P3-OS-CHAPTER 9 BOOK

Surgical Flap

is a section of soft tissue that is outlined by a surgical incision, carries its own blood supply, allows surgical access to underlying tissues, can be replaced in the original position and maintained with sutures

True

True or False: Base of the flap must be broader than the free margin to allow adequate blood supply.

True

True or False: Flap must be of adequate size for better access and visualization.

False (full-thickness)

True or False: Flap should be a partial-thickness mucoperiosteal flap

surface mucosa, submucosa, periosteum.

In full-thickness mucoperiosteal flap, what layers should you include?

False (6-8mm)

True or False: Incisions must be made over intact bone. It should be placed 8 to 10 mm away from the bony defect or opening, doing this will ensure that flaps will be reapproximated over intact bone and prevent wound dehiscence.

True

True or False: Flap should avoid injury to local vital structures.

False (are not necessary)

True or False: Vertical-releasing incisions are necessary, only used when there is insufficient access and visualization provided by the envelope flap. Single vertical-releasing incision must be placed at the anterior end of the flap and must avoid bony prominences. It should cross the free gingival margin at the line angle of a tooth and not directly on the facial aspect of the tooth.

1.Envelope flap

2.Three-cornered flap

3.Four-cornered flap

4.Semi-lunar incision

5."Y" Incision

Enumerate types of mucoperiosteal flaps

Envelope flap

Made by creating sulcular incisions in the gingival

sulcus surrounding the tooth to the crestal bone and periosteum and the full-mucoperiosteal flap is raised.

Three-cornered flap

An envelope flap combined with a vertical-

releasing incision placed at the anterior end of the

flap.

Four-cornered flap

An envelope flap with two vertical-releasing incisions

placed at the anterior and posterior end of the flap.

Semi-lunar incision

- Used to approach only the root apex of the tooth.

- Avoids trauma to the papillae and gingival margin but has

a limited access

"y" incision

Useful for surgical access to the bony palate for removal

of a palatal torus

Envelope flap

Provides sufficient access for surgery

Three-cornered flap

This provides better and greater access in the

apical region of the tooth

Four-cornered flap

Rarely indicated

Semi-lunar incision

Most useful in periapical surgery

1. No. 15 blade in a No. 3 blade holder, incise soft tissue from posterior going anteriorly. Apply one smooth continuous stroke and the blade should always contact the bone.

2. Reflection of the flap should begin at papilla using sharp end of the No. 9 Molt

Periosteal elevator followed by reflection of rest of the flap by broad end of the periosteal elevator.

3. Flap should be retracted or held in place using the broad end of the No. 9 Molt periosteal elevator, Seldin or Minnesota retractors.

Enumerate how to Develop a Mucoperiosteal Flap

o Hold flap in position and approximate opposing wound edges.

o Aid in hemostasis by acting as a tamponade

o Help hold soft tissue flap over bone.

o Aid in maintaining blood clot in alveolar socket.

PURPOSE OF SUTURES

True

True or False: Sutures should be placed in the papilla not above empty tooth socket.

True

True or False: Needles are passed first with the mobile tissue (usually the facial tissue) and then to the attached tissue.

False (smaller possible hole)

True or False: The needle should enter the surface mucosa at the right angle to make the bigger possible hole in the mucosal flap.

True

True or False: The flap should not be tied too tightly to avoid flap necrosis.

False (3 mm)

True or False: The surgeon should leave at least 4mm of tissue between the suture and the edge of the flap.

True

True or False: The knot should be positioned away (usually buccal or facial side) from the incision line and not on top of it as this will become a haven for bacteria.

True

True or False:Each suture should be placed 3-4mm away from other sutures.

False (5-7 days)

True or False: Non-resorbable sutures are left in place for 1 week, after which they must be removed.

o Simple Interrupted Suture

o Horizontal mattress suture

o Continuous simple suture

Types of Suturing Techniques

Simple Interrupted Suture

- Most commonly used suture technique in Dentistry

- Stitches are individually knotted and is not connected with the other sutures, therefore if one stitch goes off the other stitches remain intact.

Horizontal Mattress Suture

- Sometimes used for soft tissue wounds

- This suture compresses the wound together

slightly and everts the wound edges.

- This decreases the number of individual

sutures placed however when one edge goes off, the whole suture is repeated or replaced.

Continuous Simple Suture

- Used in long-span incisions and leaves fewer knots

- Watertight

- Disadvantage is that if one suture pulls through, the entire suture line becomes loose

Necrosis, delayed wound healing

What will happen if soft tissue flap is not held over bone?

"Y" Incision

This incision is useful for surgical access to the bony palate for removal of a maxillary palatal torus

6-8mm

How far are incisions placed from a bony defect or cavity?

False

Vertical-releasing incisions can be placed over a canine eminence. True or False?

Sulcular Incision

What type of incision produces an envelope flap?

- should be grasped by the needle holder at its strongest part, 2/3 up from the tip of the needle to the eye or swaged part of the needle.

- insert the needle perpendicularly to the surface mucosa so that it will only cut through a small area thus giving less resistance and avoid bending.

- when needles are passed through the mucosa it should be passed following the curvature of the needle to avoid tear of the tissue and needle bending.

WHAT ARE THE WAYS TO AVOID BENDING OF THE NEEDLE?

Surgical/open extraction

should not be reserved only in extreme cases, sometimes it is better to use this technique right away as it will result in a more conservative treatment than trying to attempt extraction using the closed technique which sometimes result in a traumatic procedure

No. 703 or 557 straight fissure bur

What straight fissure surgical bur is usually used to section a tooth?

False

Abraded teeth must be removed by an open extraction technique. True or False?

Hypercementosis

What is the apical condition that is seen radiographically as radiopaque which makes the apical root bulbous and makes it difficult to be extracted by a close technique?

Buccolingualy

In what direction or plane are mandibular molars sectioned for open extraction?

Crane Pick Elevator

If a purchase point is made in the root for its removal, what elevator is used to elevate such tooth?

-If excessive force is needed to extract a tooth

-After initial attempts at forceps extraction failed

-If pre-operative assessment reveals that patient has a thick and/or dense cortical bone

-Teeth the has severe attrition due to teeth grinding (bruxism)

-Teeth with evidence of hypercementosis

-Teeth that have widely divergent roots or severely dilacerated roots

-Close approximation to the maxillary sinus

-Teeth with large amalgam restoration, badly carious crown, and root caries

Give indications for open extraction

Yes. However, carbide burs are recommended because they efficiently cut tooth structure as well as bone. Diamond burs are less effective in cutting bone. Thus, in order for the surgeon to avoid changing burs during the surgical procedure, carbide burs are the bur of choice to use in Oral Surgery.

CAN WE USE THE SAME DIAMOND BURS USED IN RESTORATIVE PROCEDURES IN SECTIONING THE TOOTH DURING OPEN EXTRACTION?

Bone removal should only be sufficient enough to gain access and visibility on the tooth and to facilitate easy removal of the root or tooth. The width of the buccal bone removed must be the same width with the tooth mesiodistally while in a vertical dimension, bone removed is about 1⁄2 to 2/3 the length of the tooth or root

HOW MUCH BONE IS REMOVED DURING AN OPEN EXTRACTION TECHNQUE?

-Provide adequate visualization and access

-Determine need for bone removal

-If bone removal is not enough, create purchase point on to the tooth

-Bone edges smoothened using bone file

-Entire surgical field irrigated frequently with Normal Saline solution

-Flap is sutured back in to place using 3-0 black silk or chromic sutures

Enumerate some techniques for open extraction on single rooted teeth

-Reflection of adequately sized flap

-Tooth is sectioned

-Divided roots are elevated and luxated

-Bone edges smoothened using a bone file

-Entire surgical field must be irrigated frequently with Normal Saline solution

-Flap is sutured back in to place using 3-0 black silk or chromic sutures

Enumerate some techniques of open extraction for multi rooted teeth

Submandibular space

Where do roots of mandibular second molars usually gets displaced?

Open-window technique

Technique used to remove a root fragment by removing bone only at the apical portion of the root

Three-cornered flap

What is the preferred flap for the technique asked in question number 2?

True

A 3mm root fragment can be left in place if all techniques fail to retrieve such. True or False?

Bone fill

What instrument is used to remove small bony spicules?

Oral surgeons highly recommend to do multiple teeth extraction one side at a time. Upper and lower teeth on the same side can be extracted in one sitting. This is recommended to avoid prolonged surgical procedures and to give the patient one side to chew on food while the other side is healing.

CAN WE EXTRACT MULTIPLE TEETH FROM LEFT AND RIGHT QUADRANT IN ONE SITTING?

Aside from properly informing and discussing the patient about the decision to leave the root fragment in place, a signed informed consent is necessary. This consent is attached to patient's chart together with properly documented radiographs. A properly documented case or procedure will greatly help the dentist if medicolegal cases are to be filed.

HOW DO YOU DOCUMENT PATIENT'S CONSENT FOR RETAINING A ROOT FRAGMENT IN ITS PLACE?

-Removal by closed technique

-Removal by open technique

What are the two types of removal of root fragments and tips

Open-window technique

In this technique, bone removal is only at the portion where the root tip is located