Mental Dental: Oral Surgery

Impaction & Extraction Facts

Indications for Extraction:

 Caries
 Endo (Trauma/Internal Root Resorption)
 Perio
 Ortho
 Cracked teeth
 Impacted teeth
 Supernumerary
 Pathology
 Questionable teeth should be extracted before radiation therapy (to prevent osteoradionecrosis [ORN]:
dead bone as a result of radiation therapy)

Relative Contraindications for EXT:

 Unstable diabetes (risk for infection)
 End Stage Renal Disease
 Unstable angina (high risk of med emergency
 Leukemia (easy bleeding) and lymphoma (WBC immune system  risk for infection)
 Hemophilia or platelet disorder (easy bleeding)
 Head and neck radiation (ORN  use hyperbaric oxygen before and after EXT)
 IV bisphosphonates (try to RCT or restore)
 Pericoronitis (treat infection first)

Impacted Teeth
 Fail to erupt into dental arch w/in the expected time
 Mandibular third molars > maxillary third molars > maxillary canines
 Primary reason is inadequate arch length

Congenitally Missing Teeth

 Fail to form
 Third molars > maxillary lateral incisors > mandibular second premolars

Nature of Overlying Tissue

 For any impacted teeth
 Soft tissue impaction = height of contour is above bone level and gingiva is completely or partially
covering tooth (easiest to extract)
 Hard tissue impaction
o Partial bony impaction: height of contour is below bone level
o Full bony impaction: tooth is entirely encased in bone (most difficult to extract)

Winters Classification
 For impacted third molars
 Based on position of long axis of the 3rd molar in relation to the long axis of the 2nd molar
 For lower molars:
o Mesioangular = easiest
o Disoangular = most difficult (D for distoangular and D for difficult)
Pell and Gregory Classification
 For impacted lower third molars only
 Class A: same plane as other molars
 Class B: halfway down from other molars
 Class C: below cervical line (CEJ) of 2nd molar (most difficult, more bone coverage & close to IAN)
 Class 1: crown anterior to ramus
 Class 2: half crown within ramus
 Class 3: entire crown within ramus (most difficult, more bone coverage & close to IAN)

Subperiosteal Abscess
 Infection/pus trapped under periosteum layer
 When necrotic bone/tooth has been left behind underneath a flap following a surgical extraction
 Possible whenever a mucoperiosteal flap is elevated for surgical extraction
 Irrigate thoroughly to removed fractured tooth pieces or bony spicuels below the soft tissue

Oro-Antral Communication (Sinus Exposure)

 Communication b/w oral cavity and antrum (sinus)
 Most common w/ maxillary first molars
 Prevent with good pre-op radiographs and avoid excessive apical pressure
 Tx:
o <2 mm do nothing/monitor
o 2-6 mm 4A’s (abx, antihistamines, analgesics, Afrin nasal spray) and figure-eight suture
o >6 mm flap surgery for primary closure
 Can lead to sinusitis or oro-antral fistula

Alveolar Osteitis (Dry Socket)

 When blood clot dislodges or dissolves before wound heals following an extraction
 Does not require abx
 Tx: irrigation and local pain control
o Dressing/dry socket paste: contains eugenol
Nerve Injury
 Most common w/ lower third molars and IAN
 Tx: Medrol dosepak
 Patients with numbness lasting more than 4 weeks should be referred for miconeurosurgical evaluation

Tooth Displacement
 Maxillary first/second molar  Maxillary sinus
 Maxillary third molar  Infratemporal fossa**
 Mandibular third molar  Submandibular space
 Tooth lost into oropharynx, send to ER for chest and abdominal xrays

Instrumentation

Bite block
 Soft rubber block patient can bite down on
 Used to keep patients mouth open which provides better visualization
 Stabilizes the mandible which provides comfort for patient

Suction Tips
 Yankauer suction: soft tissue (soft tip, can suck up fluid)
 Frazier suction: hard and soft tissue (hole can be covered to for stronger/rapid suction)

Towel Clip
 Holds drapes places around patient
 Locking handle with finger and thumb rings
 Careful not to pinch patient skin

Both Weider &

Seldin are good for
mandibular tori
removal

Benefit: you can

retract flap and
cheek/tongue at
same time

Periosteal Elevator
 Woodson periosteal: small and delicate
o Sharp end: lift flap
o Broad end: elevate and reflect flap
 #9 Molt periosteal: larger
o Sharp end: reflect papilla, lift flap
o Broad end: elevate/separate periosteum from bone

Elevators
 Parts: Blade, Shank, Handle
  Grip: Palm grip, pointer finger can rest near blade for optimal control
 Used to: Disrupt PDL fibers, luxate teeth, expand alveolar bone

Extraction Forceps
 150: Universal uppers (A premolars, S primary)
 151: Universal lowers (A premolars, S primary)
 23 (Cowhorn): Lower molars, two sharp beaks to engage bifurcation
 88R/L: Upper molars, two beaks for palatal root, one beak for buccal bifurcation
 74 (Ash): Mandibular premolars
 65: Upper root forceps

Hold blade
handle with pen
grasp for max
control

Irrigation
 Use steady stream of sterile saline or water during bone removal
 Prevents heat generation that can damage bone
 Increases efficiency of surgical bur
Curettes
 Spoon shaped end for scraping away soft tissue at base of socket
  Always curette a socket once you remove the tooth to get rid of soft tissue (better clotting and healing)

Air-Driven Handpiece:
drives air into socket 
air into fascial spaces
 air emphysema

Hemostat
 Designed for hemostasis: clamp blood vessels closed before suturing or cauterizing it
 Useful for blunt dissection of soft tissue such as in I&D (insert into incision closed, open once inside)
 Curved or straight beaks
 Serrated end allows for grasping

Needle Holder
 Short stout beaks
 Face of beak is crosshatched: allows for positive grip of suture needle unlike hemostat

Suture
 Needle and thread
 Primary purpose is to immobilize a flap
 Suture should be placed from movable tissue to non-movable tissue
 Simple interrupted is the easiest and most common technique
 Silk has wicking property that allows bacteria to invade
Surgical Extractions

Surgical Extraction
 Surgical access via elevating mucoperiosteal flap
 Surgical handpiece to remove bone or section tooth
 Suture usually needed

Flap Design
 Wider base to ensure adequate blood supply
 Incisions over intact bone, not over bony defects or eminences
 Rounded corners
 Vertical releases at line angles
 Avoid vital structures

Types of Mucoperiosteal Flaps

 Envelope: 0 vertical releases
 Three-cornered: 1 vertical release
 Trapezoidal = 2 vertical releases

Miscellaneous Flaps
 Semilunar incision
o Apical to mucogingival junction
o For apicoectomy
o Apically displaced flap is impossible in maxillary palatal
 Double Y incision
o Incision town the midline
o Two vertical releases at each end (double Y)
o For palatal torus removal
Surgical Handpiece Use
 Remove buccal bone
o Remove bone between tooth and cortical bone to create a ditch or trough
o Create a purchase point and pathway for delivery
 Remove interradicular bone
o Remove bone between tooth and cortical bone to create a ditch or trough
o Moves center of resistance apically and facilitates tooth removal
 Section tooth
o Use surgical bur to split the tooth in half (mesial portion and distal portion)
o Insert an elevator to complete the break
o Extract each piece separately

CSI:
 Curette
 Smooth bone
 Irrigate

Post-Op:
 Pressure with gauze, soft diet, no negative pressure straw spit smoking

Implants

Indications
 To replace a missing tooth
Three Implant Types
 Subperiosteal
 Transosteal
 Endosteal (most common)

Implant Components
 Implant body
 Abutment
 Abutment screw
 Implant Crown

Implant Body
 AKA implant or fixture
 Usually axisymmetric
 Sequentially enlarge the osteotomy (bone hole)
o Reduces heat generated
o Helps to maintain axis with free-hand surgery
 Usually inserted into tapped holes

Abutment: One Piece

 Abutment screw is actually a part of the abutment
 No anti-rotation component

Abutment: Two Pieces

 Abutment screw and abutment are separate components
 Has an anti-rotation component

Implant Crown: Screw Retained

 Screw through crown into implant
 Screw access hole (poor esthetics)
 Better for restricted restorative space
 Retrievable

Implant Crown: Cement Retained

 Abutment is attached separately to implant
 Better for anterior/Incisors (esthetics)
 Not retrievable
 Cement may be trapped sub-gingivally and cause peri-implantitis

One Piece Implant

 Implant and abutment are attached together
 Drilled into bone as one unit
 Cannot correct angle between the two components

Two Piece Implant

 Implant and abutment are separate components
  Implant drilled into bone, then abutment attached next

Anti-Rotation Component
 Prevents rotation (spinning) of abutment
 Provides stabilization (rocking) of abutment

Integration
 Osseointegration: direct histologic contact between bone and implant surface
 Fibrousintegration: presence of fibrous tissue layer between implant and bone (failure of OI)

Stability
 Primary stability: when you first place implant, how well the screw pattern holds into bone
 Secondary stability: osseointegration, long-term healing of the bone to the titanium alloy

Best: anterior mandible

Worst: posterior maxilla
One stage surgery
 Place implant and healing abutment in one visit
 Remove healing abutment and restore at next visit

Two stage surgery

 Place the implant with a cover screw and cover it up with gums
 Open gums and place abutment at next visit
 Benefit of 2 stages:
o Poor primary stability (want to keep all biting forces off of it while healing)
o Place graft
o Medically compromised, primary closure = less infection risk

Impression
 Once healing is complete, final impression is made so the crown and abutment are properly oriented
 Impression coping = used to transfer location and angulation of implant to a master cast
o Open tray: hole in tray (multiple units)
o Closed tray: no hole in tray (single units)
 Analog = implant replica

Socket Preservation
 Maintains height and width of alveolar ridge after extraction
 Need to have an atraumatic extraction
 Irrigate extraction site thoroughly, remove granulation tissue with curette, place graft material, cover
with resorbable collagen membrane
 Primary closure is unneccessary

Biologic Width
 Roughened surface for bone, smooth surface for soft tissue
 Gingival fibers orient next to implant PARALLEL with cuff

Surgial Stent
 Location
 Agnulation
 Depth
 Make sure any and all implants being places are aligned properly

Implant Success
 Immobile
 No peri-implant radiolucency
 Peri-implant bone loss <0.2 mm per year after first year
 Absence of symptoms like pain

Implant Failure
 Gram negative anaerobic rods and filaments
 47 degrees Celsius for 1 minute or 40 degrees Celsius for 7 minutes is enough to compromise
osseointegration
Trauma & Orthognathic Surgery

Mandibular Fractures
 Best evaluated with PAN
 Condylar > Angle > Symphysis
o Fall on R: Angle fracture on R, Condylar fracture on L
 Greenstick = not all the way through
 Comminuted = crushed into multiple fragments
 Simple = closed to oral cavity
 Compound = open to oral cavity, bone exposed thru mucosa near teeth

Mid-face Fractures
 Best evaluated with CBCT
 Le Fort 1 = horizontal fracture across maxilla
 2 = pyramidal fracture (orbit, nasal bone, maxilla)
 Le Fort 3 = complete craniofacial disjunction
 Zygomaticomaxillary complex fracture = formerly known as a tripod fracture, cased by direct blow
under the malar eminence, involves bleeding under conjunctiva

Skeletal Discrepancies
 Class 2 = retrognathic mandible
 Class 3 = prognathic mandible
 Anterior open bite = apertognathic
 Vertical maxillary excess = maxilla too long, gummy smile
 Horizontal transverse discrepancy = posterior cross bite
 Macrogenia = chin too big
 Microgenia = chin too small

Orthognathic Surgery
 To correct severe skeletal discrepancies
 Lateral cephs are the main images used in treatment planning these cases
 Acrylic splint used intraoperatively
 Le Fort 1 osteotomy  move maxilla
  BSSO  move mandible
 Genioplast  move chin

LeFort 1 Osteotomy
 For retrusive maxilla or vertical maxillary excess

Bisagittal Split Osteotomy (BSSO)

 For retrusive or protrusive mandible
 Most common post-op complication is nerve damage
 Condyle position should be unaltered

Distraction Osteogenesis
 Bone deposition between two bone surfaces that are separated by gradual traction
 For bone lengthening, but not for adding width
 First phase is osteotomy phase – bone is cut
 Second phase is latency period – appliance is mounted to bone on each side of cut but is not
activated for 1 week
 Third phase is distraction phase – appliance is used to gradually separate the two pieces allowing new
bone to fill in the gap

Orofacial Pain

Biopsychosocial Model of Pain

 Axis 1 = “bio” nociceptive input from somatic tissue, acute
 Axis 2 = “psychosocial} influence of interaction between thalamus, cortex, and limbic structures, chronic
 It is not just about the tooth (Axis 1), but also about the person with the tooth (Axis 2)
1. Somatic Pain
 Increased stimulus yields increased pain
 Musculoskeletal = TMJ, periodontal, muscles (myofascial)
 Visceral = salivary glands, pulp

2. Neuropathic Pain
 Pain independent of stimulus intensity
 Damage to pain pathways: Trigeminal Neuralgia, trauma, stroke

Atypical Odontalgia
 Secondary to deafferentation (removal of part of the neural pathway) as a result of endo therapy or
extraction  Phantom toothache

Post-Herpetic Neuralgia
 Potential Sequela of herpes zoster infection
 Burning, aching, or shock-like
 Tx: anti-convulsants, anti-depressants, or sympathetic blocks

Burning Mouth Syndrome

 Postmenopausal women (older than 50)
 Associated with type 2 diabetes, malnutrition, xerostomia
 Burning, pain, dryness, and maybe also altered taste sensation

Chronic Headache
 Also referred to as neurovascular pain
 Migraine = unilateral, pulsating, nausea and vomiting, photophobia & phonophobia
 Tension type = bilateral, non-pulsating, not aggravated by routine activity
 Cluster = intense pain near one eye
 Tx = triptans for migraine (selective serotonin receptor agonists)

3. Psychogenic Pain
 Intrapsychic disturbance – conversion reaction, psychotic delusion, malingering

4. Atypical Pain
 Facial pain of unknown cause/diagnosis pending
TMD

Bony Anatomy
 Condyle
 Mandibular (glenoid) fossa
 Articular Eminence

Lower joint space:

 Rotation

Upper joint space:

 Translation

TMJ Muscles:
 Open: lateral pterygoid
 Close: masseter, temporalis, medial pterygoid

TMJ Ligaments:
 Ligaments limit the movement of the mandible
 Capsular ligament
 Discal/collateral ligament
 Posterior ligament: prevents anterior disc displacement
 Lateral ligament: prevents posterior disc displacement

TMJ Blood Supply

Disc Displacement (Internal Derangement)

 With reduction: CLICK, condyle pops over anteriorly displaced disc and pops on the way back to its
fossa
  Without reduction: LOCK, condyle is stuck behind anteriorly displaced disc resulting in limited range of
motion and ipsilateral (same side) deviation on opening

Opening Patterns
 Deflection: deflects toward side that is stuck at max opening
 Deviation: deviates toward one side then returns back to midline at maximum opening (pain,
tenderness)

Recurrent Dislocation
 Mandibular condyle translates anterior to the articular eminence and requires mechanical
manipulation to achieve reduction (down and back)
 Tx: Botox injection of lateral pterygoid or surgery if chronic

Ankylosis
 Union b/w condyle and skull can be either bony or fibrous
 Trauma is most common cause
 Other causes: surgery, radio therapy, infection
 Severe restricted range of motion

Bruxism
 Clenching/grinding teeth
 Diurnal and/or nocturnal
 Usually caused or exacerbated by stress
 Tx: occlusal guard to distribute occlusal forces more evenly and relax musculature

Need to puncture
capsular ligament to
access the superior
joint space
Myofascial Pain Syndrome (MPS)
 Chronic muscular pain disorder
 Most common cause of masticatory pain
 Trigger points in muscles of mastication
 Diffuse pain in preauricular region
 Parafunctional habits can contribute
 Tx: physical therapy, stress management, splint therapy, medications

Biopsy

 2 weeks
 Four categories: cytology, aspiration, incisional, excisional
Biopsy Techniques
 Make Diff Dx: list of possible things, with first being most likely
 Mark lesion with indelible marker
 Block anesthesia is preferred because local infiltration can distort the architecture of the lesion
 Direct handling will crush cells (Adson forceps, silk suture thru lesion)
 Store sample in 10% formalin

Clinical examples
 Large white patch on buccal mucosa that wipes off, presumed to be candidias? Cytology
 Firm, rough 2X3 cm white lesion on lateral tongue that does not wipe off? Incisional
 Denture wearer presents with red swelling in buccal vestibule? None, check in 2 weeks

Surgical Management of Cysts and Tumors

 Cysts: enucleation, marsupialization, curettage
 Tumors: enucleation, curettage, resection

Enucleation: surgical removal of a mass without cutting into or rupturing it (removed whole)
Marsupialization: cut a slit into an abscess or cyst, suture edges open so it can drain freely
Curettage: removal of tissue by scraping or scooping
Resection: surgical removal of cyst or tumor and normal tissue around it (wide margins)

Medical Emergencies
Syncope
 Most common medical emergency
 Warm then cold, BP and heart rate go down  unconscious
 Vasovagal syncope = most common syncope, needle anxiety
 Trendelenburg position
 Left lateral decubitus if pregnant to relieve inferior vena cava
 Orthostatic hypotension = second most common
 Dizzy spell or head rush
 Blood pressure suddenly falls when standing up (esp. when dehydrated)

Epinephrine Overdose
 Rapid intravascular injection of LA with epi
 BP and heart rate go up, thumping heart

Angina
 Chest pain (coronary arteries cannot provide enough oxygenated blood to the heart)
 Stable: angina is caused by exercise, stress
 Unstable: angina is less predictable, at rest
 Ischemia without necrosis
 ONA: oxygen, nitroglycerin, aspirin
 (1) NTG (0.4 mg) – 5 min – (2) NTG – 5 min – (3) NTG, aspirin and call 911

MI
 Sudden occlusion of major coronary vessel, usually LAD (left anterior descending artery)
 Ischemia with necrosis
 MONA: morphine, oxygen, nitroglycerin, aspirin

Hypoglycemia/Diabetes
 If conscious: glucose tab or OJ
 If unconscious: IV dextrose or IM glucoagon

Hypoglycemia:
 Sweating
 Pallor
 Irritability
 Hunger
 Lack of coordination
 Sleepiness

Hyperglycemia:
 Dry mouth
 Increased thirst
 Weakness
 Headache
 Blurred vision
 Frequent urination

Conscious IV Sedation for Diabetic: Have food (low calorie meal) and decrease insulin dose

Hyperventilation
 Do not give oxygen
 Sit upright
 Brown paper bag

Asthma
 Constriction and inflammation of bronchioles
 Wheezing = high pitch on exhale
 2 puffs from emergency inhaler (albuterol)
  Avoid NSAIDS and narcotics (Aspirin CI)

Airway Obstruction
 Clear the pharynx of any food, vomit, foregin objects
 Check for breathing (rise and fall of chest, sound of mouth or nose)
 Chin tilt upwards to extend the neck
 Protrude tongue and mandible to open airway

Seizure
 Protect from injury
 Do not restrain
 IV or IM benzo
 Grand mal seizure = Dilantin/Phenytoin
 Status epilepticus = Valium/Diazepam

Stroke
 TIA = transient ischemic attack, mini-stroke
 CVA = cerebrovascular accident, stroke
 Oxygen and call 911
 Caused by hyponatremia (low sodium)
 Look for facial droop, arm drift, speech slur

Anaphylactic Shock
 AEIOU
 Albuterol
 Epinephrine (0.3 mg 1:1000 = epipen)
 IM antihistamine
 Oxygen
 YOU call 911

Anticoagulation
 Check blood tests below: Aspirin = anti-platelet drug…so it
o CBC: anemia, leukopenia, thrombocytopenia will affect bleeding time… but
o Bleeding time (time to clot): platelet function NOT PT, INR, PTT (It’s not an anti-
o PT: anticoagulants, liver damage, Vit K coagulant)
o INR (extrinsic pathway): Warfarin, Coumadin, INR = 2-3,
below 3.5 for EXT
o PTT (intrinsic pathway): Heparin, renal dialysis,
hemophilia
o Herbal anticoagulants: garlic, ginger, ginkgo, ginseng

Practice Questions

 What is the nerve most damaged in TMJ Surgery? Facial n.

 Where is the maxillary third molar most likely to be displaced during an extraction? Infratemporal fossa
 A patient has a skeletal deformity with a class 3 malocclusion (maxillary deficiency). The ideal treatment
is…? Surgical Reposition of the maxilla
 Which of the follow statements about the flap for the removal of a palatal torus is correct? The most
optimal flap is shaped like a double Y
 What is the most frequently impacted tooth? Mand 3rd molar
 What is the best diagnostic tool for evaluating the TMJ? MRI
 What is the luxator of choice for extraction of a single retained root for a mandibular molar? Cryer
 What is the minimum labio-lingual dimension of bone required to place an implant diameter for 3.5
mm? 5.5 mm
 Which of the following is the most common post-op problem associated with mandibular sagittal split
osteotomies? Neurosensory disturbances (IAN nerve damage)
 Which of the following is the least likely congenitally missing tooth? Max canine
 For surgical extraction of #30, which direction ndo you section the tooth to facilitate removal of the
roots? Bucco-lingually
 Which of the following is considered the highest and most severe classification of maxillary fracture?
LeFort III (no class 4!!!!!)
 Myofascial pain dysfunction is best described as? Masticatory pain and limited function
 You are performing a 5-year follow up on a 43-year-old patient with an implant. When comparing
radiographs, you estimate that there has been almost 0.1 mm loss of bone height around the implant
since it was placed. Which of the following is indicated? The implant is doing well; this amount of bone
loss is considered acceptable.
 This same pt is undergoing a simple extraction and discloses that he has a needle anxiety. Shortly after
the local anesthetic injection, the patient experiences an episode of vasovagal syncope. What would
you NOT do? Administer epi