ORAL AND MAXILLOFACIAL SURGERY PRELIM

FACTORS THAT DETERMINE THE SCOPE OF OS  Conventional – apex is pointed upward; one blade on
1. Desire internal surface
2. Only dentist in the community  Reverse – apex is at the base; best for approximating
tissue margins because it won’t cut the tissue
SUTURE D. Attachment: swaged/ eye
 To support unstable or movable tissue while it is healing  Swaged – end of needle is hollow and the suture
 To control bleeding material is swaged in the needle and becomes part of
 Last chance to review your procedure (if you left gauze the needle
etc.) o There is no resistance when it passes through the
 Do not suture if there is active bleeding because it will tissues
cause hematoma  Eye – end has a small hole to put the suture material
through
SUTURE MATERIALS/INSTRUMENTS Intended to be reused and creates bigger holes
1. Needle holder
 Get the 6in. needle holder E. Curvature
 Parts: Lock, shaft, beak (short and stout) with crisscross
serrations for positive grip
 How to hold: Index finger on shaft, thumb and ring
finger on the rings, middle finger above the ring
** Not hemostat
 Hemostat: longer and slender beaks (curved hemostat –
to remove debris and lesions in the socket and
immobilize or hold tissue then cut)
 Mosquito = small hemostat  3/8 or ½ circle is commonly used
 Kelly = big hemostat
TYING SUTURE ON EYE NEEDLE
 Internal surface has horizontal serrations; unstable
 Loop the thread then insert it through the eye and go
needle if caught in the serration
over the tip; loop again then secure
2. Thumb/Tissue forceps
** Eye/swage portion of the needle is the weakest part; therefore
 Holds the flap
hold the needle a little anterior to the eye/swage
 Adson or Diners; with or without teeth
3. Suture scissors (Iris scissors) SUTURE MATERIALS
 Hold it like the needle holder; only use the tip to cut  Basic purpose of a suture is to hold severed tissues in
4. Needles close approximation until the healing process provided
5. Thread “suture materials” the wound with sufficient strength to withstand stress
without the need for mechanical support
NEEDLES
A. Made of either stainless steel or carbon steel IDEAL SUTURE MATERIAL
B. Shape: Straight or curved
 Adequate strength
*Usually use curved
 Good handling and knot tying characteristic
*Straight only when approximating accessible
tissues or for applying circumferential wires above  Sterilizable
bone for immobilization  Little tissue reaction
C. Configuration: Tapered (round) & Cutting
(conventional / reverse) SUTURE MATERIAL CHARACTERISTICS
I. Resorbability
A. Absorbable
i. Natural – from plants/ animals
a. Gut
 Made of collagen
 Taken from intestine of sheep
 Monofilament
 On the second day, only 50% of the
 Round needles are used when approximating muscles strength is left
(which are very soft) or tissues close to many blood  On 4th day, zero strength is left making the
vessels like the floor of the mouth tissues unstable
 Cutting – for keratinized tissues; each edge represents a  Can’t be used to ligate major blood
blade vessels
b. Chromium Gut
 ORAL AND MAXILLOFACIAL SURGERY PRELIM

 Chromium salts were added to prolong the  The tissue should not be closed under tension since
period of solubility they will either tear or necrose around the suture
 7-10 days (blanching happens if there is tension, it
 Has preservatives (dry ice alcohol) so that compromises blood supply and may delay healing
it won’t dry up therefore need to wash or cause necrosis)
first in sterile saline solution to remove  The know should NOT be placed over the incision
alcohol because it is irritating line
c. Collagen  Suture should be placed approximately 3-4 mm
 Not used often because absorbability is apart
like gut ** Rule of 3: 3 mm away from the margin, 33 mm apart
 Used for bone grafting and 3 mm suture material left
ii. Synthetic – has higher tensile strength; absorbs  Start from deeper tissue to elevated tissue (if at
after 2-3 weeks different levels)
a. Polyglycolic acid (dexon)
b. Polyglactin (Vicryl) KNOT TYING

** Natural sutures disappear due to digestion by proteolytic

enzymes through phagocytosis (enzymatic activity)
** Synthetic disappears through hydrolysis (tissue fluids)
B. Non absorbable
1. Silk – Dacron polyester
 Most popular
2. Nylon – Teflon
 Has memory
 Difficult to tie because it opens and goes back to
original shape
 Monofilament 1. Square knot – 1 loop then 1 reverse
 Can be absorbed after 6 months 2. Surgeons knot – 2 loops then 1 reverse
3. Cotton and linen – polypropylene 3. Granny knot – same side loops (maximum of 3)
 Multifilament
4. Metal SUTURE TECHNIQUES
 Stainless steel wires are used to approximate
tissues with tension
 Deadsoft wires – can bend; won’t go back to ARMAMENTARIUM
original shape 1. Scalpel
** Gortex material is very expensive  Scalpel handle – ivory handles/ bard parker
 Scalpel blade:
II. Size  No. 11 blade – incision and drainage procedures (IND)
 Determined by number of zeros (pointed)
 More zeros = smaller diameter  No. 12 blade – one blade; (sickle shape);
 3-0 – ideal size cervical/marginal/sulcular incision and areas that are
 Sometimes 4-0 inaccessible like tuberosity and impacted teeth
 5-0 or 6-0 for cosmetic reason  No. 12 B blade – 2 blades good for periodontal
III. Number of strands surgery
 Monofilament (single strand)  No. 15 blade – multipurpose
 Polyfilament (braided or twisted to form 1 strand  No. 15 C blade – thin blade for implants
** Braided silk is most commonly used ** Pen grasp – short delicate incisions
** Table knife/palm grasp – long incisions
PRINCIPLES OF SUTURING ** Excision – Cut tissue and throw away
 If one tissue side is free (as with a flap) and the ** Incision – Cut tissue to gain access
other is fixed, the needle should be passed from the
free to the fixed side 2. Blade remover
 If one tissue side is thinner than the other, then the 3. Periosteal elevators – separate mucosa from the bone or
needle should be passed from the thinner to the to hold tissue away from surgical site (retractor)
thicker side  Prichard – narrow end is used to separate tissue
 The distance that the needle is passed into the from bone; wide end is to hold tissue away
tissue should be greater than the distance from the  Molt – narrow end to separate mucosa from the
tissue edge (3-4 mm away from the margin) bone; flat end to hold tissue away
 ORAL AND MAXILLOFACIAL SURGERY PRELIM

Mead – bladed end for fast separation of mucosa  Double ended file
from the bone; wide end to hold tissue away
 Buser – to separate papilla ** Partial thickness flap – separate mucosa and leave
 Seldin – retractor periosteum attached to the bone; done in periodontal surgery
 Austin – curved/ straight 11. Needle holder
 Castro biens – popular design
12. Curette – removes pathologic lesions and foreign
bodies inside the socket
13. Scissors
 Metzenbaum “metz”
 Dissecting:
o Sharp dissection – separates tissue and
muscle by cutting
o Blunt dissection – don’t cut the muscle,
tear the muscle -> can use scalpel handle,
4. Minnesota retractor – retract cheeks, tongue or flaps hemostat or fingers
5. Hemostat – to clot blood vessels and remove 14. Mouth prop
debris/foreign debris  Molt mouth prop – keeps the mouth open
6. Tissue forceps – hold tissues  Rubber, plastic, disposable etc.
 Allis – big teeth; clamps tissues that you will 15. Towel clamps – immobilize the towel
remove 16. Surgical suction
 Adson – immobilize or hold loose tissue  Fraser – if you place of close the hole with your
 Diners – hold loose tissue (with or without teeth) finger, you will have a higher suction pressure
 Russian – expanded tip and teeth on internal 17. Irrigating instruments
surface for positive grip  20 cc disposable syringe with gauge 16 or 18
o Used to hold loose teeth or to remove lumen
luxated teeth  NSS Saline – anesthetic and irrigation; can use
7. Rongeur – to remove or cut bone orahex and hydrogen peroxide against anaerobic
 Side cutting – blades are on the sides of the beak, bacteria (pericoronitis)
to trim the cortical plate
 End biting – to remove interradicular bone; blade is PREVENTION OF COMPLICATION
at the tip only (alveolectomy) I. Pre operative assessment
 End cutting and side cutting (combination) II. Pain and anxiety management
8. Mallet and chisel – to remove bone; not used anymore III. Attention to basic principles
because it is traumatic IV. Consider expertise and training
 Monobevel – one blade; removes bone
 Bibevel – to split a tooth I. PRE-OPERATIVE ASSESSMENT
 Splitting using bibevel chisel: only hit or tap twice 1. Medical history
because it might split the lingual place; also place a  Classic history format
finger guard  Problem oriented history format (SOAP)
9. Surgical handpiece  Questionnaire form
 Slow high torque drill – even if you run it slowly, ** Birth control pills causes dry socket formation
the drill won’t stop when it touches bone 2. Medications that influence bleeding
o Used for implants “A” Drugs
o 10-14 rotations per minute  Aspirin
o Won’t generate heat because heat kills  Anti-inflammatory (NSAID)
bone sense  Anticoagulants
 Real high speed surgical drill – head is 45 degrees  Antibiotics (Tetracyclin affects synthesis of
in relation to the shaft of the drill and air exits in vitamin K affecting coagulating factors)
opposite direction to the head (towards the shaft)  Anticancer drugs – affect healing ex.
o Only water is introduced into the surgical Hematopoietics
area  Antiplatelet drugs – hematopoietics
o Air might cause emphysema when it is
 Alcoholism – may cause severe bleeding
introduced in the tissues
3. Herbal products that affect clotting
o Air embolism if air enters blood vessels
 Ginko biloma
10. File – smoothens the bone
 Garlic – thins blood
 Use in pulling stroke
 Feverfer – prolonged clotting
 Mono ended file
 Ginseng
 ORAL AND MAXILLOFACIAL SURGERY PRELIM

 Chamomile – blood thinning

4. Bisphosphanate drugs
Generic Name:
 Alendronate
 Risedronate
 Ibandronate
 Pamidronate
 Zoledronic Acid
Brand Names:
 Fosemax
 Fosavance
 Actonel
 Boniva
 Aredia
 Zorneta
** These drugs are to build up bone; but they do the reverse
in the oral cavity; Non healing of wound because in the OC
bone resorbs during healing, since bisphosphonate drugs
inhibit resorption, the wound stays open leading to infection
 “BRONJ” Bisphosphonate Related Osteonecrosis of the
Jaw
 Risk factor depends on dosage, duration etc.
 It takes 2-3 years to be prone to BRONJ if taken orally;
if IV it takes months
5. Clinical assessment
 If broad jaw -> wide coronoid process; it moves
anteriorly when you open the mouth then blocks the
posterior area making it difficult to access it
 If long face, very narrow coronoid process so there is
great access on posterior upper site
 Class II patients -> hinge type jaw movements ->
limited access
 Class III patients -> good access
 Exostosis -> difficult extraction
6. Radiographic assessment

II. PAIN CONTROL

 Pain and anxiety measures
1. Local Anesthesia
 Articaine – longer duration compared to lidocaine
o Comes in 4% solution
o Faster onset
o Can only use a maximum of 4 cartridges
 Lidocaine – you can use up to 10 cartridges
 Mepivacaine – short duration anesthesia
o No epinephrine
 Bupivacaine – long duration 6-8 hours
Signs of sedation:
a. Verile sign –upper eyelid is halfway through the pupil
b. Slurred speech – sign of sedation
 ORAL AND MAXILLOFACIAL SURGERY PRELIM

MANAGEMENT FOR BRONJ

 Spontaneous opening of the mucosa because of
trauma will lead to infection of the bone
 Non healing wound
*When you present a complication, also present a solution

2. Conscious Sedation with Local Anesthesia

 Make sure patient is medically cleared
 Can do this in the dental office
3. General Anesthesia
 Done in the operating room Class B position C – lingual nerve is high
 Local anesthesia helps in hemostasis (less blood  High retraction of the medial tissue can paralyze
during the operation) and for post operative pain the lingual nerve

SURGICAL ACCESS
 Requires a sure knowledge of regional anatomy
and physiology

 Mandible:
1.Lingual Nerve
2. Inferior alveolar neurovascular bundle
3. Mental Nerve
4. Long Buccal Nerve
5. Buccinator artery
6. Facial artery

 Locate the lingual nerve before incision

 Make the incision lateral to the external oblique
ridge

Reason why lateral:

 Mesial to the ridge is muscular therefore there are a
lot of blood vessels leading to lots of bleeding
 Bone goes lateral and we need bone support
 Pharyngeal space is on the medial; reaction to
surgery is physiologic swelling -> edema will go to
the pharyngeal space -> difficulty in swallowing
because swelling is medial
 If an infection is on pharyngeal space, it may
obstruct the patients airway

Inferior Alveolar Nerve

 IAN -> mandibular canal -> mental nerve and
incisive nerve

Lingual Nerve:
 Incision runs laterally, not medially because you
might cut the lingual nerve
 Lingual nerve is a little below or a little above the
mylohyoid muscles
 Radiographically:
 ORAL AND MAXILLOFACIAL SURGERY PRELIM

o If you see a shadow of the canal above the  If the root is close to the sinus, tell the patient the
apices of the root, then it is buccal in possibility of perforating the sinus
relation to the tooth  Perform Caldwell lock into the opening of the
o If you see the canal below the apices, it sinus
may be buccal, right below the tooth or  “Watertight closure” which leaves no space for
lingual water to enter
o If you see a distinct canal (superior and
inferior borders can be seen) even if it
overlaps the tooth, it is far from the tooth 2. Infratemporal Space
o If the canal is clear then blurry then clear
again, it is very close to the tooth
o If the canal goes in between the apices the
roots of the tooth -> modify surgical
procedure -> may do coronal procedure
(remove only the crown)
Mental Nerve
 Even just stretching this nerve will lead to
paresthesia
 Between coronoid process and zygomatic surface
Submandibular space  If the root gets lost, localize the missing object
1. May perforate the lingual plate due to before continuing
uncontrolled force/during drilling then when
you elevate the tooth goes into the space 3. Buccal Fat pad
2. 2 complications:  Gives shape to the cheek
a. Displacement into the space If you incise too high and cut the buccinators, fat goes out
b. Perforation of the lingual plate and it is hard to place back
 Disconfigured face of patient, will need cosmetic
rehabilitation

 Maxilla
 Maxillary Sinus
 Infratermporal Space
 Buccal Fat pad Facial Artery and Vein
 Facial artery and vein  If you nip these blood vessels and do not ligate, the
 Nasopalatine nerve patient may bleed to death
 Facial artery and vein  Ligate then reappoint
 Maxillary tuberosity
Maxillary Tuberosity
A. Be careful when removing the remaining posterior
teeth
B. Walls of the maxillary tuberosity are thin and the
sinus continues to enlarge as patient loses teeth
“pneumatization”
C. The maxillary tuberosity will be prone to fracture
-> exposure of the maxillary sinus

AREAS THAT MAY BE SACRIFICED:

3 POSSIBLE PLACES WHERE TOOTH MAY BE Nasopalatine and Long Buccal Nerve
DISPLACED:  They only innervate a small area therefore they
may be sacrificed
1. Maxillary Sinus
 ORAL AND MAXILLOFACIAL SURGERY PRELIM

 It will not be obvious if there is paresthesia among

these nerves
 This happens when you retract the palate and the
nasopalatine nerve is cut

*Good bone support is required when making a flap

*Bone support is lateral because the mandible flares
laterally
*Weakest part of the mandible is the angle of the mandible
where the thick body and thin ramus meet (most fractures
occur in this area)

III. ATTENTION TO BASIC PRINCIPLES OF SURGERY
1. Sterility, suppression and control of
microorganisms in the surgical site
Time Technique – scrub area for a certain period of
time
Scrub Technique – certain number of strokes for an
area; usual 30 strokes
Methods of sterilization:
1. Mechanical – scrubbing with soap and water;
debridement
2. Chemical – phenols, salts of heavy metal, dyes,
chlorides (NaCl) -> can melt pulp tissue
3. Thermal
4. Physical
Stages of sterilization:
1. Pre-operative sterilization
- Asepsis before surgical procedure
- Sterilize instruments and self
- Surgeons’ cap/hood type
- Oral antiseptics ex. Orahex
2. Intra-operative sterilization
- During the procedure
- Do not contaminate surgical area
- Hand wrap on handle of mirror
3. Post-operative sterilization
- Mouthwash and brush teeth
- After surgery
Before the surgical procedure:
- Make sure the tissues are in healthy condition; if not
healthy, reschedule
ex . Pericoronitis, acute herpetic gingivostomatitis
Proper and meticulous handling of both bone and soft
tissues
 If need to operate on the floor of the mouth: prepare
clamps, local anesthetics with epinephrine,
electrosurgery machine because it coagulates vessels,
use round or tapered needle
 If need to extract 3rd molar near mandibular canal ->
preanesthesia and bleeding may occur therefore prepare
anti hemorrhagic material, jet foam etc.
 Use controlled force
 Oral surgical burs ex. SS white
 Dry socket if taking oral contraceptives
 Osteoradionecrosis from taking bisphosphonate -> stop
medication, do not extract 3-6 months after; do surgery
then wait until 3-6 months before continuing drug
intake; oral intake takes 2-3 years before being prone to
bronj
Pre surgical assessment for removal:
ORAL AND MAXILLOFACIAL SURGERY MIDTERM
1. Medical Risk assessment
 No health complications
 Minor health complications can be
compensated for during the procedure
 Consultation with appropriate specialist
needed
 Serious complications possible, refer to
specialist
2. Emotional Condition
 Extremely apprehensive patient – refer to GA
 Patient moderately apprehensive but
controllable with pre operative sedation and/or
IV sedation during surgery
3. Clinical evaluation
 Presence of infection
 Restriction of mouth opening
 Extent of visible caries or fracture
 Tooth mobility
 Tooth alignment in arch
4. Radiographic evaluation
 Acceptable evaluation
 Relationship to maxillary sinus
 Extent of caries, fractures or alloy
 Root number
 Combined root width
 Individual root shape (curvature)
 Previous endodontic treatment
 Amount of alveolar bone
 Bone density; older px = more difficult
Tooth extraction
 The ideal tooth extraction is painless removal of
whole tooth or tooth-root with minimal trauma to
the investing tissues, so that the wound heals
eventually and no post operative prosthetic
problem is created (treatment plan includes
restoration)
 Socket preservation – place bone graft in socket so
there will be good bone support when restoring
Indications
 Teeth affected by advanced dental caries and
sequoia
 Teeth affected by periodontal disease
 Over retained deciduous teeth
 Extraction of healthy teeth to correct malocclusion
 Extraction of teeth for esthetic reasons
 Extraction of teeth for prosthetic reason
 Unrestorable tooth
 Impacted and supernumerary teeth
 Extraction of decayed first or second molars to
prevent impaction of 3rd molar
 Teeth involved in fractures
Contraindications:
Systemic Contraindications:

 Uncontrolled metabolic disease (brittle diabetes
and end stage renal disease)
 Patients who have uncontrolled leukemia and
lymphoma
 Patients with severe myocardial ischemia
 Patients who have severe uncontrolled
hypertension
 Patients who have severe uncontrolled cardiac
dysrhythmias
 Pregnant patients -> best done in second trimester
 Patients who have severe bleeding diathesis
 “elective” – can postpone
Local Contraindications
 Patients undergoing radiation therapy
 Teeth located within area of tumor
 Patients who have severe pericoronitis
 Patients who have acute dentoalveolar abscess
*If patient is allergic to Biogesic but not to Tylenol, it could
be an allergy to the dye of the medicine
Biogesic = Paracetamol (pink); Tylenol = Acetaminophen
(white)
Methods of Extraction
 Inta-alveolar extraction (Forceps extraction/Closed
extraction)
 Trans alveolar extraction (surgical method/ open
technique) – involve creation of flap and remove
bone until you can adapt the forceps and access the
root
Chair Position of Clinician
Maxillary extraction
 Maxillary occlusal plane is at an angle of 45
degrees in relation to the floor
 The height of the chair should be such that the
height of the patients mouth is in level with the
clinicians elbow
 7 ocklock or 8 oclock – front
 12 ocklock – behind
 9 oclock if sirs way of holding forcep
 Arm is close to the body and the wrist is straight
 Non dominant hand –thumb is on lingual, index is
on the labial to lift the lip and support alveolar
process
Mandibular extraction
 Mandibular occlusal plane is parallel to the floor so
the patient is upright
 Clinicians elbow is in level with the occlusal plane
of the lower
Mechanical Principles of Extraction
 Expansion of the bony socket – dilation of the
socket
ORAL AND MAXILLOFACIAL SURGERY MIDTERM
 Use of a lever and fulcrum – to force a tooth or
root out of the socket along the path of least
resistance
 The insertion of wedge or wedges – to cause the
tooth to rise from the socket; force the instrument
in to the socket and the periodontal space
o Fulcrum – alveolar bone (buccal alveolar
plate)
o Force – forcep
 Wheel and Axel principle – use a triangular
elevator; rotate instrument to retrieve the tooth; for
the removal of mandibular root fragments and one
socket is empty, rotate elevator until it touches the
root then rotate it out of the socket
Number and Order of Extraction
 Number of extraction:
o Choice of anesthetic
o Presence of acute infection and
periodontal disease
o Psychological state of the patient
 Order of extraction
o Start extraction of posterior teeth not
anterior because fluid will flow
posteriorly and cover the posterior teeth
o Start with maxillary before mandibular
because if you start with the lower, there
is an empty socket and when you do the
upper, debris may go into the open socket
and cause infection
o Easier to deliver tooth when no posterior
tooth present because you luxate
posteriorly
o Anesthesia is faster in the maxilla
therefore start extraction in upper while
waiting for lower to be numb
o Start with Chief Complaint
o Maxilla > mandible
o Posterior > anterior
Forceps
 Forceps are designed according to anatomic
configuration of root following the long axis of the
root
 English design vs. American design
o Differ in hinge opening
o English – opens vertically
o American – opens horizontally
Parts of the Forceps:
1. Handle – usually serrated to prevent slippage;
where you apply force
a. Curved handle
b. Straight handle
2. Beaks of forceps – contacts the root
3. Hinge – force of the handle is transferred to the
beak through this
 ORAL AND MAXILLOFACIAL SURGERY MIDTERM

Ideal forcep grip – entire internal surface of the beak of 1. Straight – half moon shape in cross section
surface adapts on the root of
the tooth

Light contact: 2 point contact;

tooth is slightly bigger than the
forceps; better than heavy
contact because heavy contact
may fracture the tooth
2. Penant/Triangular Elevator aka Cryer
Heavy contact: 1 point contact;
middle part of the beak is
touching the tooth

Forceps should be adapted as far apically as possible

Displace fulcrum more apical so there is less movement 3. Pick Elevator

apically therefore lessening fracture of apical area a. Light Pick – to remove root tips inside the socket

Universal Forceps – Anterior, posterior and RF

Specific Forceps – only good for specific tooth

Upper Forceps:
A. 18L – left maxillary molar b. Heavy Pick aka crane pick elevator
B. 18R – right maxillary molar - To remove root fragments
C. 210 - third molar with good bone support
D. 150 – Universal; monorootet teeth (CI, PM, Small - Smooth and fine tips
third molar)
E. 150A – Same as 150 but better for wider teeth
F. 65 (bayonet) - root fragment of anterior and
posterior teeth f
G. 69 – root fragment of anterior and posterior teeth
Luxators
Lower Forceps: - To loosen teeth
A. 151, 151A – monorooted teeth, small 3rd molar and - Slowly tearing periodontal fibers
RF of any tooth - Popular because implants require minimal damage
B. 44 – RF (more angled than 151) better on anteriors
and premolar Sequence of Extraction:
C. 16 (Cowhorn) – Universal; beaks area adapted on 1. Separate the mucosa from the bone using periosteal
furcation of tooth elevators. Tests effectiveness of anesthesia and
creates access for adaptation of the forceps
English design 2. Luxate the tooth using luxators, elevators and
A. MB3 - monorooted teeth forceps
B. MB4 – wider beaks and middle part is pointed; 3. Adapt the forceps
adapt on furcation of root 4. Apply forcep motion
5. Traction/Removal
Elevators 6. Socket Management

Parts: How to luxate:

1. Handle 1. Know the curve
2. Shank - If the curve is distally, place the elevator on the
3. Blade – adapted on the tooth surface resting on the mesial surface and rotate elevator mesially but move
bone (fulcrum) elevator distally
- Use adjacent tooth as fulcrum IF you are to - Make sure the tip of the elevator is resting on the
remove it as well bone
- Upper edge of the elevator blade is touching the
3 Types of elevator: depends on tip or blade tooth
 ORAL AND MAXILLOFACIAL SURGERY MIDTERM

- If it is straight, buccal application and occlusal
withdrawal
2. Readapt the elevator more apical into the
cementum then rotate the other way then lift the
tooth following the curve, lower part of blade in
contact with cementum
3. Remove then readapt; do not rotate back so that the
tooth will not rotate again
 Curve dictates the pathway of removal
*It is not routine to curette
*Curetting adds trauma to an already traumatized socket.
*Some PDL are left with bone developing cells, if you
curette, you remove these cells
*Only curette if there is a pathological lesion at apex
*Gauze packing – press gauze so bleeding stops
*Give post-operative instructions – change sponge and
show where to place it

Forceps Movement and motions:

1. Apical Pressure
2. Buccal Pressure
3. Palatal or lingual pressure
4. Rotation
5. Traction
6. Figure 8 motion

1. Apical Pressure
 Adapt the forceps on the root of the tooth as far
apically as possible
 More apical is better because fulcrum of rotation
(especially monorooted teeth) is at the middle
portion. By placing the beak more apical, you are
displacing the point of rotation (apical) creating
less movement apically making it easier to displace
 Make sure the beaks are parallel to the long axis of
the tooth so it won’t fracture
 Apical pressure expands the cervical area then do
Buccal Pressure

2. Buccal Pressure
 There is expansion on cervical due to apical
pressure, then buccal expansion and palatal apical
due to buccal pressure
 Apply palatal/lingual pressure

3. Palatal/Lingual Pressure
 There will be an expansion of the palatal and
buccal apical

4. Rotation
 For monorooted and rounded teeth
 Expands the entire surface of the socket
5. Traction
 To remove the tooth

6. Figure 8 motion and buccal palatal pressure

 Monorooted teeth with flat root

Path of withdrawal
 Where there is a thinner cortical plate and less
resistance
 In general, thinner buccal plate on first molars and
anteriors
 Second molar, pathway of withdrawal is lingually
because thinner lingual plate
 ORAL AND MAXILLOFACIAL SURGERY MIDTERM

TRANSALVEOLAR/FLAP DESIGN  Reanastomosis takes 3-5 days to occur

 Design a flap, remove bone and show sufficient
amount of tooth
 Scalpel to incise (use number 15 or 15C)
 Use number 12 blade on posterior teeth (especially
on tuberosity area) because it is curved
 Number 11 blade for incision and drainage
The term FLAP indicates a section of a soft tissue that:
 Is 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 expected to
heal (uneventful)
2 kinds of flap
1. Full thickness mucoperiosteal flap
2. Partial thickness flap
 Lifting and exposing more bone leads to more
resorption
 Keep surgery time short to avoid unnecessary
bone exposure
Flap Nomenclature
Envelop Flap
 Full thickness flap in which horizontal incision is
made along the crest of the ridge or in the buccal
gingival crevice without vertical incision
 If surgery is limited to cervical third of crown
 Flap of choice because it provides the broadest
base and fully covers bone cavity
 For subgingival scaling, there is little danger in
violating major blood vessels

Full thickness Mucoperiosteal Flap

 There is generally the mistaken notion that a
mucoperiosteal flap is elevated only in the most
extraordinary circumstances
 Involves the mucosa and periosteum
 Use a flap whenever there is the slightest indication  Margin of the flap is at least a tooth away
it might be helpful
 Failure to properly utilize mucoperiosteal flap is
perhaps the most frequently omitted

Partial Thickness Flap

 Only separates the mucosa, leaves the periosteum
attached to the bone

Principles of Flap Design

 Broad base – To assure adequate blood supply (or Modifications of an Envelop Flap:
equal to the free end)
 Large enough to provide both visual and 1. Triangular / Three Corner Flap
instrument access  Envelop flap with one vertical relaxing
 Can be repositioned and sutured over a solid base incision
 Avoid anatomical structures such as major nerves
and blood vessels
 Estimated margin of the flap should be a tooth
away from the area you are removing, so you are
sure there is good bone support and that flap won’t
fall into the cavity and dehisce
 A large flap heals as rapidly as a small flap
 A flap doesn’t heal from end to end, but from side
to side across the incised surface
 If an error is made in flap design, the flap should
be made too large rather than too small
 Amount of post surgical pain doesn’t appear
related to the size of the flap as much as to the
amount of bone removed
 > bone removed > pain and swelling 2. Full / Four Corner / Trapezoidal Flap
 Lifting a flap immediately tears away the blood  With two vertical relaxing incisions
supply from the periosteum
 ORAL AND MAXILLOFACIAL SURGERY MIDTERM

Contraindications for Placement of Incision Lines

 Avoid placing incisions over canine or root
eminences or prominences – because it has a thin
mucosa, with less blood supply and it easily tears,
the flap ends up lacerated
 Avoid placing vertical incisions in the region of the
mental foramen
3. Semilunar Flap  Avoid placing vertical incisions on the palate
 For small apical lesions but with normal (danger of severing Greater Palatine Nerve, artery
bone and vein)
 Incise between bony eminences and should
terminate at the line angle of the crown
 Do not cut the interdental papilla
 Incise 5mm or a tooth away from the mental
foramen
 Avoid placing unnecessary incisions through the
incisive papilla
 Avoid placing incisions over bony lesions since a
dehiscence may form

In retracting:
a. Small flap – use wide end of the periodontal
4. Pedicle Flap
elevator
 To close a defect (ex. Perforated sinus)
b. Wide Flap - use the Minnesota

In removing bone:
 Use a surgical drill
 Make sure there is irrigation when you drill
because you will kill the bone cells
 If there is drill, you may use the chisel (mono
bevel) with mallet

In extracting:
 Tooth with 3 roots, you can cut the tooth mesio
distally separating the buccal roots from the palatal
root. Keep the palatal crown on the palatal root.
 For badly broken down crowns, separate all the
roots so you can remove one root at a time

How to retrieve root tip:

5. Modified trapezoidal semilunar flap
 Avoids marginal recession because you
cut above the margin
 For esthetic reasons (ex. Has a crown)
 Deep bone defect, therefore cannot do
semilunar flap
1. Loose root tip:
 Pick elevator using teasing action
 Suction
2. Fixed Root tip:
 Can use the endo file or low speed drill with small
round bur, look for the canal and insert it in the
root canal then run the drill, pull when there is
resistance
 Can make a triangular flap then prepare a window
through the bone using surgical bur then push the
root tip out

For hypercementosed root:

 Make a triangular flap design, remove buccal plate;
the bone removed should be equal to the
hypercementosed area, then elevate the tooth
buccally
 ORAL AND MAXILLOFACIAL SURGERY MIDTERM

How extract root fragment:

1. Do alveolar purchase:
 Make an envelop flap
 Expose cervical area
 Adapt forceps to the alveolar plate then apply
controlled force
 Try to fracture the cervical part of the bone until
the forcep makes contact with the tooth
 Forcep beaks are used to remove the bone
 Force toward area with less tooth structure
2. Adapt elevator in the periodontal space (wedge),
can luxate, apply elevator or forcep to remove the
tooth. Get a small file, smoothen the margins then
approximate the flap then suture.
3. Can use purchase point
4. Bur a hole on the tooth 4-5 mm below the
cavosurface margin using a round bur, close to the
alveolar plate because you will use it as a fulcrum.
Make sure there is a lot of tooth structure above the
burred area so you can use elevator to elevate

Socket management:
1. Use a file, smoothen the margins of the bone in a
pulling motion
2. Irrigate, remove all tooth chips
3. Lift the flap and irrigate, remove bone powders
(If there is still powder left, 1-2 months later, the
area becomes swollen. Crestal area is closed but
there is a deep pocket in the buccal area that goes
down to the vestibular area. Will need to open
again and irrigate)
4. Place back flap then suture
5. If planning to place a fixed bridge, close the socket
immediately
6. If planning to place an implant, preserve the socket