Basic Considerations of Oral Surgery

YUN PIL-YOUNG Oral & Maxillofacial Surgery, Section of Dentistry, SNUBH


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Table of Contents
1. Incision 2. Suture 3. Extraction 4. Medication 5. Special Considerations

Incision

Incision

Incision

Incision

Incision

Incision

Suture Materials
Nonabsorbable Vs. Absorbable

Suture material
Because silk is a multifilament material that wicks, it is not the material of choice when any sterile materials are used (eg, implants, bone grafts, guided tissue regeneration) or in the presence of infection. (Silverstein and Kurtzman, 2005)

Suture Needles

Suture Needles

Suturing Instruments

Goals
1. Provide an adequate tension of wound closure without dead space 2. Permit primary-intention healing 3. Maintain hemostasis 4. Reduce postoperative pain 5. Prevent bone exposure resulting in delayed healing and unnecessary resorption 6. Permit proper flap position

Principles of Suture
1. 2. 3. 4. 5. 6. Needle is grasped in the center Enter at 90 to the tissue Through the more mobile tissue first No closer 2.0-3.0mm from the margin Tension free Do not tie on the incision line

Principles of Suture

Periosteal Suturing

Simple loop modification of interrupted suture technique

Simple loop modification of interrupted suture technique

Facial and lingual flap elevated, most commonly used From facial epithelial surface Through the lingual flap the inner surface Cut the suture material 2.0-3.0mm from the knot Do not allow resistance of tension from muscle pull

Figure 8 modification of interrupted suture technique

Figure 8 modification of interrupted suture technique

Utilized in very restricted arealingual 2nd molar Interposes suture material, primary closure of the flap edges

Continuous suture

Continuous suture

Used to secure flaps over several centimeters long.

Utilized to reposition surgical flaps apically or coronally

Continuous locking suture

Continuous locking suture

Started outer of buccal through the lingual inner surface, followed by a suture knot tied at the most distal end Terminated at the mesial end by providing some slack in the last loop

Continuous horizontal mattress suture

Continuous horizontal mattress suture

Suture tied distal end first Distance buccal or lingual 5mm at least Good for the tension area by the muscle pull

Vertical Mattress suture

Vertical Mattress suture

Adapt the tissue to the tooth/Implant , while concomitantly everting the flap edges. This suture will resist tension in the flaps produced by various muscle attachments

Coronally repositioned mattress suture

Coronally repositioned mattress suture

Apically repositioned vertical mattress suture Reverse vertical mattress suture

Horizontal mattress suture

Horizontal mattress suture

All needle penetrations are at least 5.0mm lateral (mesial or distal ) to either tooth / Implant

Vertical sling mattress suture

Sling sutures

Flap raised only one side Anchored about the adjacent tooth or slung around the tooth to the hold both papilla

Single interrupted sling suture

Continuous independent sling suture

Continuous independent sling suture

Multiple papilla on only one side reflected This technique to adapt the buccal flap to lingual flap without the other side.

Cross Suture

Particularly helpful in mucogingival surgery where root coverage is desired Socket preservation

Summary

Interrupted suture -interproximal, not tension Figure eight suture -lingual mandible Sling suture -only one side Horizontal mattress suture -ant Mn, muscle pull Vertical mattress suture (CLP, Papilla up) muscle pull, apically coronally reposition Continuous independent sling suture -bone augmentation, fibrous ridge reduction Continuous locking suture -edentulous, tension

Knotting

To join the two end Different suture need different type of knot Knot security is critical, synthetic multifilament or braided sutures Square knot, Slip knot, surgeons knot

Square knot

Two overhand knots Opposite direction Easy to tie, but may loosen when a synthetic or monofilament suture material is used

Slip knot (Granny knot)

Both overhand knots made in same direction When 2nd overhand knot tied, the knot can be tightened even further & locked into place with one additional overhand knot going to in an apposite direction

Surgeons knot

Most commonly used in Implant Modified square knot the 1st knot is a double overhand knot, the 2nd is a single

Suture removal

The longer suture material remains, the more scarring S/O : 10 days later Cut as close to the tissue as possible to avoid dragging a dirty suture through the wound

Simple Extraction

Incision: Mn.

rd 3

Molar

Incision: Mx. 3rd Molar

Vertical Impaction

Mesial Impaction

Horizonal Impaction

Problematic Case

Various Techniques
Buccal advancement flap Palatal flap Sliding Bridge flap

A clinical study on oroantral fistula; J CranioMaxillofacial Surg(1998) 26, p267-271

Buccal Fat Pad Flap

Closure of Oroantral Communications Using a Pedicled Fat Pad Graft; J Oral Maxillofac Surg(1995) 53; p771-775

Anatomy: Buccal Fat Pad

Healing Process of PBFP

POD#1

POD#2

POD#3

POD#4

POD#5

Case 1

Case 2

Palatal Rotaional Flap

Bleeding
Pain Anxiety Blood Pressure

Bleeding

Screening of Bleeding

Blood Test
1. PT Sensitive in factor II, V, VII, IX (Extrinsic) * Insensitive in fibrinogen, heparin ; Warfarin therapy monitor 2. aPTT Plasma+Activator+Phospholipid=Clot (Intrinsic) * Insensitive in factor XIII, VII 3. BT Test of platelet, not coagulation factor ; Aspirin

Antibiotics
Guidelines of Antibiotics Bacteriocidal > Bacteriostatic Narrow spectrum > Broad spectrum Combination Oral Microbes Gram (+) or Gram (-) Aerobe or Anaerobe

Infective Endocarditis
1. 2. 3. 4. 5. 6. 7. Congenital Heart Disease Rheumatoid Heart Disease Rheumatic Fever Artificial Heart Valve Transvenous Pacemaker Calcified Aortic Stenosis Ventriculoatrial Shunt

Risky Groups
1. Uncontrolled Diabetes Mellitus 2. Chronic Pyelonephritis 3. Chronic Heart Disease 4. Hematologic Disorder 5. Use in Patient receiving Corticosteroid, Antineoplastic or Immunosuppressive Therapies

Prophylactic Antibiotics

If you can take oral medications and are not allergic to penicillin, 2 grams of Amoxicillin, Cephalexin, or Cephradine should be taken one hour before the procedure. If you cannot take oral medications and are not allergic to penicillin, 2 grams of Ampicillin or 1 gram of Cefazolin should be administered by injection one hour before the procedure. If you are allergic to penicillin, 600 milligrams of Clindamycin should be taken orally or administered by injection one hour before the procedure.

Pregnancy
Indication: Lidocaine, Penicillin, Erythromycin, Acetaminophen Contraindication: Aspirin, Epinephrine, Benzodiagepine, Narcotic analgesics, Nitrous oxide, Tetracycline
FDA Classification: Category A, B

Importance of Planning

Importance of Planning
1. Multiple tooth extraction
- Alveoloplasty

2. Torus Removal
- Implant, Bone graft

3. Frenectomy
- Phonetic improvement

4. Supernumerary tooth

Edentulous Patient

Differential Diagnosis

Differential Diagnosis

Dentigerous Cyst

Odontogenic Tumor

Malignant Tumor