Oral Surgery Flashcards
Discuss Open subgingival debridement?
Any form of periodontal surgery should only be considered once the owners have proven
commitment and effectiveness of oral care. Without this commitment extraction of these to
these teeth should be considered.
It is impossible to effectively perform closed subgingival debridement of periodontal
pockets deeper than about 4 mm. To accommodate effective subgingival debridement a
periodontal flap is created to expose the lesions and improve visualisation.
Gentle handling and protection of these flaps are crucially important to avoid damage.
Flaps created in this way could either be re-sutured in their normal position or repositioned
apically.
Digital pressure after replacement of the flap will reduce the amount of blood clot
accumulated and assist with adhesion of the flap to the underlying tissue.
Releasing incisions should always be made at the line angle of adjacent teeth and never
over the tooth root surface.
What is the envelope flap?
The incisions for this flap are created along the gingival sulcus and joins the same incision
on adjacent teeth. No releasing incisions are used, and it often creates enough exposure
for effective open debridement.
Discuss the triangular flap?
Triangle Flap
For this technique the same incision used for an envelope flap (within the gingival sulcus)
is augmented by a single releasing incision, created perpendicular to the gingival
margin/the sulcular incision. This creates a triangular area of improved exposure. If the
direction of blood supply to the gingiva is considered it is usually advisable to create
releasing incisions at the mesial aspect of the sulcular incision.
Discuss a pedicle flap?
Pedicle Flap
To create this flap, two perpendicular releasing incidents are made at the mesial and distal
aspects of the sulcular incision. This creates a rectangular exposure of a larger area but
also requires more suturing to close the defect, qand also increases post-operative healing
time.
What should be considered when making surgical flaps?
For all flap techniques, a sharp periosteal elevator is used to elevate the periosteum as
gently as possible away from the underlying bone. Before closure flushing with Hartmann’s
solution is indicated. Simple interrupted sutures using 5/0 or 4/0 absorbable
monofilament material on a swaged-on tapered or revers cutting needle e.g. Monocryl ®
are advised for tension free closure of these flaps.
Discuss first intention wound healing?
First intention wound healing occurs when primary
closure is achieved by accurate wound margin apposition. We anticipate this
type of wound to heal quickly, with minimal scar formation.
Discuss second intention wound healing?
Involves formation of granulation and
connective tissue.
How do wounds in the oral cavity tend to heal?
Wounds in the oral cavity tend to heal faster
and with less scarring than skin wounds.
What is Alveolar osteitis?
If the blood clot is lost or disintegrates, a localised alveolar osteitis may occur.
Healing is delayed. The infected alveolus remains open or partly covered by
hyperplastic epithelium.
What are the two types of bone healing?
Direct and indirect. In indirect bone
healing, a callus is formed. Inflammation is followed by proliferation of various
cell types, including fibroblasts, chondroblasts, osetoblasts, osteoclasts.
Granulation tissue is formed between fracture ends which is transformed into
fibrocartilaginous connective tissue and ultimately bone, given optimal
conditions. Direct bone healing will only occur with accurate bone reduction and
rigid fixation, which may be attained by the use of wires or miniplates
Discuss infection and it’s effect on healing?
Infection: Local factors can encourage a contaminated wound to become
infected; inadequate tissue perfusion, presence of necrotic tissue or foreign
material. To prevent this consider a conscientious surgical technique, and the
use of sterile instruments, in a clean operating environment (i.e. clean teeth
before extractions, and consider use of chlorhexidine solution within the oral
cavity).
Discuss Inadequate tissue perfusion and it’s effect on healing?
Adequate tissue oxygen levels are vital for
adequate healing. Ischaemic tissues due to poor surgical technique will be
poorly perfused and therefore prone to infection.
Discuss age and it’s effect on healing?
Age: Oral cavity wound healing is expected to be slower in older rather than
younger animals.
What are all the indications for extractions?
Periodontitis
o Gross mobility (Mobility grade 3)
o Furcation exposure grade 3, (2 in cats?)
o >50% attachment loss, (>33% in cats?) How do we measure
attachment loss?
o Secondary tooth resorption-type 1 (inflammatory) in cats
Pulp necrosis
o Complicated crown fracture
o Complicated crown/root fracture
o Root fracture
o Uncomplicated crown fracture
o Abrasion
o Discoloured teeth (concussion/ blunt trauma)
o Avulsion/luxation
Tooth resorption- dogs and cats
Caries/decay (dog only)
Feline chronic gingivostomatitis
Canine Chronic Ulcerative Stomatitis (CCUS)
Malocclusions
Persistent deciduous teeth
Fractured deciduous teeth
Supernumerary teeth
Unerupted teeth
Traumatically luxated /avulsed teeth
What are the contraindications for extractions?
If informed consent has not been obtained
o If the appropriate skills, knowledge and equipment are not available
o If a pre-extraction dental radiograph cannot be obtained
o Age is not a barrier to performing general anaesthesia and dental
extractions
o Extraction of teeth in the field of previous radiation therapy can lead to
osteoradionecrosis and should be avoided (therefore extract necessary
teeth before radiation therapy)
o Extraction of teeth within a potentially malignant tumour at the time of
biopsy
o ‘Disarming’ procedures
What is the periodontium?
Periodontium (the
periodontal ligament attaches the tooth via the cementum covering the root to the alveolar bone of the socket, and the gingiva also attaches to the tooth surface).
The high-speed handpiece (dental ‘drill’) should be lubricated after?
Every patient.
How does a high speed hand piece work?
Compressed air is used to drive the turbine which
rotates at 300-400 000 rpm. A friction-bur is
used (FG) and inserted by depressing the
back of the turbine. The connection to the
dental unit tubing is usually 4 hole
(Midwest), with two larger holes and two
smaller holes. The smaller of the two larger
holes takes the air to the turbine and should be lubricated before sterilising.
Most handpieces state at what temperature to be autoclaved (usually 134°).
Many manufacturers produce handpieces with the ability to swivel 360°, which
are invaluable.
How should dental handpieces be held?
Dental handpieces should be held in the modified pen grip.
What do pre-extractions x-rays allow?
Pre-extraction radiographs are strongly recommended (if not mandatory) and
allow detection of anatomical variations, assessment of quality of alveolar bone,
ankylosis or resorption that may make efforts challenging, and other pathology
that could influence extraction technique.
What do post-extractions x-rays allow?
Post-extraction radiographs are
essential in confirming complete extraction of root, plus absence of any
compromising factors (such as bone or calculus fragments within the alveolus)
What is a periodontal probe used for?
Periodontal probe
* Blunt ended, graduated mm marking for measuring gingival
sulcus/pocket depth or identifying furcation exposure
o Different styles available, e.g. UNC-15, Williams
What is an explorer probe used for?
Explorer probe
* Sharp tip, used only on hard dental tissues. E.g. for identifying
resorption, enamel hypoplasia, pulp exposure - but only in the
anaesthetised animal.
o Different styles available, e.g. Shepherd’s Hook, Orban, Cowshorn
What should dental burrs be made out of?
Tungsten carbide or diamond
What are round burrs used for?
Round burs are useful for alveolar bone removal during surgical
extraction techniques, and a range of sizes are required, such as ¼,
2,4,6.
What are straight burrs used for?
Straight burs are suitable for sectioning teeth and can be used for bone
removal during open extractions. These may be tapered, and also have cross-cuts (to reduce clogging of the bur with tooth material). These are
therefore described as taper fissure cross-cut burs. Typical sizes include
699, 701.
What are diamond burrs useful for?
Diamond burs are useful for smoothing alveolar bone (alveoloplasty)
after extracting teeth surgically. Chose large round or rugby ball shaped
versions with fine or medium grit.
What are root tip burrs used for?
Root tip burs are useful for retrieving root fragments
How should you use a burr to section teeth?
When using the bur to section a tooth, remember it is not a light sabre.
Apply gentle pressure then release, in a tapping motion through the tooth.
What are Luxators?
These are very sharp instruments designed to cut
the periodontal ligament. The blade is thin and
relatively fragile and less concave than an
elevator. They are not designed to withstand
rotational forces. Typically, they have plastic
handles (Luxator is actually a trademark of the
Swedish company Directa). They are used parallel to
the root surface. They are available in widths of 1-5mm,
with straight or angled blades. Forte versions are
available, which are stronger and can be used in a
rotational manner. The palm grip is the correct luxator
grip. The index finger is placed close to the tip of the
blade to prevent trauma should the operator slip
What are these?
Luxating Elevators
Other companies produce Luxator-like instruments,
which have fine, sharp cutting blades, designed to cut
(rather than tear) the periodontal ligament. E.g.
Luxating elevators from IM3, and the 1.3mm
and 1.8mm Luxating elevators from Cislak
which are especially useful in feline
dentistry.
What is an elevator?
The dental elevator is a thicker, stronger instrument than the Luxator, designed
to transmit rotational force from the blade to the tooth, which tears periodontal ligament fibres, or lifts (elevates) the tooth from the alveolus. Winged versions are available, which contact a greater
proportion of the root circumference thus allowing additional purchase and torque (care! This can cause root fracture).
How should elevators be used?
Elevators
should also be maintained in a sharp state.
o Use axially in a twist-and-hold technique. Insert into periodontal
ligament space, apply two-finger rotation pressure to ‘move’ root
within alveolus. Hold this pressure for 10-20s to allow periodontal
ligament fibres to fatigue, then re-position. No wiggling.
o Use perpendicularly to long axis of tooth root in a ‘wheel-and-axle’ technique, using alveolar bone as a fulcrum. This ‘elevates’ the root segment from the alveolus. Gentle and careful continuous
force.
Name some good elevators?
Elevation-In-Dent® (Accesia) These
excellent instruments come in 5 widths and
can be used for luxation and true elevation.
What is a periotome?
The periotome is a fine bladed instrument which is inserted into the periodontal
ligament space to sever the fibres, while maintaining the integrity of the
alveolus. A mechanical Vet-Tome version is available.
How should extraction forceps be used?
Use once the tooth is loosened. Ensure the beaks of
forceps maintain 4-point contact with tooth as close to
apex of root as possible. Do not crush the gingiva.
Rotate until you feel tension, then hold. Rotate in
opposite direction until you feel tension, then hold in
position for 10-15 seconds. Apply traction at the same
time. No fence-post wiggling- a force is created at the
alveolar margin of bone, which will probably cause the
root to fracture. The twisting fatigues and tears the periodontal ligament fibres,
but this does not happen instantly.
Name some good root tip forceps?
Root tip forceps and picks are worthwhile purchasing. The very small beaks
allow retrieval of small root tip fragments e.g.
Stieglitz style
What are Periosteal elevators used for?
Used during elevation of a mucoperiosteal flap, to elevate periosteum off
underlying alveolar bone. They must have a sharp cutting edge and be
sharpened regularly. The back surface is atraumatic.
Hold them in either the palm or modified pen grip, using in a push-and-twist
action, but with the edge at an angle to the bone to
engage the cutting surface (not parallel to it).
A variety of sizes are required for cats, small dogs
and larger dogs.
o Styles include: Molt, Goldmann Fox,
24G, Freer.
What do tissue retractors do?
o Protect tissues and flaps when using
high-speed handpiece.
o Senn, Minnesota
o Tongue depressor, composite spatula
What scalpel blades and handles should be used?
o Size #11 or #15/#15c blades are suitable for dental
work, and should always be attached to a scalpel
handle.
o Beaver handle and blade
o Round or hexagonal handles are useful in the
mouth- facilitates cutting the gingival
attachment around the circumference of a tooth.
What scissors are needed in dental kit?
o Curved iris/ LaGrange/ Double curved for tissue dissection, periosteal
releasing incisions
o Separate suture scissors
What forceps should be in your dental kit?
o Gentle tissue handling forceps should be used, such as the Adson 1x2.
How should canine maxillary molars be sectioned?
The first cut is to section the palatal root
from buccal roots. Next section the two
buccal roots- move bur from buccal to
palatal to the initial sectioning cut.
How should an envelope flap be made?
A horizontal incision alone is created, without any vertical releasing incisions.
This is created in the gingival sulcus, and
extended as far caudally as needed- along
the alveolar margin between teeth, then into
the sulcus of the next tooth. A sulcular
incision is made around the entire
circumference of the tooth to be extracted
to release the gingival attachment. A periosteal elevator is then used to raise
both the gingiva and mucosa off the underlying alveolar bone.
How is a triangular flap made?
A horizontal sulcular incision is made, plus one
vertical releasing incision which extends beyond
the mucogingival junction. Why? Also consider
blood flow to the flap- where should the vertical
incision de made, caudal or more rostral?
What is a pedicle flap?
A sulcular incision is made, plus two
vertical releasing incisions which extend
beyond the mucogingival junction.
How should buccal bone be removed?
Buccal bone removal
Once the flap is elevated, ideally a bur in a low-speed handpiece with
sterile water cooling is used to remove buccal alveolar bone overlying the
root structure. If this is not available, a bur in a high-speed hand-piece is
used. Bur choice is personal, I prefer a 701L in dogs and 699 in cats,
(taper-fissure cross-cut), but a round bur would also work. Be aware that
the size of the round bur is significant when creating gutters at the
periodontal ligament space (see below). If the bur is too large (e.g. 4 or
above) then the resultant gutter may be too large to allow effective
elevator use. Estimate the length of the tooth root, and then aim to
initially remove bone overlying 33-50% the length of the root. In addition,
we will remove bone overlying the periodontal ligament, creating ‘gutters’
which will allow placement of hand instruments (elevators). Do not go too
deep when removing bone, as it is easy to start burring into the root. You
should see a pinkish colour as you approach the periodontal ligament.
Stop once this is approached. Try to remove bone in a neat way, creating
a dome-shape of bone removal.
How should periodontal ligament gutters/grooves be made?
Using a bur of correct size (699, 701L, round ½-1), we then aim to create
gutters in the mesial and distal periodontal ligament space, just over 50%
depth of the root. This must be exactly where the periodontal ligament is,
so do not guess, visualise it! If this is performed after initial buccal bone
removal, you can follow the curvature of the root to lead you to the
position of the periodontal ligament.
What should you do to the alveolus before closure?
Debride any granulation tissue/bone or calculus debris from within
the alveolus using a surgical curette e.g. a Lucas curette
. Obtain a post-extraction radiograph to ensure all root substance is
removed, and no foreign
material or bone fragments are
within the alveolus.
Discuss alveoplasty?
Using a fine/medium round/rugby ball diamond bur on a
high-speed handpiece with water-cooling/rongeur/bone file to smooth all
bone edges before closing the flap. Run your gloved finger over the bone
to detect any sharp spikes and smooth them off.
How is a crown amputation done?
This is an alternative to extraction for cases of type 2, replacement resorption.
This must be diagnosed radiographically. The periodontal ligament surrounding
the root will not be visible, and the root radiodensity will be diminshed, and
match that of surrounding bone. An envelope or triangular gingival flap is
created. For premolars, an envelope flap is appropriate, while a triangular more
suitable for canine teeth. An incision within the gingival sulcus is extended 1-
2mm beyond the tooth of interest both buccally and lingually. The gingiva is
then elevated from the underlying bone using a periosteal elevator, and
protected while the crown is amputated level with, or just below the alveolar
margin using a tapered fissure bur (e.g. 699 or 701) in a high-speed handpiece.
The area is then smoothed with a fine diamond bur. A post-operative radiograph
confirms no sharp edges of bone/tooth, and then the site closed with 1-2 simple
interrupted sutures. Do not leave exposed bone/tooth substance!
What is the surgical anatomy of the palate?
Surgical anatomy
The incisive, maxillary, and palatine bones form the roof of the mouth. The major palatine arteries are the main arteries to the mucoperiosteum of the hard palate and emerge at the major palatine foramen coursing rostrally in the
palatine groove. These foraminae are located medial to the maxillary 4th premolar, roughly halfway between the dental arcade, and mid-line.
How is the Von Langenbeck technique done?
In this technique, bilateral releasing incisions are made 2mm from the maxillary
teeth, parallel to the dental arch. The margins of the cleft are excised. The
mucoperiosteum is undermined, taking extreme care not to damage the palatine
arteries. The flaps are re-positioned medially and sutured over the defect. The
resulting gaps at the lateral edges are left to heal by second intention.
What is the Overlapping flap technique?
This technique is often preferred as there is less tension on the suture line,
the suture line is not directly over the defect and the area of opposing
connective tissue is greater (hence stronger repair).The first incision is made
on one side, 2-3 mm from the maxillary teeth and extended perpendicularly
at the rostral and caudal aspects to extend to the cleft. The caudal incision
should lie over hard palate bone (not in soft palate). This flap is then
elevated to the edge of the cleft, ensuring the palatine artery is preserved. At
the level of palatine fissure, the flap is only partial thickness, ensuring some
tissue remains over the fissure. This flap will be then hinged completely over the cleft. It is therefore vital not to penetrate the epithelium here- where the
oral and nasal epithelium are confluent. The second incision is made along
the entire length of the defect on the opposite side at the cleft margin, and
then the oral mucoperiosteum is elevated only 8-10mm from the edge. The
first flap is then rotated 180 and tucked under the mucoperiosteum of
second flap, so it rests between hard palate and flap- allowing two
connective tissue surfaces to contact one another. Multiple horizontal or
vertical mattress sutures are placed from caudal to rostral- these can be preplaced and held with haemostats. The defect created by the hinging of the
first flap is left to heal by second intention and is usually re-epithelialised
within 4 weeks.
What is the simplest form of oronasal fistula repair?
The simplest form of repair is using a single layer buccal mucosal
advancement flap.
What are Transposition flaps (greater palatine axial pattern flap) good for?
These are recommended for small circular defects, especially if lateral to the
midline and rostral to the 4th premolar. They utilise and mobilise the greater
palatine artery and vein. These flaps should be designed significantly larger
than the defect to be covered. The rim of the fistula is initially excised. The flap
is designed as a “U” shape, with one arm adjacent to the defect. Rostrally the
palatine artery must be identified and ligated. The mucoperiosteum is elevated
using a periosteal elevator, taking care not to traumatise the palatine artery. It is
then rotated (transposed) to cover the defect and sutured with simple
interrupted sutures.
When is a Split Palatal U Flap used?
This is useful for caudal and central palatal defects. The margin of the defect is
excised. Two U-shaped mucoperiosteal flap are created on both left and right
sides. Each will contain the major palatine artery, which should be ligated at its
most rostral aspect as the flap is raised. One side is rotated over the palatal
defect and sutured to the margin. The second flap is also rotated and positioned
rostral to the first flap, and then sutured to the first flap. The rostral area of
exposed bone is left to heal by secondary intention.
