ORAL SURGERY - - Diagnosis and surgical treatment of diseases, injuries, and defects of the mouth and dental structures Diseases Defects Injuries Types of hemorrhage: - MANAGEMENT OF BLEEDING: - REQUISITE OF SURGERY: 1. Work as a team o Know your limitation o Consult another specialist 2. There should be maturity of thinking o Surgical judgement 3. Should have profound respect and reverence for life o “humanism” 4. Respect for living tissue o Do justifiable trauma o No harm when necessary o Know the anatomy very well Primary hemorrhage Intermediate hemorrhage Secondary hemorrhage - Apply pressure with gauze o This compresses the capillaries o Acts as a mesh, releases thromboplastin Use of medicine Suturing/ligation Cold compress Tea bag Gel foam Bone wax Electrocautery machine Vasoconstrictors 3. MAINTENANCE OF PATENT AIRWAY - Remove all dental appliance/prosthesis 4. PREVENTION OF TRAUMA BASIC PRINCIPLES OF ORAL SURGERY 1. ASEPSIS, PREVENTION/CONTROL OF INFECTION OF WOUND - Exercise aseptic technique - Instruments - Dental Chair and Unit - Dental clinic (floor, fixtures, etc) - Disinfectants - Control the environment of the wound - Antiseptic - CASE HISTORY - 2. CONTROL OF HEMORRHAGE Types of veins: - Arterial Venous Capillary Use sharp instrument (needles, scalpels, etc) Use a bur (carbide burs-self-cleansing) bode reduction Every move of the scalpel should be purposeful Use electrocautery machine - A professional conversation o Symptoms o Feelings o Fear Evaluation of the patient prior to dental treatment o A case history is of immense value in the following ways: - To establish the diagnosis To detect any medical problem Evaluation of other systemic problems Discovery of communicable diseases Prevention of emergencies For effective treatment planning History of present illness (HPI) - CASE HISTORY - Patient’s information Chief complaint History of present illness Medical history dental history Family history Personal and social history Name Age Gender/sex Address Contact number Occupation Status Weight Religion Nationality A chronological description of the development of the patient’s illness HIP INCLUES: o Onset o Location o Quality o Severity o Duration o Timing o Modifying factors o Associated signs and symptoms Medical History - Patient’s information - Esthetics - Pre examination patient interview, which helps identify conditions that could alter, complicate or contraindicate proposed dental procedures General health Current treatment Hospitalization Chief Complaint - The problem that initiated the patient’s visit FOUR CATEGORIES: o Comfort o Function o Social Dental History - The dental history consists of reviewing previous dental experiences and current dental problems Family History - Diabetes Hypertension Cancer Heart disease Stroke Hemophilia Personal and social history - Oral habits Oral hygiene practices CLINICAL EXAMINATION GENERAL EXAMINATION EXTRAORAL EXAMINATION o o o Head and Neck Lymph nodes Facial asymmetry INTRAORAL EXAMINATION: - - Lips Tongue o Volume of the tongue o Integrity of the papillae o Cracks or fissures Floor of the mouth o Color o Swelling - - - o Presence of patches o ankyloglossia Buccal mucosa Gingiva o Color o Texture o Tone o Inflammation Palate o Clefts, perforations, ulceration or any swelling o Recent burns or hyper keratinization o Fistula tori, papillary hyperplasia Tonsils Teeth o Missing teeth o Restoration o Defective restoration/overhanging margins o Missing restoration o Open contacts o Diastemas o Malposition o Erosion, abrasion, attrition o Extrusion o Recurrent caries o Fractured restoration o Supernumerary tooth o Fluorosis Tooth Mobility: - All teeth have a slight amount of physiologic mobility The destruction of periodontium makes the tooth loose in the socket Tooth mobility is graded as: - Grade I: slight mobility, up to 0.5mm - Grade II: moderate mobility, more than 0.5mm but less than 1mm Grade III: severe mobility, tooth is movable both mesiodistally and labiolingually and may be depressible in the socket DIAGNOSTIC TEST AND TECHNIQUES - Inspection o 3 C’s (color, contour and consistency) The following can be detected: o o o o o o - - Carious lesions Fractures of teeth Defective restoration Periodontal disease Soft tissue infection Aided by exploration, transillumination Palpation o For identifying subperiosteal swelling o To delineate borders and relative firmness of an abscess o Detect lymphadenopathy/lymphadenit is also a critical tool for ruling in/out cancer from the differential diagnosis Percussion Periodontal probing o Probing is walked along the tooth surface keeping it parallel to the long axis of the tooth o Pocket depths > 3mm indicate disease Results/findings: o - - Bleeding on probing: means active gingival infection o Sensitivity on probing: periodontal problem o Isolated narrow pocket that traverses to the apex of the tooth: concurrent endodontic and periodontal problem o Isolated deep pocket: vertical tooth fracture Tooth mobility o Confirms the presence and severity of occlusal trauma, periodontal abscess o Determines the tooth’s prognosis o Determines the usability of the tooth as future abutment for a prosthesis o Mobility is a strong indicator of bone support loss Pulp vitality testing o To determine the state of health of the pulp in an offending tooth o A test used to ascertain the vitality of the tooth (-) non-vital (+) vital o Electric pulp tester o Application of heat and cold Radiographic Investigations: Types of radiographs: - Occlusal Periapical Bitewing Panoramic DIAGNOSIS - The identification of the nature of an illness or other problem by examination of the symptoms ORAL DIAGNOSIS - Examination of the mouth and teeth toward the identification and diagnosis of intraoral disease or manifestation of non-oral conditions PROVISIONAL DIAGNOSIS: - - Is arrived at after evaluating the case history and performing the physical examination The positive findings are listed down and the possibility of a specific diagnosis is evaluated DIFFERENTIAL DIAGNOSIS: - - - If the diagnosis is not conclusive for a definite disease process, a list of probable diagnoses is recorded in the patient’s case history These diseases may have a similar course, progress, or signs and symptoms A final diagnosis may be possible only after carrying out further investigations FINAL DIAGNOSIS: - Usually reached by chronologic organization and critical evaluation of the information obtained from patient’s case history, physical examination and the result of radiological and laboratory examinations - It usually identifies the chief complaint first and then subsidiary diagnosis of other problems TREATMENT PLAN EMERGENCY PHASE - - First and preliminary phase of treatment planning The emergency complication is the first thing to be treated and managed e.g relief of pain It addresses the chief complaint PREPARATORY PHASE: - CORRECTIVE PHASE: - - Second line of treatment Protection from and prevention of the high-risk factors such as: Sticky, sugary diet Calculus retentive factors Deep pits and fissures Achieved by: o o o o o Dietary counseling: eat more cereal, milk & dairy and poultry products Pit and Fissure sealant application: indicated for newly erupted molars with deep pit and fissures Fluoride treatment: Below 6 years of age: fluoride varnish application Above 6 years of age: APF gel (Acidulated Phosphate Space Maintainer Permanent restoration and other prosthetic replacement Stainless steel crown MAINTENANCE PHASE - PREVENTIVE PHASE - Oral prophylaxis Caries control Endodontic treatment Extraction - Check condition of existing restoration, new caries formation, calculus or plaque accumulation OP/TFA every six months PROGNOSIS - The prognosis is the prediction of the probable course, duration, and outcome of a disease based on a general knowledge of the pathogenesis of the disease and the presence of risk factors for the disease INSTRUMENTS IN ORAL SURGERY INCISING TISSURE scalpel no. 3, scalpel blade 15: 12: mucogingival procedure / most posterior region 11: used in making a small stab incision in draining an abscess 10: incision extraorally seldin: freer: molt 9: MINNESOTA RETRACTOR HEMOSTAT - used to grasp debri or root/bone fragments or the socket. dettach granuloma periapical currette: remove debri from socket needle holder: for stabilization of needle REMOVING SOFT TISSUE FROM BONY CAVITIES PERIAPICAL CURETTE -used to remove debris from tooth socket SUTURING SOFT TISSUE NEEDLE HOLDER IRIS SCISSORS, METZENBAUM SCISSORS HANDLES - - - EXTRACTING TEETH are usually adequate size to be handled comfortably and deliver sufficient pressure and leverage to remove the required tooth have a serrated surface to allow a positive grip and to prevent slippage are usually straight but may be curved. This provides the operator with a sense of better fit The handles of the forceps are held differently, depending on the position of the tooth to be removed o Maxillary forceps are held with the palm underneath the forceps so that the beak is directed in a superior direction EXTRACTION FORCEPS o FORCEPS COMPONENTS The forceps used for removal of mandibular teeth are held with the palm on the top of the forceps so that the beak is pointed downward toward the teeth - HINGE - - Like the shank of the elevator, is merely a mechanism for connecting the handle to the beak Transfers and concentrated the force applied to the handles to the beak The usual American type of forceps has a hinge in a horizontal direction - Are the source of the greatest variation among forceps Are designed to adapt to the tooth root near the junction of the crown and root Are designed for single rooted teeth, two rooted teeth, and three rooted teeth The design variation is such that the tips of the beaks will adapt closely to the various root formations, improving the surgeon’s control of forces on the root and decreasing the chance for root fracture The more closely the beaks of the forceps adapt to the tooth roots, the more efficient the extraction and the less chance for undesired outcomes AMERICAN TYPE OF FORCEPS - - Some forceps beaks are narrow because their primary use is to remove narrow teeth, such as incisors Other forceps beaks are broader because the teeth they are designed to remove are substantially wider, such as lower molar teeth ENGLISH TYPE OF FORCEPS - BEAKS The beaks of forceps are angles so that they can be placed parallel to the long axis of the tooth, with the handle in a comfortable position o Breaks of maxillary forceps are usually parallel to the handles o Beaks of mandibular forceps are usually set perpendicular to the handles #150 forceps - used to extracts mx anterior teeth (1323) + mx premolars (mx root fragments) #210 FORCEPS - used to extract mx 3rd molars #18R FORCEPS - used to extract mx 1st 2nd 3rd molars on the right #65 FORCEPS - #18L FORCEPS - used to extract mx 1st 2nd 3rd molars on the left used to extract root fragments on the mx arch #69 FORCEPS - used to extract root fragment on the mx arch #17 FORCEPS - universal forceps to extract 1st, second, third molars #151 FORCEPS - used for mn anteriors & premolars (also mn root fragments) #16 FORCEPS (cow horn forceps) - used to extract mn first molars (only) #44 FORCEPS - mandibular root fragments DENTAL ELEVATORS - - used to laxate/loosen the tooth from the surrounding bone by creating movement peior to application of beaks of forceps can prevent fractur of the tooth/root/bone laxating dettached it from alveolar bone loosen tooth prior to removal of malpositioned tooth TYPES OF ELEVATORS 1. straight type o most commonly used elevator to luxate teeth o the blade of the straight elevator has a concave surface on one side that is placed toward the tooth to be elevated o o COMPONENTS OF THE ELEVATOR HANDLE - - is usually of generous size, so it can be held comfortably in the hand to apply substantial but controlled force in some situations, cross bar or T-bar handles are used these instruments must be used with great caution because they can generate an excessive amount of force SHANK - simply connects the handle to the working end, or blade, of the elevator is generally of substantial size and is strong enough to transmit the force from the handle to the blade BLADE - is the working tip of the elevator and is used to transmit the force to the tooth, bone, or both o The small straight elevator, No. 301, is frequently used for beginning the luxation of an erupted tooth, before application of the forceps Larger straight elevators are used to displace roots from their sockets and are also used to luxate teeth that are more widely spaced or once a smaller-sized straight elevator becomes less effective The shape of the blade of the straight elevator can be angled from the shank, allowing this instrument to be used in the more posterior aspects of the mouth Millers elevator Potts elevator o o 2. triangle type o second most commonly used type of elevator o these elevators are provided in pairs: a left and right o most useful when a broken root remains in the tooth socket and the adjacent socket is empty o typical example would be when a mandibular first molar is fractured, leaving the distal root in the socket but the mesial root removed with the crown o The tip of the triangular elevator is placed into the socket, with the shank of the elevator resting on the buccal plate of bone The elevator is then turned in wheel-and-acle rotation, with the sharp tip of the elevator engaging the cementum of the remaining distal root; the elevator is then turned and the root is delivered Triangular elevators come in a variety of types and angulations, but the Cryer is the most common type 3. pick type o the third type of the elevator that is used with some frequency o is used to remove roots o the first type (heavy version) of the pick is the Crane pick is used as a lever to elevate a broken root from the tooth socket o o o o o Usually it is necessary to drill a hole with a bur (purchase point) approximately 3mm deep into the root just at the bony crest The tip of the pick is then inserted into the hole, and with the buccal plate of bone as a fulcrum, the root is elevated from the tooth socket Occasionally the sharp point can be used without prepping a purchase point by engaging the cementum or furcation of the tooth o o The second type of pick is the root tip pick or apex elevator The root tip pick is a delicate instrument that is used to tease small root tips from their sockets It must be emphasized that this is a thin instrument and should not be used as a wheel-and-axle or lever type of elevator like the Cryer elevator or the Crane pick The root tip pick is used to tease the very small root end of a tooth by inserting the tip into the periodontal ligament space between the root tip and socket wall INDICATIONS FOR THE USE OF ELEVATORS - - To luxate and remove teeth which cannot be engaged by the beaks of the forceps To remove roots, fractured or carious teeth To loosen the tooth prior to the application of forceps To split the tooth which have had grooves cut in them To remove interradicular bone RULES IN THE USE OF ELEVATORS - - - Never use adjacent tooth as a fulcrum unless that particular tooth is subsequently extracted Always use finger guard to protect the patient in case the elevator slips Be certain that the forces applied by elevator are under control and that the elevator tip is exerting pressure in the correct direction When cutting interseptal bone, take care not to engage the root of an adjacent tooth; inadvertently forcing it in its alveolus DANGER IN THE USE OF ELEVATOR - Damaging or extraction of adjacent tooth Fracturing the maxilla or mandible Fracturing the alveolar process DANGERS IN THE USE OF ELEVATOR - - Slipping or plunging the sharp points of the instrument to the soft tissue with perforations of blood vessels and nerves Penetrating the maxillary sinus or forcing a root or 3rd molar into the antrum - forcing the apical 3rd of the root of a lower 3rd molar into the mandibular canal or lingual plate of the mandible into the lingual space BASIC EXTRACTION SET-UP
