Oral Midterm 1

Introduction Lecture Definition: • Speciality of dentistry of which includes : Diagonsis—Surgical—adjunctive treatment of disease, injuries and defects involveing both functional and esthetic aspects of hard and soft tissues of the oral and maxillofacial region (Head and Neck) Scope of Oral Surgery General Dentist: Provides common, usually less complicated, surgical services in the office • Interests, Pt. Needs, Office schedule • Training/Experience, Skill level • Physical plant, Instruments, Assistant • Good assistant will have a greater influence • Pt. is more comfortable w/ assistant than the dentist Specialist: Provides full scope of services including services requiring adjunctive anesthetic or hospital management • Availability of specialist—Geographic proximity • Standard of care • “Team” approach to pt. care = referral is an important thing to keep line of communication Pain and Anxiety Control • Surgery is both Art and Science • Compassion/Kindness/Humanism/Attention to Detail are required to be an excellent surgeon • Patient safety and well-being are the ultimate goals --------------------------------------------------------------------------------------------------------------Principles of Surgery 1- Developing a surgical diagnosis • • Gather data and evaluate before deciding the procedure to be performed Evidence based therapy: Treatment is based on research and science, not just “good ideas” 2- Developing the Diagnosis Chief Complaint: A direct quote from the patient • • History of Present Illness: The story of the patient’s Chief Complaint (this is NOT the Past Medical History) Past Medical History (PMH): A summary of the patient’s medical status as 1

it relates to dental care: Includes Dangers, Rxs, Allergies, Need for Prophylaxis Physical Examination: • Pertinent Extra-Oral Findings • Pertinent Intra-Oral Findings Diagnostic Imaging: • PA’s, Panorex, CBCT Formulate a Differential Diagnosis: a list that defines potential diagnoses Determine the Final Diagnosis: This may include more than one problem i.e.: Acute Irreversible Pulpitis Acute Apical Periodontitis Grossly Carious Non- Restorable --------------------------------------------------------------------------------------------------------------Treatment Options Discuss possible treatment alternatives with the patient: RCT vs. Extraction RCT with Crown vs. Bridge (FPD) vs. Implant Review Financial Commitment by the Patient (cost) +++++++++++++++++++++++++++++++++++++++++++++ +++++++ Proposed Treatment • Determine an appropriate treatment option harmonizing the diagnosis with patient needs • Discuss and Obtain Informed Consent • Document the Consent Discussion and add the Signed Consent Form to the permanent record Accomplish Treatment • Obtain profound anesthesia, employing adjunctive measures to aid patient comfort and facilitate the procedure • Accomplish the procedure with attention to avoiding, not creating, complications • Instruct the patient for post operative care • Follow up check and treatment, as needed Principles of Surgery 1- Basic Necessities For Surgery 2

Qualified Assistant – A CRITICAL factor • • • • Good Visibility of the Surgical Site Access – Retraction and Protection of Soft Tissue Lighting – Adjustable Light or Headlight Clear Surgical Field – Suctioning of debris/blood/saliva/irrigation

2- Principles of Surgery (safety measures) • Aseptic technique – relative, minimize wound contamination by path. microbes • Sterile Instruments – Avoiding Cross Contamination • Operatory Disinfection • Barrier techniques • “Sharps” Protocol Protection of Patient and Staff ---------------------------------------3- Principles of Surgery-- Incisions-Basic Principles • • • • • • • Sharp blade of proper size (# 15) Firm, continuous stroke & LONG Avoid anatomic structures—Mental and IA Nerves Perpendicular to surface Place incision in proper location for closure and healing – over intact bony margins or attached Gingiva Bone + Ligament dull blade faster Buccal mucosa doesn’t dull the blade as fast -----------------------------------------4- Flap design • Will discuss in detail with surgical extraction techniques • Base broader than free margin to allow adequate blood inflow and outflow • Margin away from surgical site and located over sound bone BE KIND TO THE SOFT TISSUE !

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------------------------------5- Tissue handling • Gentle retraction • Careful suctioning • Avoid burns from drills –labial commissure • Tissue forceps – injury to patient or “crush artifact” for biopsy specimen 6- Hemostasis EXAM • Prevent excessive bleeding – flap design • • Preserve visibility to facilitate surgery Prevent hematoma – meticulous hemostasis prior to closure ◦ Hematoma is a greater source of bacterial infection • Prevent Necrosis ◦ ◦ ◦ ◦ • Base wider than apex, unless major artery is found Side should be parallel or …….. Length shouldn’t become more than 2 the base Base should be free of any grasped that might damage blood vessel

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Retard Wound breakdown and infection ◦ Pressure ◦ Packing ◦ Place Drain, if needed ◦ Closure – “watertight” closure usually NOT Indicated Obtaining Hemostasis: ◦ Assisting natural hemostatic mechanism ◦ Use heat to fuse ends of a cut vessel ◦ Suture ligation ◦ Place a vasoconstrictor substance

Hemostasis • Thoroughly Debride Granulation Tissue 4

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Control Bleeding from Socket, Bone Pressure Directly on wound or vessel – “Pack the Socket” Soft Tissue: ligation of vessel

Hemostasis • Burnishing of Bone – “crushing” of bone to occlude vessel • Cautery: Chemical, Electrocautery – Caution re: IAN • Infiltrate LA with vasoconstrictor • Hemostatic agents: clot “promoters” (collagen ‘plug’, HemCon®) Debridement: “the surgical excision of dead and devitalized tissue and removal of all foreign matter from a wound” ◦ Bone spicules/granulation tissue/tooth fragments ◦ Adequate irrigation Late infection is a quality of care measure “Antibiotics make a mediocre surgeon out of a really bad one.” - Larry Peterson --------------------------------------7- Control edema Edema: is accumulation of fluid in the interstitial space bc of transduction from damaged vessels and lymphatic obstruction by fibrin • Normal response to surgical trauma • Careful tissue handling • Pressure dressing • Elevation of head – Gravity Dependent • • • • Ice? May or may not help - gives the patient something to do Corticosteroids (must give before injury/surgery) NSAIDS Post-operative Mobilization !!! •

Infection Control/Asepsis (summary - important): • Patient Care and Regulatory issues • Protects patient as well as dentist, staff and other patients • Often cited violation by State Dental Board • Indication of Commitment to Patient Care/ Professionalism • Normal Orla flora contain: ◦ Aerobic G+ Cocci (Streph), actinomycte ◦ Anearobic (Canada) • Total Number of Oral Organisms is held in check by: ◦ Rapid epi. Turn over w/ desquamation 5

◦ IgA ◦ Dilution by saliva flow ◦ Competition btw oral organism for avalible nutrients and attachment sites Infection Control • Communicable Pathogenic Organisms • Aseptic Technique and Standard (Universal) Precautions • Instrument sterilization/disinfection • Operatory disinfection • Surgical staff preparation Staff Preparation: “Clean Technique” for Office Surgery • Non-sterile gown • Gloves – Change as often as needed • Mask • Hair, shoe covers as needed • • • Instruments are sterile when opened Used for most office based intra-oral procedures Cross-contamination is a major problem ◦ Emphasis must remain on avoiding touching of any contaminated item - mask, glasses, charts, chair, etc. ◦ !! EMPLOY BARRIER TECHNIQUES !!

Surgical Staff Preparation: Sterile Technique • Sterile Technique is practiced in OR even when operating intra-orally (Consistent Technique) • Necessary for uncontaminated wounds (extra-oral) such as skin biopsy, TMJ, Salivary gland surgery where no oral contamination is present • Sterile gloves, gown, drapes with strict adherence to touching only sterile objects (touch only what is blue) • Precise and formal surgical scrub, gloving, and gowning techniques End of Lecture 1 Peri-Operative Management Goals of Post-op Care • Minimize Discomfort and/ or the PERCEPTION of Discomfort • Regain pre-operative function • Return patient to normal activities of daily life • Avoid Infection • A General Rule Pt. should feel better after 3-4 days 6

Avoid infection Post-operative Instructions (POI) • Educate patients about anticipated/ expected post op events • Instruct patients how to care for themselves • Instruct patients how to avoid complications • Educate patients to recognize complications • • • • • Things that are normal.Not good, but normal. Soreness Swelling Chapped lips Bruising Minor Bleeding

Post Operative Bleeding • Minor bleeding is normal and expected ◦ “First part of the healing process” ◦ Gauze pressure should be placed directly over the surgical site ◦ Gauze pressure should be maintained for 30-60 minutes, prior to replacing gauze Bleeding must be well controlled before discharge from the office Gauze pressure must be placed directly on the surgical site, not the occlusal plane Do NOT change the gauze TOO often - acts like a dry sponge – pulls clot from socket, causes bleeding to continue Moistening the gauze pad may be of benefit Minor bleeding may occur after meals or brushing the teeth Mild oozing may occur for 24-36 hours post-op NO SPITTING ! NO STRAWS! NO SMOKING! – if the patient “must” smoke, then draw very lightly on the cigarette Minimize negative pressure intra-orally Avoid strenuous exercise for 12-24 hours post-op May have bleeding on pillow overnight “A little blood and a lot of saliva, looks like a lot of blood” Prolonged bleeding, bright red bleeding , and large (“liver”) clots may indicate the need for a return visit Initially, “liver “ clots may be wiped from the socket, the area rinsed, and gauze reapplied with biting pressure If needed, office evaluation should be accomplished on a after-hours basis 7

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Postoperative bleeding – causes • • • • Edema • • • • • Failure of POI - poor instructions, poor emphasis, poor compliance Poor quality tissue Suboptimal surgical technique Very rarely due to undiagnosed coagulopathy Edema is ALWAYS expected after surgery Degree is dependent upon the extent of surgery and quality of tissue Maximum edema at 48-72 hours post-op Gravity dependent

Ice packs may be used for 24-36 hours to limit swelling. MAY or MAY NOT HELP LIMIT EDEMA • 20 minutes on and 20 minutes off during waking hours • Dry cloth interposed between cold and skin –avoid “frostbite” • Allows patient to take an active role in their care • Edema is, in part, gravity dependent • Surgical site should be elevated above the heart • Resting in a recliner is a good position Limited inter-Incisal opening • Trismus – an inability to open the jaw due to inflammation associated with trauma or infection, a spasm of the muscles of mastication • Guarding – limited opening due to pain or anticipated pain • Post-op – patient may have both Trismus -Inflammation, trauma • • • Masseter, Temporalis insertion may be traumatized with removal of lower 3rds Medial Pterygoid may be traumatized during local anesthetic injections Masseter, Buccinator may be inflamed due to buccal hematoma secondary to PSA injection, removal of maxillary 3rd molar

Limited Inter-Incisal Opening • Warn, advise patients for potential decreased IIO • Early mobilization of the mandible retards muscle stiffness, increases IIO • Advance to a regular diet in the early post op period Ecchymosis 8

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“A… hemorrhagic spot… in the skin or mucous membrane forming a nonelevated, round or irregular, blue or purplish patch” “Blood in the subcutaneous tissue” A “bruise” May be quite extensive More likely in older patients with decreased tissue tone, intracellular attachments Red-heads > blonds > brunettes Fairly complexioned > darkly complexioned persons May be quite alarming to patients!! Reassure the patient. Reportedly does not increase pain or chance of infection Onset over 2-4 days post-op Purple → green/ brown → yellow Usually resolves at 7-10 days post-op

Control of Infection • Careful surgical technique is the most important consideration • Topical antimicrobials (chlorhexidine) may be of benefit • Antibiotics may be appropriate for selected individuals – i.e. depressed host-defense responses, extensive surgery, violation of anatomic spaces • For NON-surgical pt. use penicillin • For Surgical pt. use …….. Diet • • • • • • • • Pain, fear may discourage patients from eating “ The more you eat and drink, the better you will feel.” “Anything you want to eat or drink is fine” Soft, cool foods until “Novacaine” is gone: “Nothing scalding hot until the ‘Novacaine’ wears off” Best to avoid coarse foods – chips, popcorn, nuts High calorie diet > 2 liter fluid volume during 1st 24 hours Limit caffeine or any diuretics

Oral hygiene • Good hygiene promotes healing • Gently brush in routine fashion 3X / day • Avoid the areas of surgery • • Minor bleeding is to be expected –particularly after meals or brushing the teeth. Gentle chlorhexidine gluconate or saline rinses may promote healing

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Retainers • Orthodontic retainers, appliances should be used in routine fashion, beginning on the day of surgery • Place the retainer once the “novacaine” has worn off. Do NOT wait until edema precludes appliance placement. Post-operative contact • Patient should be instructed to call early in the day for post-op questions or concerns • Facilitates scheduling of post-op visits in the daily schedule • Patient should receive “emergency contact numbers” – i.e. cell phone, beeper, & home phone Considerations for Sinus Communications • Anatomy: teeth develop in proximity to the maxillary sinus • The surgical approach often determines the extent and size of the communication • Uncontrollable factors: size, depth , location – influence need for and extent of surgical closure • Tissue available for closure – may require extensive repositioning of soft tissue POI – Sinus Communications • Maintain equal pressure between sinus and mouth to avoid displacement of the clot !!! • Do NOT blow the nose! • Do NOT play a wind instrument ! • Do NOT use a straw! • Do NOT smoke! • • • • • • If a cough or a sneeze is unavoidable, open the mouth, turn the head toward the floor and direct The Healing of the sinus depend on: location and communication o the sneeze or cough toward the floor through your OPEN mouth! Gently rinse the surgical sites as directed Take all medications as prescribed. Prophylactic antibiotics such as amoxicillin or Augmentin® are commonly employed Use of a nasal decongestant drops, not spray, may be helpful (i.e. ½ % Neosynephrine). Check with your physician if you have high blood pressure. For one-sided communications, please rest or sleep with the involved side tilted up . This will promote drainage from the affected side. (ostium of the sinus is above the level of the floor) 10

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Some bleeding from the nose may occur. Blot the area. Do NOT blow the nose

Postoperative pain • Pain - “a sensation of discomfort, distress or agony resulting from the stimulation of specialized nerve endings” • Always anticipated postoperatively • Perception and psyche are significant influences • Should be addressed pre-operatively • “Sore, but not miserable” • “Pain medication will help” • Patient’s past experience and perception are very important !!! • • • • • • • Different philosophies: o “You’ll be fine with Tylenol” vs. “Everyone gets a prescription” “ What pain medication has worked well for you in the past?” NSAIDs coupled with a Class III or Class IV analgesic are a good combination for most patients Analgesic should be started BEFORE the local anesthetic effect has diminished – delayed onset of p o Rx Take with food – buffers against nausea, GI distress Excessive narcotic use may cause drowsiness Constipation occurs rarely

Class III analgesics • Hydrocodone compounds (Vicodin ®, Lortab®) • Codeine compounds (Tylenol #3®) • Dihydrocodeine compounds (Synalgos DC9®) Class II analgesics • Oxycodone compounds – limited use (Percocet®, Percodan®, Tylox®) • Other Class II analgesics - seldom, if ever , used (Demerol ®, Dilaudid®, morphine) End of Lecture 2 Armamentarium Scalpel • Handle: number 3 • Blades: #’s 15 (most common),11 (incision and drainage) ,12,10 (larger version of #15) 11

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Proper technique for loading/ unload ▪ Always use an instrument ▪ NEVER USE FINGERS! ◦ Cut with “belly” of blade perpendicular to epithelium (mucosa, skin) ◦ Firm, uniform cut – uniform pressure ◦ Cut to depth (usually through the periosteum to bone) in a single stroke ◦ Single patient use - Disposable ◦ Change as needed, if blade becomes dull ◦ Proper grip (pen grasp)

Periosteal Elevator • For elevating muco-periosteum from bone • #9 Molt • Pry/push and roll/scrape

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Retractors • Fingers are NOT routinely used unless palpating underlying structures Examples: Minnesota*, Mouth Mirror,Weider (tongue)* - see pictures

Hemostats NOT for Driving Needles • • • • Commonly used to clamp bleeding vessels (general surgery Curved, Straight Employed to debride follicle, granulation tissue, deliver fragments of teeth, alloy NOT for Handling delicate tissue or biopsy specimens – will create a “crush artifact” rendering the specimen unreadable

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1. Instruments for Grasping Tissue • Tissue forceps ◦ Russion – large, for teeth ◦ Adson: with and without teeth, for soft tissue ◦ Stillies – longer ◦ Allis- clamping – removing large pieces of tissue ◦ Cotton plier 2.Instruments for Removing Bone • Bur and handpiece ◦ High torque, no venting into wound = rear exhaust or electrical to ELIMINATE AIR EMPHYSEMA ◦ DO NOT USE A CONVENTIAONAL HIGH SPEED HANDPIECE !!! 14

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Nitrogen (90-100psi) or Electrical (Caution: Overheating) #8 round, #701, 703 fissure Erupted teeth - consider a 45 mm bur Impacted teeth - consider a 51 mm bur

# 701, 8, 703 Burs: 45 vs. 51 mm – see picture

2. Instruments for Removing Bone • Rongeur ◦ Combination of side and end cutting ◦ Works like a hedge shears or nail nipper • File or Rasp

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Dental Curette – “spoon” ◦ Small - Periapical curette to debride apical “cyst” 15

◦ Large – Remove follicle of impacted tooth ◦ Removes tissue from bony defect – double ended

3. Instruments for Suturing • Needle ◦ Various Sizes and Shapes ◦ Cutting, reverse cutting, taper Suture material ◦ Size (0 to 000000 or 0 to 6-0) common to OMFS ◦ Monofilament vs. braided ◦ Resorbable vs. Non-Resorbable Needle holder ◦ Proper grip: thumb and ring finger with palm down ◦ Scissors

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Dean Scissors -Commonly used for sutures and soft tissue 16

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Other ◦ Bite block ◦ Suction ◦ Irrigation Tonsil Suction ◦ Vacuums pharynx Surgical Suction ◦ Clears surgical field

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#8 Frazier Suction with Stylette – see picture

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4. Instruments for Extracting Teeth • • • Elevators ◦ “screwdriver or chisel” Forceps ◦ “pliers” Dental Elevators

Components ◦ Handle, shank and blade Most of our elevators use same handle and shank with variation of blade • Basic types – see pictures for these ◦ Straight-luxate teeth. ▪ Small straight-301, Large straight-34S

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◦ Triangle or pennant-shape – recover root from socket ▪ usually paired ▪ Broken root remnants ▪ Cryer (aka East/West) are most common

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◦ Potts Eleveators: ▪ Maxillary 3rd Molars ▪ Portion of impacted teeth ▪ Elevates and rolls

◦ Curved – “roll” teeth out of socket i.e. maxillary 3rd molar ▪ Maxillary 3rds molars ▪ Portions of impacted teeth ▪ Elevates and rolls ◦ Pick – small, straight elevator ▪ Remove roots ▪ Crane/Cogswell-heavy ▪ Root-tip pick-thin and delicate – Heidbrink or double ended ▪ * Hu-Friedy Heidbrink Root Tip Picks - Handle design improves leverage

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Extraction Forceps ◦ Provides a “HANDLE” on the tooth ◦ Improves the LEVER ARM ◦ Works in similar fashion to a VISE GRIPS® pliers ◦ Components: ▪ Handles • Hinge: English vs. American ◦ Horizontal=American ◦ Vertical=English (i.e. Ash) ▪ Beak: Greatest variation 23

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Adapts to the ROOT NOT CROWN

◦ Maxillary Forceps

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▪ Universal: - #150

▪ Site specific:

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Universal Molar (Note Offset or Bayonet Design)

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Right molar (53R, 88R)

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Premolar (150-A)

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Anterior (1-A)

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Left Molar (53L, 88L)

Several Pictures in this section.

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#88 Right and Left“Upper Cowhorns” Maxillary Anterior #1A

Proper hand position for maxillary forceps

Mandibular Forceps Universal: - #151 “A” Style beak Site specific: - Molar (17, 23) “ #23 also called [Cowhorn] - Premolar (151A) - Mandibular incisors, canines, premolars (Ash)

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Uncomplicated Exodontia Baisc • • • • • • • • • • Principles Clinical evaluation Presurgical assessment Radiographic evaluation Proper diagnosis/treatment plan - understand the indication for removing the tooth/teeth Informed consent Surgeon and patient preparation – Surgical assistant, instrumentation Proper pain and anxiety control- Excellent Local Anesthesia Access – Chair position, soft tissue retraction, lighting Extraction of tooth: closed or surgical Post-op care of patient

Indications for Removal of Teeth • Infection/ Acute Abscess – Possible difficulty with local anesthesia, refer for IV Sed or GA indicated, prior to attempting removal • Severe Caries • Pulpal Necrosis • Severe Periodontal Disease • Orthodontic Treatment Indications for Removal of Teeth • Malopposed Teeth, non-functional teeth • Non-Restorable/ Cracked Teeth • Pre-Prosthetic Extractions • Impacted Teeth • Supernumerary Teeth • Teeth Associated with Pathologic Lesions • Pre-Irradiation / Pre-Bisphosphonate Therapy • Teeth in the Line of Jaw Fractures • Aesthetics • Economics Relative Contraindications for Removal of Teeth -Systemic • Uncontrolled Metabolic Disease –IDDM, ESR Failure, Hyper-thyroidism • Malignancy –Leukemia, Lymphoma • Recent MI(b4 6 mo.), Unstable Angina, Uncontrolled HTN, CHF • Pregnancy • Immuno-compromise – HIV/AIDS, Chemo/Radiation Therapy, Steroids • Bleeding Diatheses- Hemophilia/ Factor Deficiency, Platelet Disorder- ITP, Anti-Coagualtion 30

Medications that compromise hemostasis or ability to heal – warfarin (Coumadin®), anti-resorbtive use (I.V. bisphosphonates, anti-resorbtive medications) Have them check their INR Relative Contraindications for Removal of Teeth - Local • Previous Head and Neck Irradiation → osteo-radio-necrois (ORN) • Previous Systemic (I.V.) Bisphosphonate (Anti-resorbtive) Therapy → ARONJ (formerly BRONJ) • Acute Pericoronitis → increased likelihood of infection of major fascial spaces ( manage pericoronitis with local care, usual resolution in several days, then extract) • Anatomic Considerations – IAN, Sinus, Compromise of adjacent teeth, Periodontal Defects • Potential for Pathologic Fracture • INFECTION / ACUTE ABSCESS IS NOT A CONTRAINDICATION TO EXTRACTION !!!!! • REFER FOR TREATMENT FOR SYSTEMIC SIGNS, SWELLING, TRISMUS Clinical Evaluation for Tooth Removal • Patient Attitude/ Ability to Cooperate • Access - MIO, Angle’s class, tongue size, “gag reflex” • Location and Position of the Tooth • Mobility – Periodontal Involvement, Patient Age, Resiliency of Bone • Condition of the Crown, Previous Endo Tx • Condition of the Adjacent Teeth/ Restorations • Condition of Bone - Lack of Resiliency, Tori Radiographic Evaluation for Tooth Removal • Proper Name/ Date (< 1 year old) • Proper exposure ◦ Angulation ◦ mas, kvp ◦ developed properly - traditional films ◦ enhancement of digital radiograph • Entire root visible • Relationship to vital structures ◦ Sinus ◦ IAN Radiographic Evaluation for Tooth Removal • Configuration of roots ◦ Length and morphology ◦ Previous endodontic therapy, internal resorbtion 31

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Condition of surrounding bone ◦ Density ◦ PDL ◦ Pathology CAN YOU “SEE” WHAT YOU NEED TO “SEE”?

Prior To Procedure • PMH Verified? Previous Medical Hx • Proper diagnosis/treatment plan - understand the indication for removing the tooth/teeth • Will the Proposed Procedure Obtain the Desired Result? • Will the Patient be Happy with the Result? • Informed consent: documented, signed, dated, witnessed Surgeon and Patient Preparation • Aseptic technique - relative • Personal protective equipment ◦ Mask, gloves, gown, glasses - OSHA Compliant • Safety glasses for patient per clinic recommendations • Personal hygiene ◦ Clothes, hair • Gauze “throat screen” Chair and Operator Position for Dental Extractions • Access and visibility –overhead light ◦ angulation and focal length • Stability ◦ feet apart, weight distributed on “balls” of feet • Controlled force • Mechanical advantage • Surgeon’s health ◦ chronic musculoskeletal strain (PROTECT YOUR BACK) • Patient comfort Chair and Patient Position: Standing Surgeon • Maxillary teeth ◦ Maxillary plane >60° to floor ◦ Maxillary arch level with surgeon’s elbow or below (elbow bent >90 °) ◦ Turn head so quadrant of extraction is easily visible ◦ Lateral protrusive position of the mandible- moves coronoid process laterally and away from the maxillary surgical site • Chair and Patient Position: Standing Surgeon 32

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Mandibular Teeth o Chair Upright so that when mouth is open, occlusal plane is parallel to floor, adjust headrest as needed o Bite block to support TMJ and Maintain IIO o Lower Chair ( Elbow at >120 ° ) o Turn Head so that quadrant of extraction is easily visible o Some prefer a “Behind the Patient” approach

Basic Principles • CONTROLLED FORCE • • • • • Mechanical Advantage, NOT Strength NEVER USE EXCESSIVE FORCE !!! RECOGNIZE WHEN YOU ARE NOT MAKING PROGRESS AND PROCEED TO A SURGICAL APPROACH Place finger/thumb on buccal plate to stabilize alveolus and evaluate degree of force transmitted and tooth/mobility DO NOT “PULL ” THE TOOTH – Intrude, Push, Rock, Rotate, “Draw”, and Deliver

Simple Machines: Basis of Extraction Techniques • Lever • Wedge • Wheel and Axle LEVER • Requires a FULCRUM • Lever-mechanism likely to break fragile elevators (root tip picks), teeth and/or bone • Straight Elevator • Cryer elevators, Potts elevators • Cogswell, Crane, and others • Forceps are actually paired, opposing levers WEDGE • • • • SAFER with MORE CONTROL of FORCE Straight elevators, root tip elevators Direct along the axis of the root, in the periodontal ligament space, between the tooth and the bone Surgical blade is a form of a wedge

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WHEEL AND AXLE • • Used to “SCOOP” tooth from socket May generate EXCESSIVE FORCE

Purpose of Elevators Primary: • Loosen teeth in preparation for extraction with forceps • • Create space for forceps May be primary mechanism for extraction, particularly for impacted teeth

Secondary • Remove parts of tooth or root

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Specific Elevators: Straight Elevators • Usually the initial instrument used during extraction • • • • • • Primary use is for initial expansion of alveolus and loosening of tooth/PDL (Lever and Wedge) Often used incorrectly- DO NOT FULCRUM FROM THE ADJACENT TOOTH FULCRUM ONLY FROM THE CRESTAL or INTERSEPTAL BONE When used between teeth and only one tooth is to be extracted, care must be used to avoid damage to adjacent tooth/restorations Use with working end pointed from facial toward the lingual or apically along the axis of the root NEVER USE IN “CROSS ARCH” FASHION—because the elevator can penetrate the cheek

Proper way to elevate • Elevator is used to force the tooth to expand the bone • Wedges the apical edge of the elevator against crestal,interseptal bone and “pushes” the tooth • Avoids force on adjacent tooth Straight Elevator • When used to “scoop” the tooth out, significant force is placed on the adjacent tooth. Don’t do this routinely! ACCEPTABLE TO USE THE ADJACENT TOOTH AS A FULCRUM ONLY WHEN THAT TOOTH IS ALSO TO BE REMOVED !!! --------------------------Cryer Elevators 35 •

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Lever, and/or wheel & axle forces Careful as will fracture tooth, bone – generates much force Primary use is for removing residual roots of multi-rooted teeth, especially retained mandibular molar roots Sharp tip removes inter-radicular bone providing access to the retained root (“two scoops”)

Root Tip Elevators • • • Appearance seems to indicate they would be good lever for “prying” out root tips. This will ruin the instrument. FRAGILE - Prying forces will bend or break these instruments

Sole use is as wedge. Push fine tip apically to wedge root tip from socket or wedge tip into PDL to displace root Wedging out a root tip with a straight elevator: 1- Finger rest to control apical force 2- Insert elevator within PDL 3- Avoid pressure that will displace the root into the sinum FORCEPS • Paired, opposing LEVERS • CLASS II LEVER: The load (tooth) is situated between the fulcrum (apical bone) and the force (operator) • Primary force is initially in an apical direction to seat the forceps – MOVES FULCRUM TO APEX OF THE TOOTH o Usethe root of the tooth to expand the alveolus o If you keep closing the forceps you can fracture the crown • Not for “pulling teeth”- use the forceps as a handle and lever – comparable to a “Vise Grips ®” • Secondary force is buccal, lingual, and rotational to EXPAND THE ALVEOLUS and release the tooth • Lastly, minimal tractioning force – “DRAW” = DELIVER the tooth” • Forceps movement produces significant wedging forces • The tooth is used as a wedge to expand the alveolar bone o Use in lingual/buccal apical direction • Initial and greatest magnitude of force of apical. Secondary force is B/L. Expansion of the alveolar bone is the goal. Non-Surgical Extraction No such thing as a “simple extraction” Closed or Non-surgical is proper description What makes it easy (or difficult) is the skill of the surgeon (or lack thereof) 36

Step by Step Approach to Non-Surgical (Closed) Extraction: • • • • • • • • • Confirm profound anesthesia of soft, hard tissues, and pulp Release soft tissue around tooth- Be Kind to the Soft Tissue Elevate tooth with the elevator Adapt forceps to the tooth: Luxate with forceps to expand the alveolar bone. o Luxate: To throw out of place or out of join Remove the tooth from the socket Confirm that roots have been delivered in their entirety : Confirm normal root anatomy, Check for cleavage planes and accessory roots: look for pdl fuz Examine socket and debride soft tissue, debris, granulation tissue-curette Compress socket (realign the labial cortical plate) • u don’t want it narrow bc it iwill be diffic. For implant or ortho treatment • If you have undercut compress it a little Place 2x2 gauze directly over socket and compress with occlusal force

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Make sure you have good anesthesia, and Articane Shouldn’t be used for mandibular Block Loosening of Soft Tissue Attachment • Sharp end of periosteal elevator (convex side toward periosteum): #9 Molt, curette, Woodson –reflect to the crest • Also confirms soft tissue anesthesia • Allows forceps to be seated apically or elevator to be placed interproximally • BE KIND TO THE SOFT TISSUE Luxation of the Tooth with Dental Elevator • A straight elevator is commonly the first instrument employed • Perpendicular to interproximal space or parallel to the long axis of the tooth. DO NOT USE THE ADJACENT TOOTH AS A FULCRUM. • Luxate tooth • Tear, Disrupt PDL- bleeding into PDL ↑ hydraulic pressure facilitating expansion of the alveolus • Expands the bone • Avoid injury to adjacent teeth –crowns, interproximal restorations • Confirms degree of mobility or establishes need for surgical extraction • If successful you can use forceps if not you go surgically • Never use Exccessive force or sth BAD is gonna happen • Fulcrum up the crest bone

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Adaptation of the Forceps to the Tooth • Choose forceps that has beaks that will adapt well to subgingival morphology of tooth - engage intact cementumn • Confirm long axis of beaks “clears” adjacent teeth to avoid trauma. Generally this requires the beaks to be parallel to the long axis of the tooth • We want to shorten the length of th root by placing the forceps more apically on the tooth • Seat with apical force (lingual/palatal before buccal) • Avoid pinching soft tissue – place lingual or palatal beak first • Firm apical force • Moves fulcrum to apex • Moves center of rotation apically to retard root fracture • Expands alveolus and widens PDL space • If crown: Root ration is big • It is BAD for perio • It is Good for extraction • It is easier to see lingual/palatal Luxation of the Tooth with the Forceps • Firm grip to hold forceps handles together in a stable position. Do NOT continuously “squeeze” the handles together as this will fracture the crown (exception is the mandibular #23 forceps = “cowhorns”) • • • • • • • • • • Straight wrist with controlled force generated from shoulder and upper arm, not wrist Firm, steady, sustained force – hold, flex the bone to allow expansion of the alveolus Initial force displaces the tooth apically Lateral force is then applied buccally and then with less lingual/palatal force Rotate the tooth gently after initial mobilization JUST LIKE “WIGGLING” A FENCE POST OUT OF THE GROUND –often compared to a “figure of 8” motion Continue to re-seat the forceps apically as tooth mobilizes DO NOT FRACTURE THE CROWN It is hard mechanically to use forces. But…… Pt. Postion + good mechanis = good extraction

***Opposite hand stabilizes alveolus and palpates for alveolar fracture or movement of adjacent teeth. It protects adjacent tissue and prevents slipping that could harm the patient.*** Removal of the Tooth from the Socket • Slight traction, usually buccal is usually the final step to removal of a tooth 38

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Not a “pulling” motion Traction = “DRAWING” motion Draw: to cause (an unwanted element) to depart (as from the body or a lesion)

Post-Extraction Care of the Socket • Remove Debris, if present ◦ PA Lesion – small curette ◦ Calculus, Amalgam ◦ Tooth Fragments • Realign Buccal Plate – “gently compress socket” • Restore Pre-Extraction Anatomy • Do NOT collapse the B-L dimension of the alveolus, except for preprosthetic purposes • • • • • Debride Granulation Tissue from Gingival Sulcus Smooth any Sharp Bone Irrigate as needed Control hemorrhage Pressure with moist 2x2 gauze placed over the extraction space Specific Forceps and Their Use: Technique for Extracting Specific Teeth Universal Maxillary and Mandibular Forceps:150 and 151 and Variations • • • • • • • Seat beaks with firm and deliberate apical pressure Moves center of rotation apically to decrease root fracture Secures purchase on non-carious/sound tooth Further wedging force augments that already accomplished by elevator Buccal-lingual force (primarily buccal) and rotation (single rooted teeth) Figure-8 motion works well with multi-rooted teeth Luxate as in removing a fence post

Maxillary Molar Forceps:53 and 88 39

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Off-set beaks may allow better access along vertical axis of the tooth Less chance of damage to adjacent teeth Beaks are designed to engage root morphology and improve apical purchase Use with “figure-8” movement DO NOT use TOO much FORCE DO NOT FRACTURE TUBEROSITY or BUCCAL PLATE Low threshold for surgical extraction if only limited or no movement !!!

Mandibular Molar Forceps:Cowhorn #23 • Designed to engage the furcation of lower molar • No crown required to engage the tooth – may be better than Universal forceps for “broken down” mandibular molar teeth • Must seat into furcation with “pumping” up and down action BEFORE any buccal-lingual rotation • OK to squeeze the handles together, but anticipate a crown fracture or rapid delivery of the tooth • Works best for parallel = non-divergent roots • • • Seat on lingual first taking care not to injure soft tissue Up and down motion with gentle pressure closing beaks together squeezing handles together Once seated, use “water-pump handle”, buccal-lingual motion, &/ or figure8 motion

Primary Teeth • If roots are not resorbed, long, divergent and fragile roots complicate exodontia. • Likely to fail due to differential resorbtion caused by erupting permanent teeth – especially premolars. • Bone is more flexible. • Care not to damage succedaneous tooth. Post-Extraction Care of the Socket • Remove obvious PA pathology or socket debris. • • • Remove soft tissue pathology/granulation tissue Realign Buccal Cortical Plate (“Compress Socket”) to restore preextraction anatomy. Moist gauze for pressure hemostasis.

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Complicated Exodontia Complicated Exodontia Surgical Extraction : • Delivery of the tooth requiring construction and elevation of a mucoperiosteal flap, removal of supporting/ impeding bone, and/ or delivery of the tooth in multiple pieces

MATHEMATICS OF EXTRACTION ↑ FORCE + ↓ SURGERY =  (↑ SURGERY + ↓ $ ) ↑ SURGERY + ↓ FORCE = Complicated Exodontia • • • • Flap design, construction, and elevation Removal of supporting/ impeding bone Sectioning (Dividing ) the tooth into smaller segments Multiple extractions  + ↑ $

CONCEPTS : NON-SURGICAL EXTRACTION • • • NON- SURGICAL = UNCOMPLICATED EXTRACTION: Removal of a “fence post” Push and wiggle side to side to expand the “dirt” and allow the post to be “drawn” and removed

Concepts: Surgical Extraction • Goal: Expedite delivery of all tooth structure while maintaining necessary alveolar contour • Create a “path of withdrawal” for the entire tooth or each individual segment of the tooth • Consider the shape/ contour of the remaining alveolar bone – different goals for implant, removable prosthesis, no prosthesis Conditions Leading to Need for Surgical Extraction • Avoid Excessive Force !!! - fractures • Dense bone 41

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Exostoses, tori Root morphology ◦ Multi-rooted teeth ◦ Dilacerations ◦ Internal resorbtion Age: Dense Bone vs. Ankylosis vs. Atrophic Periodontal Ligament ? Body Build/ Genetic considerations- Race Bruxism Previous Endodontic therapy Deep Caries Adjacent Anatomic Structures: Sinus, IAN proximity Compromised adjacent teeth – crown, recurrent caries Multiple extractions Impactions

CONCEPTS • SURGICAL EXTRACTION: ◦ Removal of a “rock” from the lawn ◦ “Push back the sod” = expose the tooth by constructing and elevating a full thickness muco-periosteal flap

CONCEPTS • Options: ◦ Remove a lot of “dirt” to remove the whole “rock”, • Or ◦ Divide the “rock” into many smaller pieces, • Or ◦ Remove some “dirt” and divide the “rock” into a few large pieces. • • • The initial plan for the approach to the tooth may be an uncomplicated or closed extraction. As the tooth is manipulated and more information as gained, the approach may progress to a surgical approach. The approach to, and delivery of, the tooth is a dynamic process.

Flap Design: Development and Management • • • Design parameters Types of muco-periosteal flaps Technique for developing a muco- periosteal flap 42

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Design Parameters BLOOD SUPPLY: Flap base MUST be broader than free margin ◦ Allows inflow of arterial blood and outflow of venous blood. Lack of adequate outflow leads to venous congestion and death of the tissue. Nice picture slide #17 Adequate size: ◦ “Big Flap = Big Surgeon” ◦ “See what you are doing” Full thickness- Do NOT tear the flap ◦ BE KIND TO THE SOFT TISSUE

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Design Parameters • • • Incision over intact bone Avoid injury to vital structures – LINGUAL, MENTAL nerves Releasing Incision, if needed, to avoid tearing

Adequate Size: “DON’T work in a hole” Visualization: “If you can’t see it well, you can’t do it well”. Patient Position Lighting Suctioning Adequate Exposure of Surgical Site • • • • Elevation of flap margins over intact bone Proper Instrumentation – Retractors to displace and protect the soft tissue Prevent tearing (sharp incision heals better than a tear) If releasing incision required, extend at least one tooth anterior or/and one tooth posterior – flap margin must rest on sound bone

Common Flap Designs • Sulcular Incision – ◦ Envelope Flap – No Vertical (Oblique) Releasing Incision ◦ Envelope Flap with Releasing Incision ▪ Posterior ( Distal ) Oblique Release May be Preferable Cosmetically ▪ Release Tissue “around the corner” of the canine eminence Anterior Vertical (Oblique) Release Incision • • May Compromise Anterior Aesthetics – try to avoid creating flaps around anterior crowns which may expose the finish line and compromise aesthetics Probably Easier to design and “work under” an anterior release 43

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“Around the Corner”- Canine Eminence

Vertical (Oblique) Release Incision • Base is broader than free margin = “loose edge” of the flap • Cross gingival margin at the line angle of the tooth (May include tissue of embrasure to facilitate suturing) • Incision over intact bone, but not on an osseous prominence such as the Canine Eminence – “tiger trap” Types of Muco-periosteal Flaps • Envelope ◦ Sulcular incision in dentate patient ◦ Crestal incision in edentulous area • Three cornered flap ◦ Single vertical (oblique) release – Posterior (distal) or Anterior (mesial) release • Four cornered flap ◦ Anterior and posterior releasing incisions • Semi-lunar flap ◦ apical to attached gingivae ◦ periapical access – retrograde endo Y- flap ◦ Palatal access for removal of tori Pedicled flap ◦ allows repositioning of tissue with its own blood supply ◦ closure of oral-antral communication

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Developing the Flap • Sub-peri-osteal injection of LA - hydraulic force facilitates reflecting the periosteum from the bone • Incision ◦ Firmly, with scalpel blade contacting bone ◦ Blade perpendicular to bone and soft tissue ◦ A “single stroke” – not multiple “cuts” Developing the Flap • • Reflection – “lift” the periosteum and flap from the bone Comparable to lifting up carpet or sod ◦ Sharp end of periosteal elevator between periosteum and bone ◦ Elevate along a broad front Retraction – protect the soft tissue 44

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Surgical Extraction of Single Rooted Tooth • Reflect the Flap • Determine Extent of bone removal, if any • Remove Bone – Bur and COPIOUS IRRIGATION • Apical purchase of forceps on cementum • Irrigate well under depth of flap – NO retained debris • Elevate Flap and Gain Better Access Without Removing Bone “Deliver, Debride, Suture” Surgical Extraction of Multi- Rooted Tooth • “Divide and Conquer” Strategy • Identify furcation – remove bone, if needed • Fissure bur (703,701) to “section” = divide tooth through pulpal floor into furcation • Avoid violation of maxillary sinus floor • “Split” tooth: divide root from root with straight elevator • Converts multi-rooted tooth into several single rooted pieces • Elevate or luxate and deliver root segments Some options for divide and conquer: • Molar → 2 “Premolars” • Molar → Single rooted crown + root • Molar Roots→ 2 Roots • Max Molar→ 3 Roots Fractured Roots • Some roots will fracture due to unfavorable curvature, or brittle nature • Thorough mobilization of the root prior to fracture facilitates delivery • Remove bone to create space into which the root can be elevated • Gently engage elevator into PDL space Root Tip Elevators (Pick) • Fragile elevators • Appearance seems to indicate they would be good lever for “prying” out root tips • Easily damaged: use to wedge root tip from the socket • Prying forces will bend or break these instruments! • Only use is as a wedge. Push fine tip apically to wedge root tip from socket or wedge tip into PDL and “draw” in a vertical vector to displace root tip or displace into created space Root Tips:Tease or wiggle !!!Do NOT force apically !!!May displace root into sinus 45

Remove Bone • Use bur to remove buccal or inter- radicular bone • Create a space into which the root can be elevated or expose adequate tooth structure to engage with the forceps Carefully Elevate the Root Tip! • Gently elevate the root • If not mobilized, remove more bone • NEVER use excessive force !!! • May displace the root into sinus, submand space, FOM, or through the buccal plate Apical Window • Buccal bone overlying the apex is removed – a “window” is created • Crestal, buccal bone is preserved • Root tip is elevated from apical area through window or into socket • Do NOT violate sinus or IAN Leaving Root Tips ? Indications: • Small piece- <4mm • Deeply embedded in bone • Adjacent to anatomic structures – IAN, Sinus, Submandibular/ Sublingual space • Absence of pulpal or periapical pathology • Root MUST BE IMMOBILE • Risk of removal greater than that of retaining • Will attempting to recover root make things better or worse? ◦ Destroy bone ◦ Encroach, damage vital structures ◦ Risk of displacement into sinus, submandibular/ sublingual space • • SHOULD I HAVE ATTEMPTED TO TAKE THIS TOOTH OUT IN THE FIRST PLACE ? WHAT DID I LEARN FROM THE EXPERIENCE ? ◦ Should I have done more surgery or used less force?

Leaving Root Tips? • • • • Radiograph to confirm root presence Inform and counsel patient Document in chart Refer as indicated 46

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Evaluate at recall appointments Multiple Extractions Treatment planning Sequencing Technique

Multiple Extractions: Treatment Planning – Replacing the Tooth you just pulled. • Replacement: Implant vs. Bridge ◦ Implant: Maintain maximum volume of bone ◦ Bridge: Favorable contours for pontic • Pre-prosthetic surgery: RPD vs. CD ◦ Smooth alveolar contour • No prosthesis: May concentrate on delivering tooth expeditiously Multiple Extractions: Sequencing • Maxillary first theory ◦ Anesthesia obtained first and of shorter duration ◦ Debris does not fall into lower ext sites • Mandibular first theory ◦ Blood from maxilla does not obscure surgical field ◦ Harder teeth first- surgeon is not fatigued Multiple Extractions: Sequencing • Usually from posterior to anterior • Recover all roots from one tooth before proceeding to the next tooth !!!! • Dense bone over 1st molar and cuspid ◦ May elect to mobilize 1st molar and cuspid initially (loosen), extract adjacent teeth, then extract 1st molar and cuspid ◦ Hydraulic forces from sheared PDL may expand alveolus (?) Treatment Plan: Implant ? • Preserve Bone height and width • If surgical approach, attempt to maintain • a “4-walled bony defect” to allow osseous fill • Consider grafting = “socket preservation”, if applicable Treatment Planning: RPD or CD? • Maintain bone over canine eminences • Maintain buccal plate contour • Smooth osseous prominences • A “take away” process. “Is this as smooth as I can make it ?”, “ Will 47

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removing more bone make things worse ?” Palpate the alveolar contour through the soft tissue

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