in fluid+

ngiogenesis

- under the influence of ;7s fibronectin and chemokines produced by platelets and

macs w3in the wound8 stem cell endothelial cells proliferate and migrate along thefibrin matrix to create new capillaries

o critical step brings oxygen and nutrients to migrating fibroblasts and

other cells

o tissue appears erythematous due to presence of large P capillaries

- to migrate8 endothelial cells produce collagenases8 metalloproteinases andplasminogen activator to degrade the clot and '0#

- low $.tension and lactic acidosis in wound is essential for platelet and mac

production of ;7s and chemokines

- when $.tension is restored8 production of these factors ceases- fibroblalsts secrete

o '0# components ;A;s8 glycoproteins8 collagen )type %%% later to be

replaced by type % after wound matures+

o ;7s for epithelial cell proliferation and migration

7ollagen Deposition

- fibroblasts begin to secret collagen by day . or ? )peaks at -? weeks+- collagen production continues for .-2 weeks )afterwards8 destruction matches its

production+- essential for wound strength before that8 only thing holding wound closed is

fibrin fibronectin clot

- once maturation begins8 fibroblasts undergo apoptosis and decrease in number signals the end of the proliferative phase and granulation tissue

o maturation phase can now begin

Epit"elialization

- ;ranulation tissue in wound permits re-epithelialiation

o S,in an mu%osa must migrate over t"e granulation tissue- 'pithelial cells migrate and proliferate across wound under surface scab to form a

new barrier

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o ;ranulation tissue persists if wound gets infected back to inflammatory

phase and granulation tissue is broken down whole process restarts

o %f there9s inade(uate oxygenation8 granulation tissue can9t be formed

wound will persist as non-healing ulcers )D%A


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Maturation an 0emoeling

- 0ollagen production and degradation are e(ual

o 0an last a year or more depending on sie of wound

o &ype %%% collagen is replaced by stronger type %

- 0ollagen fibers are rearranged8 cross-linked and aligned along tension lineso %ncreased tensile strength )only I5-J56 or original strength+

o 7unction is not completely regained either

- 'lastic fibers are not replaced flexibility of tissues is reduced

o Scar tissue is much more rigid important in cosmetic sx

- Fascularity )redness + decreases

- Nound contraction is also undesirable in burns and curved wounds

o Skin grafting has been shown to reduce wound contraction

- &issues returns to normalcyEby 1 months8 clinically appears as normal tissue

)not histologically though+

>a%tors t"at $mpair ;oun Healing

- foreign material

- necrotic tissue- ischemia like in diabetic pts

- tension why we suture wounds scab are only I6 strength of original tissue

>oreign Material

- anything host9s immune system considers non-self

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o decreased blood supply thus decreasing delivery of $.and nutrients to

wound necrosis L lessens delivery of Abs8 N


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-


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- reat for%e %an &e exerte

o %are must &e ta,en to avoi alveolar fra%ture

Maxillary >or%eps #1@9

- single rooted teeth )incisors and canines+- beaks curve to meet only at tips- beaks ?5/ to handle

Moifi%ations of #1@9 >or%eps

- 1@9

o parallel beaks that do not touch

o for premolarso :$& for incisors )poor adaptation to roots+

- 1@9S

o same as I5A except they have serrations

se peo for%eps (1@9S) for pts 4"o %an


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- removes conical rooted max .ndand ?rdmolars

- broad smooth beaks

- beaks offset from handle

#FG- for root tips

- offset molar forceps w3 narrow beaks

- :arrower beaks fit right into socket- may also be used for narrow premolars and mandibular incisors

#1@1

- mandibular universal forceps- beaks similar to I5 and meet only at tip

- beaks at 15/ angle to handle

- useful for single rooted teeth

- can be used for primary teeth8 including molars

J

.J1

.5S

I


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#1

- mandibular molars

- pointed tips in center for bifurcations

o -ea,s engage &ot" fur%ations

- beaks at 15/ to handle

- :$& for molars w3 conical or fused roots- straight handle )usually+

#

- similar to P* or%eps

- &issue 7orceps

o Adson with teeth to pick up tissueK can crush

o Allis clamp

used a lot in neck surgeryK not as much in oral surgery

great for grabbing tissue )also crushing tissue+

o OT use if you


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0 -a%, %tion Elevator

- blade similar to ?5

- offset to permit better access to posterior teeth )has a bend in it+

*i%, TypeK 7ryers Elevators

- pennant-shaped

- come in pairs !ight and Ceft- useful to remove broken roots adjacent to an empty root socket

- tip of blade is placed in empty socket

- shank rests on buccal bone and cortical plate

- can remove interseptal bone if crown fractures then remove roots

7rane *i%, Elevator

- used as a lever to remove roots

- place hole in tooth )purchase point+o &hen elevate w3 the crane pick

0oot Tip pexo Elevators

- used to tease small root tips from sockets

- much more delicate than 0ryer or 0rane ick

- can9t be used as a lever type or wheel and axle elevator

- come in pairs !ight and Ceft- 0oot "as to &e elevate+ loose or mo&ile in orer to use t"is

o se to get &et4een root an alveolus

*otts Elevators- come in pairs !ight and Ceft

- used mainly to remove maxillary ?rdmolars

- long with cross-bar handles

o generate a lot of force

o %an fra%ture maxillary tu&erosity

- used after a straight elevatorK secondary instruments

*eriosteal Elevator #8 Molt

- double ended- pointed end sharp8 used in prying motion to elevate mucoperiosteum from bone

)usually interdental papilla+o 'levates the gingival cup and breaks the gingival fibers

- rounded end push stroke once under periosteum to lift it from bone

o also used in a pull3scrape stroke to lift mucoperiosteum )greater risk

tearing tissue+

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Mis%ellaneous Surgi%al $nstruments

- mouth mirror - Dean scissors )tissue cutting8 suture cutting+

- retractors

o

Benahan gingival )does not elevatemucoperisoteal flaps+

o Austin gingival

o #innesota

o


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2, 0entric points on the I?! and C and on the * are to engage root furcations

I, P.? )0owhorn+ are forceps > elevator in one #HS& use a biteblock

1, &he way you estimate the closeness of beaks is to look at the proximity of thehandles

*, Allis clamp is for grabbing tissue can9t use it for tissue that will be submitted to

pathology because it also crushes tissueJ, "ou have more control of forces with elevators than with forceps

4, &he tip of an elevator should be placed towards the apex of the root to avoid

putting pressure on adjacent teeth5, !oot-tip elevators are designed to go between the root and alveolus and should be

used when the tooth is already partially elevated

, A possible complication of using a otts elevator is fracture of the maxillary

tuberosity., &he direction of force when using a bone file is in one direction only pull you

use it in a push-pull manner but you will only be cutting bone in the pull direction

)so only put force in the pull-direction+

Extraction ForcepsHanle

Fertical

- creates more force- mandibular teeth

- more ris, of root tip or %ro4n fra%ture

- ;ives apical type pressureBoriontal

- S&A:D%:; %: 7!$:& $7 A&%':&

o #ax alm Hp

o

#and alm Down- S&A:D%:;


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>or%eps for t"e Extra%tion of Maxillary Teet"

!oot

Shape

7orceps

to Hse

Additional :otes

Anteriors conical

triangular

44-0

- can use even if there is no clinical crown

- transmit forces directly in apical directionremolars oval I5

I5-AS

- universal forceps

- not best suited for trifurcated teeth

- good for sectioned molars- stpremolars can have buccal and palatal

roots palatal root tends to break be

careful

- for crownsK does not move apically as well

as I5- Nhen removing maxillary st premolars 8

remember the palatal root is just as long as

the buccal root- &herefore always expand palatal-buccally

)more of an emphasis on the buccal

movements+

- alatal root more likely to snap off8 so goslowly

stL .nd#olars

trifurcated J445

JJ! L C

I?! L C

- palatal beak adapts to palatal root ratherthanentering furcation

- T"e pointe &ea, is al4ays on t"e &u%%alsie

- @upper cowhorn

- < and furcation prongs- must use caution to avoid alveolar fracture

or tissue damage

good adaptation but should be avoided when

- caries is extensive- large amalgam

- !0& has rendered tooth brittle

'rupted ?rd#olars

trifurcatedfused

.5-S

pedo

I5S

- beaks similar to I?- no central point to engage furcation

- to remove conical rooted ?rdmolars

- especially for split roots

!oot7ragments

.J1 - bayonet shaped- long slender beaks

- sometimes for very small premolars

*rimary Teet"

- I5-S

o smaller version of I5

.I


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>or%eps for t"e Extra%tion of Mani&ular Teet"

!oot Shape %nstrument Additional :otes

Anteriors L

remolars

!ibbon

shaped L

*28 *2-:8 *2-

extra :)aka @Ash+

I8 I-A

.5?

- vertical handle

- must continually reposition fulcrummore apically

- a lot of tor(ueK can twist crown right

offse a &u%%al6lingual motion+ not

rotation

- universal forceps

- thinner beaks for incisors and root

fragments

stL .nd

#olars


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*rimary Teet"

- I-S Anteriors use Ash forcep )*2+

Bas a lot of tor(ue )potential to twist off crown+

Cong lever arm allows you to apply a lot of force


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o urchase point can be made with drill in the tooth

o Adjacent tooth should not be used as a fulcrum

o 0up shaped elevator


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ee to o "emi%oronal in%ision to get unerneat" t"e

zygomati% ar%"

- $f t"e toot" goes &a%,4ars+ t"e elevator 4ill stop it- oo retra%tion is ,ey

7rane *i%, (#J1)

- wheel and axle type- most dangerous

- most often used w3 a purchase point

o point should be at least ?mm apical to 0'Q and ?mm deep

7ryer (?9 an ?1 03)

- wheel and axel type

- may be used w3 or w3o purchase point

- primarily use to remove roots 4"en t"ereorm >itters (03)

- a cross between a cryer and a potts

- not often used- very pointed tip

pexo Elevator (03)

- wheel and axle type- not designed to be a displacement instrument

o may break tips

o may dislodge root tip into sinus

- great for getting retained root tip fragments

o note not all root tips need to be removedo only remove ones that are associated w3 pathology $! R?-2mm+

o #ust weigh the pros and cons of removing root tips

#aintenance of elevators

&o be effective8 it must be sharp to engage the root surface

Sharpen periodically

Bistory

7irst dental chair )J2J+ Naldo Banchett

7irst electric dentist drill )Qan .18 J*I+ ;eorge ;reen

7alse teeth date back as far as *55

oral surgery exam 1

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