INBDE Bootcamp High-Yield Oral Surgery

INBDE Bootcamp High-Yield Oral Surgery Impacted teeth Congenitally missing teeth Most commonly affected: 1. Mandibular third molars 2. Maxillary third molars 3. Maxillary canines Most commonly affected: 1. Maxillary and mandibular third molars 2. Mandibular second premolars 3. Maxillary lateral incisors Extractions Indications Contraindications ● Severe caries ● Endodontic ○ Internal root resorption ● Periodontal ○ Severe attachment loss ● Orthodontic ○ Severe crowding ● Cracked teeth ● Ankylosed teeth, complicated impactions, or supernumerary teeth ● Poorly controlled medical conditions ○ Diabetes, end-stage renal disease, angina, bleeding disorder, etc. ● Immunocompromised or immunosuppressed ○ Leukemia, lymphoma, high doses of steroids ● History of head & neck radiation ○ Increased risk of osteoradionecrosis ● History of bisphosphonates ○ Increased risk of medication-related osteonecrosis of the jaw (MRONJ) ○ Not an absolute contraindication, dependent on type & duration of bisphosphonates ○ Surgical procedures should be conservative Extraction procedure Basic steps 1. Sever soft tissue attachment with periosteal elevator 2. Luxate tooth to expand socket 3. Deliver tooth with forceps 4. Curette socket, smooth bone, irrigate Forceps ● Seat as apically as possible, place along lingual surface, then buccal ● Deep into sulcus, along long axis of the tooth ● Toward the center of resistance ● Most initial movements are buccal, then lingual (due to thinner buccal plate) ● Rotary movement for single-rooted teeth ● Apical pressure to expand socket Surgical extractions ● Consider for long or divergent roots, endo-treated, crown fracture, retained roots ● Often requires full-thickness flap (buccal flap to avoid lingual nerve damage) ● Removal of buccal bone to create trough ● Removal of interradicular or cortical bone ● Sectioning of tooth Third molars ● Extraction will eliminate periodontal problems, alleviate pain, allow cleaning of second molars ● Maxillary third molars should be delivered distobuccally Primary closure ● Physical closure of a wound at the end of surgery ● Not necessary in non-surgical extractions, as it damages mucosal tissue Secondary closure ● Wound left open at the end of surgery ● Will heal via granulation, contraction Post-op instructions ● Gauze pressure ● Soft diet ● No negative pressure ● No smoking ● Salt water rinse after 24 hours INBDE Bootcamp High-Yield Oral Surgery Extractions Complications 1. Subperiosteal abscess ● Infection under the periosteum due to trapped necrotic bone or tooth ● Treatment: irrigate to remove bone or tooth 4. Nerve injury ● Common with extraction of mandibular third molars, IAN block ● Refer to OMFS if they do not have normal sensation after one month 2. Oro-antral communication (sinus exposure) ● Common with maxillary first molars ● <2 mm: monitor, suture ● 2-6 mm: antibiotic, antihistamine, analgesic, nasal spray, suture ● >6 mm: flap surgery to close 5. Tooth displacement ● Maxillary sinus: maxillary first and second molars ● Infratemporal fossa: maxillary third molars ● Submandibular space: mandibular third molars 3. Alveolar osteitis ● “Dry socket”, dislodged blood clot, extremely painful ● Multifactorial: associated with oral contraceptive use, smoking, and using straws ● Treatment: anesthetize, irrigate, dry socket paste with eugenol, pain control 6. Bleeding ● Risk increases for patients on blood thinners or with bleeding disorders ● Treatment: gauze pressure, sutures, hemostatic agents (gelfoam, topical thrombin) Flap design Flap considerations ● Wide base, incision over intact bone, vertical releases at line angles ● Avoid vital structures such as arteries, nerves, and thin tissue 0 vertical releases 2 vertical releases 1 vertical release For apicoectomy of maxillary anterior teeth Down the midline of the palate for torus removal INBDE Bootcamp High-Yield Oral Surgery Grafting ● Performed after some extractions to preserve ridge ● Performed independently to restore bony defects or gain ridge thickness Osteoconductive Osteoinductive Osteogenic Provides scaffold for new bone Presence of signals to encourage tissue growth Capable of growing tissue Autograft: same individual + + + Allograft: same species + +/- - Alloplastic: synthetic or natural materials, not from living source + - - Xenograft: other species (bovine, porcine) + - - Type and source Implants ● Most commonly used implant is endosteal Implant components Implant body ● Inserted into osteotomy ● Made of titanium, highly biocompatible ● Various diameters and lengths Cover screw ● Soft tissue is closed over screw ● Second stage surgery needed to uncover screw after healing Healing abutment ● Used in single stage implant placement, emerges from the soft tissue ● Contours tissue for restoration Impression coping ● Inserted into implant body when taking conventional impression ● Coping is different based on closed tray or open tray technique Scan body ● Used when taking digital impression for implant crown Implant analogue ● Used by lab when pouring cast to replicate position where implant has been placed Abutment and screw ● Can be custom or stock, 1 piece or 2 pieces ● Connects the implant body to the restoration Implant crown ● Cement-retained: good for esthetic zones because no screw hole ● Screw-retained: presence of access hole, easier to remove Indications and contraindications Indications ● Replace missing tooth Contraindications ● Inadequate vertical or horizontal bone thickness ● Uncontrolled medical conditions or immunocompromised ● History of head & neck radiation or bisphosphonate use ● Bruxism ● Children and adolescents Forces exerted on implants Measurements for placement 1 mm: from buccal/lingual plate, inferior border of mandible, maxillary sinus, nasal cavity 1.5 mm: from adjacent natural teeth 2 mm: from IAN 3 mm: from adjacent implants 5 mm: from mental nerve Common width of implant: 4 mm INBDE Bootcamp High-Yield Oral Surgery Implants Stability Bone quality Primary stability: biomechanical stability of the implant when it is first placed Secondary stability: osseointegration of the implant into the bone, long-term healing ● Osseointegration describes a direct histologic connection between the bone and implant Ordered most dense to least dense: ● Type I: anterior mandible (best primary stability) ● Type II: posterior mandible (best osseointegration) ● Type III: anterior maxilla ● Type IV: posterior maxilla (worst prognosis for implants) Trauma & surgery Traumatic injuries Midface fractures Le Fort I: - Horizontal across maxilla - Only maxillary bone involved Orthognathic surgery Le Fort I osteotomy: - For retrusive maxilla, vertical maxillary excess - Le Fort I fracture created to move upper jaw forward or upward Bisagittal split osteotomy (BSSO): - For retrusive or protrusive mandible - Splitting of the mandible to set it back or bring it forward - Most common complication is nerve damage (IAN) Distraction osteogenesis: - Appliance provides gradual traction that allows for bone deposition - Osteotomy phase → latency phase → distraction phase Le Fort II: - Pyramidal across midface - Involves orbits and nasal bones Le Fort III: - Complete craniofacial disjunction - Involves zygomatic arch Mandibular fractures From most common to least common: condyle > angle > symphysis Simple: Compound: Greenstick: Comminuted: Closed to the oral cavity Open to the oral cavity (breaks skin) Partial thickness fracture Fractured in multiple pieces