Complicated Exodontia and Flap + Wound Closure Flashcards
What are the indications for a mucoperiosteal flap?
Utilize flap whenever there is the slightest indication that it might be helpful
What are the principles of flap design?
- Broad base
- Large enough to provide both visual and instrument accessmore to the amount of bone removed
- Repositioned and sutured over solid bone
- Avoids major anatomical structures (nerve and blood vessels)
- Full thickness (skin + subcutaneous tissue/connective tissue + periosteum)
Whatdoes a flap need a broad base?
to assure adequate blood supply
Why does the flap need to be large?
- Large flap heals as rapidly as a small flap
- Flap does not heal from end-to-end by side-to-side
- Post surgical pain does not correlate with size of the flap but more to the amount of bone removed
What are the two common flap designs?
- envelope flap
- flaps with vertical releasing incision
What is an envelope flap?
1 tooth distal and 2 teeth mesial
What is a flap with vertical releasing incision?
- 1 tooth distal and 1 tooth mesial
— Includes papilla - Vertical release incision must be originating from either
— Mesial or distal line angle
What are the contraindications for placement of vertical release incision lines?
- Canine Prominence
- Mental Foramen
- Palate
- Incisive Papillae
- Bony lesion
- Major Frena
- Lingual side of mandibular arch
Never Ever place vertical incision on __________ side of the mandibular arch
lingual
When repositioned, a flap needs to be over an adequate margin of solid…
bone
Margin of flap should be at least ___mm from the margins of a bony defect
5
An incision can be made from tip of one coronoid process down the anterior border of the ramus and along the crest of the alveolus to the tip of the coronoid process on the opposite without cutting any major structures except…
buccinators artery and long buccal nerve
Why is the lingual region of 3rd molar area hazardous for a mandibular flap?
- Lingual nerve damage
- Permanent anesthesia and loss of taste
Why is the premolar buccal vesibular area hazardous for a mandibular flap?
- Sever mental nerve/vessel
- Permanent loss of labial sensation
- Recovery of sensation maybe possible by proliferation of collateral innervation from C2,C3 and contralateral mental nerve
Why is the depth of the vesibule near 2nd molar hazardous for a mandibular flap?
- Facial artery/ vein
— Cross mandible at the anterior edge of masseter muscle
— If cut, needs to ligate the vessel and/or prolonged firm pressure - Prevention:
— Buccal releasing incision needs to be directed “upward toward” the crest of the alveolar ridge
What nerves and arteries do you need to avoid when doing mandibular flaps?
- Lingual Nerve
- Facial Artery
- Mental Nerve
- Long Buccal Nerve
- Buccinator (Buccal) artery
An incision running from one tuberosity to the other along the alveolar crest will sever…
NOTHING larger than a capillary
Why is the greater palatine artery a hazardous area for a maxillary flap?
- Pass anteriorly toward incisive foramen
- Runs between palatal gingiva and midline of the palate
- If artery is cut, need direct pressure at
proximal end of the vessel
Why is the nasopalatine nerve a hazardous area for a maxillary flap?
- Avoid incision through incisive papilla
What areas should be avoided for a maxillary flaps?
- Greater palatine vasculature
- Nasopalatine nerve
Never perform any vertical incision(s) on the…
mandibular lingual area
What types of thickness of flaps can you do?
- Full thickness
— Mucosal tissue + Periosteum
— Preserve periosteum
— Most popular flap in dentistry - Partial thickness (split thickness)
— Periosteum is left attached to bone
— Able to apically reposition flap
— Increase amount of attached gingiva
— Special OMS/Perio procedures
What is the flap of choice for most procedures?
- envelope flaps and full thickness flaps
What are the requirements for envelope flaps?
- Full thickness flaps
— sulcular incision without vertical releasing incision - At least one tooth distal to two
teeth mesial
— Extend the “coverage” as clinically
necessary
— Add on one or two vertical release incisions
Where should you never cut for a vertical release incision?
- In the middle of the papillae
- At the most apical point of facial gingiva
What are the requirements for vertical release incisions?
- Apical portion must be wider than coronal portion
- Beware of the blood supply pattern
- Incision must be over “sound” bone
What are the uses for an envelope flap with 1 vertical release incision?
- Next most useful flap for exodontia
- Provide even greater access
— Proximity to apex
— Deeply impacted tooth
What are the uses for an envelope flap with 2 vertical release incision?
A.k.a. Rectangular Flap
* 2 vertical releasing incisions added to a basic envelop flap
* Basic envelop flap
— 1 distal and 1 mesial from surgical site
What are the characteristics of curved flaps (semi-lunar)
- Full thickness
- Not involve gingival sulcus
- Placed partly in attached gingiva and extend into mucosal tissue
- Utilization
— Periapical endodontic surgery
— Retrieval of small root tips - At least 2mm apical to the base of the gingival sulcus
What are the characteristics of pedicle flap?
- Long, narrow flap for complete tissue coverage over osseous cavity
- Periodontology
— Correct gingival recession - OMS
— Closure of oro-antral fistula - High potential for necrosis and rejection
— Technique sensitive to maintain adequate blood flow in the flap
How do you reflect a full-thickness mucoperiosteal flap?
1) Grasping the Knife Handle
* Hold like a pen and not in you palm
2) Making the Incision
* #15 knife blade applied at right angle to tissue and underlying bone
* Firm pressure
* ONLY ONE pass incise tissue all the way to bone
— Multiple passes will create ragged margins
3) Flap Reflection
* Begin with sharp-pointed end of the elevator
— Pry the interdental papilla free
— Free the attached crestal gingiva
— Complete for the entire length of incision
* Use Broad end of the elevator
— Continue reflect attached gingiva & alveolar mucosa to the desired apical depth
4) Flap Retraction
* Proper use of retractor is needed
— Small flaps: use periosteal elevator
—Larger flaps: use Minnesota, Austin or others
* Place the tip of the retractor ON BONE
Flap should be enlarged using knife & periosteal elevator followed by ________ retraction
passive
* Aggressive retraction will tear flap
How do you perform closure of surgical wound?
- Any surgical wound must be closed
after flap - Remove any surgical debris under flap prior to closure
— Entrapment of debris/oral flora leads to postsurgical infection or pain - Copious normal saline irrigation needed
— With detailed visual inspection
— Watch for base of the flap
What are the primary objectives of wound closure?
1) Restore tissue to its original location
2) Move tissue to desired position
What are the general guidelines for suturing?
- Hold tissue in position, passively
— Not pull or stretch tissue into position - Not close tightly unless there is specific need
- Hemorrhaging should not be controlled by suturing of flaps
- Suture needle should pass from mobile tissue to non-mobile tissue
- Suture needle should not be too close
to wound margin
What can happen if you pull the tissue to tight to suture?
- Compromise circulation
- ↑ suture tearing loose
- Prevent drainage of small post surgical infections
- If marginal tissue turns white, it is too tight!!
Intraoral suture should be left in place for ______ days
4-7
Extraoral is left for 3-5 days
Suture needle should not be too close
to wound margin… minimum ___mm from flap margins
3
What is the proper suture removal?
- 1) Irrigate & remove debris
- 2) Suture cut flush with tissue
- 3) Pull loose from the knot side
- 4) Pull toward incision line
What are the suturing supplies?
Small 3/8 circle reverse cutting
* FS-1, FS-2 by Ethicon company
* Swaged (crimped)
* 3-0 or 4-0 size ( higher the number,
smaller the diameter)
How do you choose a suture?
- Familiarity
- Ease of handling
- Tissue characteristics
- Knowledge of physical and biological characteristics of the suture
- Patient factors-infection, debility, obesity
What is the primary purpose for sutures?
- Approximate wound margins
- Enhance tissue healing
What are the early roles for sutures?
- Wounds do not gain strength until 4-6 days after injury
- Approximating of tissues depending on suture strength
The more zeroes in the number, the ________ the diameter of the suture
smaller
Smaller the size of the suture, ______ tensile strength
less
What are the different suture material sizes used for?
- 9-0 or 10-0 for microsurgery
- 5-0 or 6-0 facial skin closure
- 3-0 or 4-0 for muscle, deep skin, intra oral mucosa
What are the types of non-resorbable sutures?
braided sutures
monofilament
What are the features of braided sutures?
- Multiple filaments braided as a rope
- ↑flexibility
- Suture material of choice for intraoral surgery
- Down side: Could draw oral flora into the wound
What are the features of monofilament sutures?
- Single fiber material
— Example: fishing line - Down Side
— ↓flexibility
— ↑ tendency to untie
What are the features of resorbable sutures?
- Ideal for deep closure of wound
- Made from Gut
- Gradually dissolved by proteolytic activity
- Down side:
— Unknown time of wound support
What are the classifications of non-absorbable and absorbable sutures?
What are interrupted sutures?
- Most frequently used
- If one suture is untied, other can still support the wound
- Down side
— Time-consuming procedure
What are vertical mattress sutures?
- When more tension is needed
- Seldom used for intra-oral surgery
- Frequently useful for closure oro-antral fistulas
What are horizontal mattress sutures?
- Better wound compression
- Not as efficient as vertical mattress
What are continuous mattress sutures?
- Used for long incisions
- Not always accurately approximate wound margins
- Suture may unwind if ONE knot is untied or cut
What are continuous locking mattress sutures?
- Used for long incision
- Better wound margin proximation
- Less prone to unwind if one gets untied
What are figure eight sutures?
Holds gel-foam or materials in
socket
How do you tie an interrupted suture (step 1)?
- Correctly grasp the needle holder
- Position the needle @ beak of the holder
- Thumb and 3rd or 4th finger at loop of holder
- Index finger as guide
- Needle is placed at right angle to beak and grasped about 4mm from the swaged end
How do you tie an interrupted suture (step 2)?
- Use tissue forceps to evert the unreflected tissue so needle can pass through tissue at 90 degree
- Needle is passed 3mm from wound margin
- Needle enter from mucosal side to periosteal side by “rotating” your wrist
How do you tie an interrupted suture (step 3)?
- Reflected side of flap is then supported with tissue forceps
- Needle pass through about 3mm from wound margin
- Passing from periosteal side to mucosal side
How do you tie an interrupted suture (step 4)?
- Needle end of suture thread is pulled through the tissue
- Leaving about 2-3cm of thread from the opposite end
How do you tie an interrupted suture (step 5)?
Suture thread is wrapped TWICE around beaks of needle holder in a COUNTER-CLOCKWISE direction
How do you tie an interrupted suture (step 6)?
- Short end of the suture thread is grasped with needle holder
- Pull through the loops which wrapped around the beaks of the needle holder
How do you tie an interrupted suture (step 7)?
- Pulling the loose end through the loops after sliding the loops off the end of the beak -> first knot is made.
- Make sure you “Proximate not Strangulate”
- If the tissue blanch white, your knot is too tight
How do you tie an interrupted suture (step 8)?
Suture grasped again and wrapped ONCE around beaks of needle holder in a CLOCKWISE direction
How do you tie an interrupted suture (step 9)?
- Short end of the suture is grasped with needle holder
- Pulled through the single loop
- Now, 2nd knot is secured
How do you tie an interrupted suture (step 10)?
- Repeat Step 8 and 9 again
- Cut both threads short.
- You are DONE
Summarize how you tie the knot for an interrupted suture?
1) Wrap twice, clockwise (or counter-clockwise)
2)Wrap ONCE, counter-clockwise (or clockwise)
3)Wrap ONCE, counter-clockwise ( or clockwise)
What is a root fragment versus root tip?
- Root Fragment
— Root with more than their apical 1/3 present - Root Tip
— Root portion in the apical 1/3 of the root
How do you remove a root fragment?
- Gain adequate purchase
- Flap maybe needed for better access
- Removal of buccal bone
- If needed, may need to remove bone all the way down to apex!
How do you remove a root tip?
When do you leave root tips?
- Risk-Benefit ratio should be in patient’s favor NOT yours
- Inordinate damage would be done to bone or soft tissue
— Small roots adjacent to maxillary sinus or inferior alveolar nerve
— Its wise not to remove if it may force them into those structures
Maxillary molars are usually sectioned and removed one _____ at a time
root
Advantage of sectioning maxillary molars
- Reduce surgical risk of oro-antral perforation
- Make difficult extraction easy
- Reduce incidence of alveolar fracture
How do you section a maxillary molar if the crown is intact?
- Reflect a flap
- Remove buccal bone
— To the level of trifurcation - Section crown at cervical line to divide buccal roots
— Leaving crown and palatal root intact - Remove “palatal root” component
- Divide buccal roots with a bur
- Remove each root
How do you section a maxillary molar if the crown is not intact?
- Reflect a flap
- Remove buccal bone
- Section all three roots in a “Y” pattern
- Remove each root
Mandibular molars are usually sectioned and removed one ______ at a time
root
Advantage of sectioning mandibular molars…
- Excessive force can damage TMJ
- Fracture mandible
- Extremely negative experience
What is the sectioning technique for mand molars with crown intact?
- Reflect a flap
- Reduce buccal bone with bur
- Section the crown
— 1)From buccal-lingual fashion
— 2)From bifurcation of root
— 3)Protect lingual tissue with tongue retractor - Twist an elevator into buccal slot to fracture tooth into 2 halves
- Remove each root
- Trim interseptal bone if necessary
What is the sectioning technique for mand molars with crown NOT intact?
- Section the remaining tooth
— 1)From buccal-lingual fashion
— 2)Protect lingual tissue with tongue retractor - Use Cryer elevator in the section line to engage distal root
- Rest elevator on the mesial root as a fulcrum, distal root is elevated out of socket
- Engage mesial root while use buccal plate as fulcrum to elevate the mesial root out
- Interseptal bone is trimmed with a rongeurs
