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Practical Oral Surgeryfor the General Dentist

JayB.Reznick,D.M.D.,M.D.Diplomate,AmericanBoardofOralandMaxillofacialSurgery

Tarzana,California

Star of the South

March 28, 2008

Hands-On

Outline

Reviewsurgicaltray/instrumentsFlapreflectionSinglerootedteethextraction:

Proximators/ apical retentionforceps

Multirootedteeth:premolarsSectioning with handpiece

Elevators/ Cryer elevators

Outline- continued

RoottipretrievalRoot tip pick

701 bur/ troughingImpactedteeth

FlapBony exposureSectioning

SocketPreservationgraftingBioHorizons (bone/ membrane)Premolar sites


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Outline- continued

AlveoloplastySuturing

Closure of 3rd molar flapTransposed papilla closure over

alveoloplasty areaBiopsy

Excision with marginPrimary closure w/ undermining

flaps

Strategy

Mentallyvisualizetheprocedurefromstarttofinish

Anticipatewhatinstrumentswillbeneeded,andhavethemready/readilyavailable

Anticipatecomplications Headlight,loupes

Measuretwice,cutonce

Exodontia Surgical Setup

Local

Retractor(s)MouthpropScalpelPeriosteal elevatorToothelevator(s)Universalforcep

Curette

Hemostat(s)Suctiontip(s)Needleholder/sutureScissorsGauze


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Exodontia Surgical Setup

Extraction Instruments

ElevatorsPeriotomes/ProximatorsForceps

ElevatorsUsedto

Luxate teeth

Try to luxateagainst bone Avoid

excessivepressure onadjacentcrowns

Elevate roots


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Forceps Extraction

TOOTH

Max.Anterior

Max.Premolar Max.Molar Mand.Incisor Mand.Canine/PM Mand Molar

LUXATION

MOVEMENTBL,Rotation

BL

B

BL

BL,Rotation

BL

Surgical Handpiece

Allowsectioningoftoothandremovalofbone

Doesnotallowairtoventintothesurgicalfield

Subcutaneousemphysema

Angled Surgical Handpiece

Sabra OMS45 45 degree head

Sabra OMS105 105 degree head

Air exhaustedto rear

400-500K RPM


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Pig Jaw Anatomy

Incisors:3Canine:

1

Premolars:4Molars:3

Surgical Flap Design

Purposeofflapistogainaccesstosurgicalsite,toobtainadequatevisualizationoffieldandavoidtraumatosofttissues.

Shouldbebasedonanatomy,bloodsupply

Base

broader

than

apex

Surgical Flap Design

Flapshouldbe

broaderat

base

Size of flap depends

on purpose

Releasing incision


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Flap Reflection

Sulcular incision premolar

regionFlapforimpactedteeth distal

release

Instruments:#15 blade

Periosteal elevator

Surgical Extractions

SingleRootedTeethMultiRootedTeeth

Single-Rooted TeethMaxillary/MandibularAnteriors

Atraumatic extraction

desireable

Want to minimize flap

reflection and bone removal

Proximators are ideally suited

for this task


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Root Retrieval

Roottip

elevatorsTrough with 701

Impactions

Visualizeprocedurefromstarttofinish

Haveinstrumentsavailable

Adequateflaptovisualizetargetandminimizesofttissuetrauma

Lower 3rd Molar Incisions


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Bony Exposure

Sweepawaybone

Thetoothcrownisharderthanbone

Lightpressure Lettheburdrive

itself

Fullyexposefurcationtofacilitatesectioning

Impacted Teeth

Expose crown

Bisect crown/roots

Deliversections

Alveoloplasty

Multipleadjacentteeth

Removalofinterdentalbone,andcontouringofridge

Eliminatesharpedges,sorespots


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Alveoloplasty

PremolarSites

RongeurBoneFileRotaryinstruments

Rongeur

Rotary Instrument


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Suturing

Toreapproximatesurgicalflaps

Toholdpackinginplace Asuturealonedoes

notholdthebloodclotinplace.

Suture

Size 3-0: basic

4-0: finer

Type Silk

GutPlain

Chromic

Vicryl (PGA)

TransposedPapillae

Closure

Closure of Multiple AdjacentExtraction Sites


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Transposed Papillae Closure

Ridge Preservation Grafting

Optimizestheamountofbonepresentatextractionsite

Reducesearly(1st 6months)ridgeresorbtion byabout75%

Ridge Preservation Grafting

Afterextractionsocketisdebrided

and

irrigated,

graft

materialispackedintosocket

Barriermembraneisplacedovergraft

Suturedinplace


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Biopsy Technique

Excisedowntoconnectivetissuelayer

Ifulcerative,biopsynearedge Ifsuspect

malignancy,biopsyworst area

Ifexcising,excisecompletely,considerclosure

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