BREAD AND BUTTER ORAL SURGERY

1
BREAD AND BUTTERORAL SURGERY

• FOR THE GENERAL PRACTIONER

2
(No Transcript)
3
(No Transcript)
4
(No Transcript)
5
KANSAS CITY CHIEFS ARROWHEAD STADIUM
6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
METH MOUTH
10
DENTISTRY

• The main duty of dentists today is to maintain
  the dentition and the alveolus, thereby allowing
  function relative to mastication, deglutition,
  maintenance of facial form and cosmesis.
• The most common infection seen in man is caries
  and periodontal disease
• The most common operations today involve surgery
  in and about the dentoalveolus

11
BASIC PRINCIPLES OF DENTOALVEOLAR SURGERY

• ANATOMY

12
(No Transcript)
13
(No Transcript)
14
TOPOGRAPHY
15
TOPOGRAPHY
16
TOPOGRAPHY
17
TOPOGRAPHY
18
TOPOGRAPHY
19
(No Transcript)
20
TOPOGRAPHY
21
(No Transcript)
22
RETROMOLARTRIANGLE
23
(No Transcript)
24
BSSRO good bone contact present despite
movement of distal segment compression of
segments should be limited to the site of best
contact to avoid torque rotation of the condyle
IAN
25
LINGUAL NERVE
26
CASE PRESENTATION
27
39 yo AAM

• Lower (mand) premolar 21, nonrestorable with
  caries at gingival line, acute pulpitis and
  cellulitis
• PMH benign, except patient is abusive of Etoh,
  tobacco, and some street drugs
• Meds none All NKDA

28
CLINICAL CONCERNS

• Tooth fracture (coronal) down to bone level
• Relatively uncooperative patient
• Can profound anesthesia be produced
• Flap vs. no flap
• Friday afternoon at 415pm

29
(No Transcript)
30
THE INTRAORAL FLAP

• The incision is in soft tissue and should be
  designed to allow access to the hard tissues
• The base of the flap should be designed so the
  base is wider than the margins of the flap
• The flap should be wide enough to expose the
  entire surgical site and to close over bone
• Design of the flap incorporates vital structures
  and protects these entities
• Retraction

31
FLAP TYPES

• Envelope flap
• Envelope flap with releasing incision
• Semilunar flap
• Palatal flap

32
ENVELOPE FLAP
33
ENVELOPE FLAP WITH RELEASE
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
SEMILUNAR FLAP
39
(No Transcript)
40
CASE PRESENTATION CONT
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
(No Transcript)
48
(No Transcript)
49
(No Transcript)
50
PEARLS TOOTH FX BELOW CRESTAL BONE

• Good anesthesia
• Good lighting
• Flap design,elevation,exposure
• Irrigation, airway protection
• Replacement of flap, suture selection
• Selection of analgesic, antibiotic?
• F/U and drain removal

51
CASE PRESENTATION

• MULTIPLE EXTRACTIONS

52
(No Transcript)
53
(No Transcript)
54
(No Transcript)
55
(No Transcript)
56
(No Transcript)
57
MAXILLARY MOLAR

• Damage to adjacent teeth
• Sinus involvement
• Root fracture
• Multirooted tooth

58
(No Transcript)
59
(No Transcript)
60
(No Transcript)
61
(No Transcript)
62
THE T SPLIT

• Section roots split buccal from palatal
• Section the two buccal roots and remove
• Remove the palatal root

63
MANDIBULAR MOLARS

• Anesthesia concerns
• Neurovascular bundle concerns
• Damage to adjacent teeth
• Injury to the TMJ articulation

64
(No Transcript)
65
SECTIONING TECHNIQUE- MANDIBULAR MOLARS
66
TUBEROSITY REDUCTION
67
BULBOUS TUBEROSITIES
68
(No Transcript)
69
(No Transcript)
70
PROSTHETICALLY FRIENDLY ARCH
71
ODONTOGENIC CYST REMOVAL
72
CASE PRESENTATION

• 56 yo AAM presents c/o pain and swelling times 3
  months.
• Area of interest located in the anterior mandible
• 24 and 25 with dilacerated roots
• Teeth are viable, mobile

73
(No Transcript)
74
CLINICAL CONCERNS

• Need for teeth removal pro. vs. con
• Flap design exposure, nerve concerns, cosmesis
• Need for endodontic therapy before or after oral
  surgery
• Pre-extirpative need for biopsy

75
(No Transcript)
76
SURGICAL MANAGEMENT OF CYSTS

• Stepwise approach i.e. physical exam to include
  inspect/palpate/auscultate
• Aspirate with 18g
• If no aspirate, lesion may be a tumor and
  incisional bx indicated.
• If air, probable traumatic bone cyst.
• If fluidyellow vs opaque/cheesy vs blood

77
CYST TREATMENT

• Elimination is the aim. May be accomplished by
  decompression, marsupialization and enucleation
• Decompression flap, aspirate, open into cyst,
  maintain drainage over weeks to months. Difficult
  secondary to hygiene problems and if inadequate
  bx specimen, the lining will continue to
  propogate.

78
CYST THERAPY
18 GAUGE ASPIRATION
79
(No Transcript)
80
ENVELOPE FLAP
81
(No Transcript)
82
ASPIRATION
83
BX OKC
84
ALVEOLAR DEFECT
85
CLOSURE
86
FAILURE OF TOOTH ERUPTION

• THE ART AND SCIENCE
• OF IMPACTION REMOVAL

87
(No Transcript)
88
INCIDENCE OF IMPACTED TEETH

• Grover PS, Lorton L Triple O 1985 Looked
  at 5000 army recruits
• Very high incidence/frequency of impacted
  teeth
• 1st mandibular 3rd
• 2ndmaxillary 3rd
• 3rdmaxillary canine
• 4thmandibular premolars, then max.
  premolars and max 2nd molars

89
FREQUENCY OF IMPACTION
90
IMPACTION FREQUENCY

• Impactions of first molars and incisors are
  relatively uncommon
• Impaction of permanent teeth is a relatively
  common finding, the lack of eruption of a primary
  tooth is apparently rare. When it occurs, it is
  almost always a mandibular molar. Submerged
  teeth are common in the primary dentition

91
EMBRYOLOGY

• The mandibular 3rd molar tooth germ is visible
  radiographically by age 9, and cusp
  mineralization is completed by age 11. At age
  11, the tooth is located within the anterior
  border of the ramus with its occlusal surface
  facing almost directly anteriorly

92
EMBRYOLOGY

• Crown formation is usually complete by age 14,
  and the roots are approximately 50 formed by age
  16 years
• Lenthening growth of the mandible occurs at the
  expense of the anterior border of the ramus,
  therefore the angulation of the crown becomes
  more horizontal

93
EMBRYOLOGY

• The roots are completely formed with an open
  apex by age 18 years
• By age 24, 95 of all third molars that will
  erupt have completed their eruption
• The change in orientation of the occlusal surface
  from a straight anterior inclination to a
  straight vertical inclination occurs primarily
  during root formation

94
IMPACTIONS-WHY? (1)

• Differential root growth between the mesial and
  distal roots. Underdevelopment of the mesial
  rootmesioangular impaction. Ovedevelopment of
  the mesial rootdistoangular impaction.
  Overdevelopment of the distal root for severe
  mesioangular or horizontal impactions

95
IMPACTIONS-WHY (2)

• Some teeth become impacted involves the relation
  of the bony arch length to the sum of the
  mesiodistal widths of the teeth in the arch
  i.e.inadequate bony length will have a higher
  proportion of impacted teeth

96
IMPACTIONS-WHY (3)

• A final factor involved in the development of
  impacted teeth is retarded maturation of the 3rd
  molar
• When dental development of the tooth lags
  behind the skeletal growth and maturation of the
  jaws, there is an increased incidence of
  impactions. Impactions are more common in Class
  II vs Class III skeletal relationships

97
TOOTH IMPACTIONOR RETENTION

• Occurs at the population level with a frequency
  of approximately 20

98
EPIDEMIOLOGY

• CLASS I OCCL. 87 OF POPULATION
• CLASS II OCCL. 10 OF POPULATION
• CLASSIII OCCL. 2.5 OF POP.

99

• Extraction of this 3rd molar reveals smooth
  roots which shows where the follicle in-
  serted into the completed roots

100

• Posterior marginal cyst. Growth into the distal
  area of the follicle is a result of the partial
  retention of the tooth under the temporal ridge
  of the ramus

101

• Follicular cyst in a 60 year old on the rt 3rd
  molar
• The wall of the cyst surrounds the crown and
  extends beyond the cementoenamel junction

102

• This dentigerous cyst on this 45 year patient of
  the left mand. 3rd molar occupies the total
  height of the mandibular body. Note the
  involvement of the roots of the 2nd molar.

103
THE KISSING MOLAR IMPACTION
104
FACTORS INFLUENCING ERUPTION DISTURBANCES

• Extraction of primary teeth
• Sequelae of caries in primary teeth
• Genetics
• Ethnic background- Chinese with 2.5X gt than
  Caucasians

• Sex MgtF
• Body height chronological age skeletal age
• Endocrinologic disturbances
• Nutrition,socioeco-nomic factors

105
OBSTRUCTION BY HARD AND SOFT TISSUES

• Eruption cyst
• Compact bone
• Supernumerary teeth
• Odontomas
• Odontogenic tumors central odontogenic fibroma,
  AOT, ameloblastic fibroma,CEOT calcifying
  odontogenic cyst, dentinoma, OKC, follicular cysts

106
INDICATIONS FOR REMOVAL OF IMPACTIONS

• Pericornitis prevention or treatment
• Prevention of dental disease
• Orthodontic considerations
• Prevention of Odontogenic Cysts/Tumors
• Root resorption of adjacent teeth
• Teeth under a dental prosthesis
• Prevention of jaw fracture
• Unexplained pain

107
PREVENTION OF JAW FRACTURE

• Halmos DR et al JOMS 62(9) 1076-81,2004 Sep
• Looked at 1,450 subjects and found a 2.8-fold
  increase risk for angle fractures with the
  presence of M3s. M3 position had an associated
  variable risk for fracture but interestingly, the
  deep impaction was not associated with an
  increased risk for fx.

108
REMOVAL CRITERIA

• I Dentitio difficilis and pericornitis
• II Small cysts
• III Possible source of infection
• IV Inadequate space
• V Caries/pulpitis
• VI Vague, undiagnosed pain

109
PERICORNITIS AND SPREAD OF INFECTION
110
The exposed partially erupted tooth
111
DEEP NECK SPACE INFECTIONS

• Bacteria commonly involved in association with
  pericornitis Peptostreptococcus Fusobacterium
  Bacteroides(Prevetella or Porphyromonas)
• 25-30 of Mand. 3rds removed due to this

112
FASCIAL SPACES ABOVE THE HYOID BONE
113
Progression of an odontogenic infection to a
Ludwigs angina
114
DEEP SPACES ASSOCIATED WITH MANDIBULAR INFECTIONS

• Space of the body of the mandible
• Sublingual
• Submandibular
• Submental
• Ludwigs angina
• Masticator

• Lateral pharyngeal
• Retropharyngeal
• Pretracheal
• Carotid sheath
• Danger space-space 4
• Mediastinum

115
CONTRAINDICATIONS FOR REMOVAL OF IMPACTED TEETH

• Extremes of age
• Compromised medical status
• Surgical damage to adjacent structures

116
CLASSIFICATIONOF IMPACTIONS

• Pell GJ,Gregory GT
• Impacted mandibular third molars
• Dent Dig 193339330

117
ANATOMIC SITUATION OF THE TOOTH

• The orientation of the great axis of the tooth
• The relationship of the tooth to the ramus of the
  mandible
• The depth of the impaction

118
ORIENTATION OF AXIS
119
RELATIONSHIP TO RAMUS
120

• CL I Space between ramus and distal of 2nd molar
  sufficient for eruption
• CL II Space between ramus and distal aspect of
  2nd molar less than mesiodistal diameter of 3rd
  molar crown
• CL III Temporal crest against distl of 2nd molar

121
DEPTH OFIMPACTION

• Erupted
• Soft tissue impaction
• Partial bony impaction
• Full bony impaction

122
TOOTH BUD

• Type 1 fully formed crown
• Cannot use elevator
• Rotation in crypt

123
Impaction type 2

• Incomplete root development
• Follicular space
• Easy to remove

124
Impaction type 3

• Completely formed roots
• Normal axial orientation

125
IMPACTION

• Mesially tipped or
• horizontal

126
IMPACTION

• Distally tipped
• Very difficult to remove

127
IMPACTION

• Transverse position

128
Impaction

• Aberrant position

129
MAXILLARY IMPACTIONS
130
Impaction

• Mesioangular orientation
• Difficult removal

131
Impaction

• Vertical impac.
• DIFFICULT!

132
IMPACTION

• Distoangular
• Concept of
• dislodgement

133
Multiple Impactions
134
Impaction with supernumary
135
INTERESTING ROOT FORMATION
136
INSTRUMENTARIUM
137
INSTRUMENTARIUM
138
CRYER ELEVATORS
139
(No Transcript)
140
POTTS ELEVATOR
141
CRANE PICK
142
SCALPEL DESIGN
143
SURGICAL TECHNIQUE
144
MANDIBULAR 3RD MOLAR
145
The lingual nerve may be at risk with scalpel
misadventure
146
LINGUAL NERVE NEUROMA
147
WRONG DIRECTION
148
TECHNIQUE

• Envelope flap
• Vertical release is an option, however will
  increase swelling and discomfort
• Controlled force with elevation of a
  full-thickness mucoperiosteal flap. Use your
  finger to pull tissue taut. Palpate the external
  ridge. EXPOSURE!
• Ostectomy with high torque/non high speed
  handpiece

149
THE TOOTH IS MINE AND THE BONE IS THE PATIENTS
150
Copious irrigation and place a throat pack.
151
Root structure can fool you
152

• Closure the neater you sew, the neater it grows
• Primary closure produces gt postop pain and
  swelling is worse
• Greater incidence of subperiosteal infec. At 30
  days
• Pasqualini D. et al International JOMS 34(1)
  52-7, Jan 2005

153
(No Transcript)
154
(No Transcript)
155
32 REMOVAL
156
MAXILLARY IMPACTION TECHNIQUE

• Envelope flap with/without vertical release
• Flap is easy to tear
• Can be complicated with buccal fat pad extrusion
• Dislodgement into airway or infratemporal fossa
• EXPOSURE!

157

• Sm max sinus
• Cn nasal cav
• Mb buccinator m
• BgB fat pad

The tuberosity extends the alveolar process of
the 2nd molar. Pterygomaxillary junction is
posterior limit
158
Always place a large periosteal elevator
(Seldon/Minnesota) behind the impaction to
prevent dislodgement. Throat pack mandated.
159
(No Transcript)
160
(No Transcript)
161
(No Transcript)
162
COMPLICATION RATES

• Bui CH et al JOMS 61(12) 1379-89,2003 Dec.
• 583 pts. The overall complication rate was 4.6.
  Increasing age, a positive medical history, and
  the position of the M3 relative to the IAN were
  associated with an increased risk for
  complications. Most texts reveal a rate 10

163
COMPLICATIONS

• Include swelling, pain, stiffness, bleeding
• Other complications include inferior alveolar
  nerve dysfunction and fracture of thje mandible
• The accepted rate of Infer alveolar and lingual
  nerve injury is 3. As many as 45 of
  compression injuries result in permanent
  neurosensory abnormality

164
NEUROPRAXIA
AXONOTMESIS
NEUROTMESIS
AXONOTMESIS
165
(No Transcript)
166
(No Transcript)
167
ALVEOLAR OSTEITIS

• The incidence of alveolar osteitis (dry socket)
  varies between 20-25
• Pathogenesis related to clot breakdown
  (fibrinolysis) by saliva , tissue agents, and
  bacteria. Decreased bacterial load reduces the
  incidence of dry socket by 50-75

168
INFECTION RATES

• Incidence ranges from 1.7 to 2.7
• Of the above cited rate, 50 are the
  subperiosteal type
• Infection rates in the first week are
  approximately 0.5-1. Do not use prophylactic
  antibiotics as there is no indication.

169
ADJUNCTIVE AIDS

• Resorbable suture
• Utilization of corticosteroids
• Tiwana PS et al JOMS 63(1)55-62, 2005 Jan.
  Will not hamper recovery and will improve
  health-related quality of life, nausea lt on POD
  1, reduced recovery by 1 day
• ANALGESIA

170
(No Transcript)
171
ASSESSMENT OF SEQUELAE

• Pain usually peaks 6-8 hours after 3rd molar
  surgery, disappearing over the next week
• Swelling reaches a maximum about 36 hours after
  surgery
• Trismus reaches a maximum 2-3 days, then slowly
  resolves

• The severity of sequelae correlates with duration
  of surgery
• The tooth most likely to be involved with
  pericornitis is the erupted vertically positioned
  tooth
• Good age for surgery is 17-20 years

172
MAXILLARY SINUS

• First of the paranasal sinuses to begin devt.
  Begins between day 65 and 70 of fetal devt
• Can see on x-ray 4-5 months of age
• Growth is biphasic 1st period during 1st 3 years
  of life. The 2nd phase at 7-18 years of age
• Concept of pneumatization

173
MAXILLARY SINUSANTRUM OF HIGHMORE

• First of paranasal sinuses to begin devt. Devt
  begins between day 65 and 70 of fetal devt
• Can visualize radiographically 4-5 months of age
• Biphasic growth1st period during 1st 3 years of
  life 2nd period between 7-18 years of life
• Pneumatization

174
DRAINAGE

• The space under each turbinate or conchae is
  designated as inferior, middle, superior meatus
• The osteomeatal complex is a space within the
  middle meatus into which the maxillary, anterior
  ethmoid, and frontal sinuses drain. This OMC is
  the site of impaired ventilation and drainage

175
(No Transcript)
176
ANATOMY
177
MAXILLARY SINUS

• Largest of all paranasal sinuses
• Adult sinus dimensions 34mm AP 33mm in
  height, 23 mm width
• Baselateral nasal wall
• Apex extends laterally into zygomatic process
  of maxilla
• Rooffloor of orbit
• Floor formed by maxillary alveolus

178
OSTEOMEATAL COMPLEX
179
OSTEOMEATAL COMPLEX
180
EXAMINATION

• CLINICAL manual palpation, symptomotology,
  epiphora, transillumination

181
PANAELIPSE VIEW-NORMAL
182
PANELIPSE- Left antrum
183
WATERS VIEW
184
PERIAPICAL VIEW
185
CAT SCAN
186
CAT SCAN
187
ORAL-ANTRAL COMMUNICATION

• A communication between the mouth and the sinus.
  If gt than 3mm, anticipate surgical closure. If lt
  than 3mm place gelfoam and have patient utilize
  sinus precautions

188
TREATMENT PRINCIPLES

• Place patient on appropriate Abos, antihistamines
  and nasal spray. Instigate sinus precautions.
• After 4-6weeks, perform closure with a
  buccal/palatal/buccal fat pad technique. Use
  vicryl or silk sutures. May have to utilize a
  palatal splint. Abos/antihistamine/nasal spray
  and sinus precautions

189
(No Transcript)
190
(No Transcript)
191
DEMONSTRATION OF COMMUNCATION
192
(No Transcript)
193
(No Transcript)
194
(No Transcript)
195
(No Transcript)
196
(No Transcript)
197
(No Transcript)
198
CLOSURE AT 10 DAYS
199
CLOSURE AT 1 MONTH
200
(No Transcript)
201
ELEVATOR MISADVENTURE
202
(No Transcript)
203
GOIN TO KANSAS CITY