DIDACTIC NOTES

This power point presentation is designed to benefit the general dentist who already has at least limited outpatient oral surgery experience. It is not intended to be a complete treatise on exodontia. Rather it is a potpourri of clinical oral surgery tips that have proved helpful to general dentists who wish to expand their expertise in outpatient oral surgery procedures.

The worst thing that can happen to you during your professional dental career is to have a patient die in your office because you were unprepared for a medical emergency. Therefore the most important thing in dentistry is to prepare for medical emergencies. Check with the dental command or chief dentist to learn the medical emergency plan for the dental office. A proper Medical Emergency Plan should include: 1. Appropriate equipment, supplies, and medications 2. Written emergency protocol and procedures for the most common medical emergencies 3. Documented training for all staff on a routine basis. The Magnificent Seven No, it is not the name of a 1960 movie staring Steve McQeen, it’s the seven most important drugs for a general dentist to have in a medical emergency kit: Epinephrine, Diphenhydramine, Albuterol, Nitroglycerine(tablets or spray), Glucose, Aspirin, and Oxygen. There are many available handbooks and references for medical emergencies. Perhaps the most widely used and “standard” is Malamed’s Medical Emergencies in the Dental Office. Note: Ensure that patients who are already on nitroglycerine or albuterol bring their medication to the dental appointment. Some authorities recommend that stress related asthma patients take a huff of albuteroal at the beginning of the dental appointment.

Automated External Defibrillator (AED): These are rapidly becoming a “standard of care” medical device. Ensure that all of your staff know how to operate it and that it is well maintained and fully charged. Note the disposal razor shaver. The pads will not adhere to a hairy chest which will result in an ineffective application of the AED.

Personal protective equipment for the medical environment is equivalent to the military’s MOPP IV equipment for the NBC environment. Infection control procedures are designed to protect the patient against infection or injury in the medical environment. OSHA procedures are designed to protect the health care provider against infection or injury in the medical environment. Both measures are addressed by strict adherence to universal precautions.

Every dentist should develop a personal philosophy on their approach to patient management. This is important for all aspects of dentistry but especially true in oral surgery where patient apprehension is high. Be yourself, don’t be aloof or overly professional; patients can usually see through a phony persona. A positive and confident attitude puts the patient at ease, generates trust in your abilities, and raises pain threshold. Be relaxed. Tension is contagious. Use light humor but be careful to be tasteful; no sexual, off color, or political jokes. When ever you treat dental patients you must address two complexes; the dental disease/injury complex and the pain/fear complex. You can not provide competent dental care with out treating the pain/fear complex through the use of your personality, adequate anesthesia, sedation prn, and a soothing treatment room environment, latrosedation. A relaxed patient is comfortable and has a higher pain threshold which makes dentistry much easier and your life more comfortable.

- Introduce yourself, ask a few questions e.g. hometown, comment on the weather”break the ice” to relax patient. A patient who is uncomfortable in the operatory will also have a dentist who is uncomfortable in the operatory. Find out why the patient is here. #32 may be indicated for extraction in the dental record but #29 gave him a toothache last pm; that’s why he came to the dental clinic today. Review medical history verbally and written; update prn. Patient may have completed written medical history last week but just received Vicodin® yesterday from M.D. for “bad back”. Examine dental record and radiographs for accuracy, completeness, and timeliness. Perform a clinical examination and evaluation to update dental record. Confirm the diagnosis and treatment plan are appropriate and in agreement with your clinical findings and evaluation. Don’t treat new patients for the first five minutes. Use that five minutes to thoroughly examine and evaluate patient, radiographs, dental record, diagnosis, and treatment plan. i.e. “Know Your Patient”

Always carefully evaluate a current diagnostic radiograph before performing oral surgery. What are the consequences of extracting #31 if the mandibular lesion is a dentigerous cyst, primordial cyst, odontogentic keratocyst, or an ateriovenous malformation?

This is an essential step to keep from getting in “over your head”. Don’t hesitate to refer if you lack confidence in your ability to treat a specific patient or procedure. Informed Consent is necessary for irreversible procedures especially in private practice. A standard pre-printed form with check boxes for specific risks and information is often utilized. Informed Consent requires three elements; 1) Info & risks of your proposed treatment, 2) alternative treatment options, 3) and a signed consent form by a responsible adult. Once the patient has accepted your proposed treatment you can start preparations for the dental “Plan of Attack”.

- Determine if you’ll need a standard surgery instrument set or if you’ll need an extensive set up with additional instruments for alveoloplasty, tori, or biopsy. If you have to stop in the middle of the procedure to get additional instruments you will waste your most precious commodity:time. You’ll also compromise your patient’s trust in your knowledge and experience. Note: Ideally plan to limit non-sedated out patient oral surgery procedures to less than one and a half hours to minimize post-op swelling and patient discomfort. Normally maxillary teeth are taken out before mandibular teeth; posterior teeth before anterior teeth. You may decide to perform the most complex extraction last in order to immediately place and maintain a pressure dressing and ice on it to minimize post-op swelling. Examine anatomy on radiograph and clinically to determine appropriate sectioning patterns Boney access is determined after clinical examination and tooth sectioning patterns are planned. Flap design is determined by clinical examination to determine requirements for boney access and soft tissue closure. The base of the flap should always be wider than the apex to allow for adequate collateral circulation. Proper closure is extremely important as soft tissue is essential to healing of hard tissues. Do not shortchange the time you spend on proper closure of the surgical site. Closure of the surgical site should be a consideration in the initial flap design. Suture patterns are determined by the flap design and surgical site. Suture type is determined by the type of tissue being closed and the procedure. Normally external skin requires 5-0 nylon, mucosa or gingiva, 3-0 gut or chromic gut; deep tissues, Vicryl® or chromic gut; extensive prosthetic procedures and surgical drains, 3-0 black silk. Finally make certain you have all the appropriate instruments and supplies necessary to complete the surgical procedure without interruption.

The standard tray set-up should contain 90% of the instruments routinely utilized for surgery. With thoughtful anticipation and planning you can identify the remaining 10% required for the specific procedure. If you try to include 100% of the instruments required in each instrument pack, the trays will be overwhelmed with unnecessary clutter, it will be more difficult to find the correct instrument among the clutter, and the staff will be unnecessarily burdened with excessively large instrument packs and sterilization.

These are extra coronal forceps that work best on teeth which still have crown integrity. The 150 and 151 are often considered universal forceps. They frequently appear as the only forceps in small emergency dental kits. The 151S is technically a pedodontic forcep but is very useful in small mouths, limited openings, and limited space situations.

The 150 is useful for most maxillary extractions. The 151 is better suited for mandibular extractions but is often utilized on maxillary molars. The 151S can be very useful for extraction of maxillary 3d molars where space is very limited due to a large coronoid process or thick tight buccinator muscles.

The 65 and 69 are particularly well suited for extaction of maxillary bicuspids. The offset and narrow nibs provide excellent traction on the crown while allowing adequate maneuver room for extraction forces. These forceps may be adapted to many situations where space and access are compromised. (Quarter for scale)

These are intra radicular forceps used to extract molars with weakened or inadequate crown structure. The 88’s are maxillary and 23 are mandibular rforceps. They provide traction at the furca of the tooth instead of the around crown. This is an advantage for teeth with missing or weakened crowns such as endodontically treated teeth. The disadvantage is they impinge slightly on the alveolar crest and may cause some collateral damage during extraction. However judicious use of these forceps may preclude surgical extraction which preserves alveolar bone in the long run.

These are often considered standard elevators and are often included in basic dental emergency kits.

The Cogswell elevators are often used for more complicated extractions especially impactions. The Cogswell A can often be inserted into a lot in a tooth to fracture off a portion. The Cogswell B can be inserted into a purchase point made in the tooth to elevate it.

It is imperative to protect the patient from unintended consequences. A bite block (1) must be utilized any time torque is applied to the mandible via an elevator or forcep. This protects the contralateral TMJ from injury. It may also be used at any time for patient comfort or for the dentist’s convenience. A pharygeal pack (2) must be used at the time of delivery to prevent aspiration of the tooth or its fragments. Patients who have a gag reflex may tolerate a 2X2 gauze unfolded (3) and gently place on the back of the tongue. Have these patients lean their head to that side so that gravity favors the buccal rather than the lingual side of the arch. Many gaggers are easily treated with the use of Nitrous Oxide.

The first item to consider in anesthetic selection is the patients current medical history. Patients may often say they are allergic to ‘Novocain”. Question the patient to determine what type of reaction they experienced. Often they had a simple case of syncope, possibly a vaso-vagal reaction. Check the record for documentation of a previous reaction to anesthetic. Patients with a history of cardiovascular disease, hypertension may not tolerate excessive vasoconstrictor. Patients on tricyclic anti-depressants, MAO inhibitors over respond to epinephrine. The general rule is that two carpules of 1/100,000 epn is equivalent to their endogenous epn and is usually considered safe. Patients with impaired liver function from hepatitis or cirrhosis may tolerate Septocaine® as it is cleared by blood esterases rather than the liver. Consult with their physician when in doubt. Tailor the anesthetic to the length of the procedure. Impactions usually require Marcaine® or Duranest® for maximum duration and post-op comfort. Short procedures can be anesthetized with 3%Carbocaine w/o vasopressor, or with Septocaine® 1/100,00 epn if a vasopressor is required. Infection always requires extra anesthetic and extra time to take affect. Plan ahead and inform the patient so they will not lose confidence in your ability when you give twice as much anesthesia and take twice as long to achieve acceptable anesthesia. Septocaine® and Carbocaine® are excellent choices for infected areas because they have a relatively low pKa. Infected tissue has a slightly acidic environment ( ph 5.5-7.0) which takes longer for the anesthetics with a higher pKa to disassociate into their active basic components. Note: the closer the anesthetic’s pKa is to the body’s pH 7.4, then usually the less painful the injection: Mepivicaine 7.6 Etidocaine 7.7 Articaine 7.8 Lidocaine 7.9 Bupivicaine 8.1 Procaine 9.1; Note: Prilocaine (Citanest®) 7.9 is generally recognized as the least painful anesthetic injection and used by many practitioners as a “pre-injection” injection. Pregnancy Category B: Lidocaine, Etidocaine, Prilocaine Pregnancy Category C: Articaine, Buivicaine, Mepivicaine

Curved surfaces are stiffer than flat surfaces; that is why tin roofs are corrugated and airplanes and egg shells have no flat surfaces. A stiffer needle is less likely to be deflected and miss the “anesthetic target”. A curved needle can be manipulated easier into difficult or tight areas and minimizes excessive and uncomfortable stretching of the corners of the mouth.

A gentle uniform curvature of the needle will stiffen the needle and reduce deflection. A sharp bend in the needle will significantly stress the needle and lead to metal fatigue and breakage. The hub of the needle is especially subject to this type of structural stress and breakage. Never “Bend” the needle!

Using a straight needle on a PSA injection requires a significant displacement of the lip commisures causing stress on the lips as shown in left slide. A small obicularis oris, exotosis, thick buccinator, or coronoid process may interfere with the ability to position a straight needle and administer an effective PSA. IAN: If the barrel of the syringe is not stretched against the opposite commisure a straight needle will hang up on the lingula and miss the injection target. A small obicularis oris or limited opening will interfere with correct positioning of the syringe. Stretching the opposite commisure with the barrel of the syringe will often cause the mandible to close slightly which moves the lingula and anesthetic target superiorly and out of access.

A curved needle is much easier to manipulate into maxillary posterior areas particularly in patients with exostosis, thick buccinator muscles, or a large coronoid process. A curve needle is also easier to manipulate along the medial surface of the mandible without excessively stretching the commisures of the lips. Best results are obtained on an IAN block when the curved needle is passed both buccally and superiorly. A curved needle must be inserted along a curved path of insertion to minimize resistance and potential trauma.

Traditional dental textbooks advise to locate the lingula for an IAN injection by bisecting the angle between the maxilla and the mandible. The relation of the lingula to the maxilla changes progressively as the mandible is opened farther. However the relation of the lingula to the occlusal table of the mandible is constant. If you are having difficulty with IAN injections utilizing traditional techniques try orienting the barrel of the syringe with the occlusal table of the mandible.

Crown and root shape and angle or “bend” of tooth. Keep in mind that radiographs are 2 dimensional while teeth are 3 dimensional. Consider Pell & Gregory classification and angle of tooth in the socket. Adequate access should allow for proper sectioning and elevation of tooth while recognizing anatomical features such as maxillary sinus and inferior alveolar nerve. Cone beam CTs may be indicated if serious risks may occur.

The Pell and Gregory Classification System has been used for many years to describe the degree to which a third molar is impacted. Even if you choose another classification system you should still understand the Pell and Gregory system when consulting with other dentists/oral surgeons. Class A  3d molar occlusal plane at/above 2d molar occlusal plane Class B  3d molar occlussal plane between occlusal plane and CEJ of 2d molar Class C  3d molar occlusal plane below 2d molar occlusal plane. Class I  3d molar entirely anterior to anterioir border of ramus Class II  3d molar bisected by anterior border of ramus Class III 3d molar entirely posterior to anterior border of ramus Note: The Pell and Gregory A,B,C classifications may be applied to maxillary teeth.

Textbook anatomy tends to portray molar root structure as relatively symmetrical resulting in a straight line path of extraction. In reality molars, especially third molars, have a distinctive distal curvature of the root structure which is approximately at a 15 degree angle to the crown and buccal groove. This curvature is important in preparing a space distally for elevation of the tooth and for the curved path of extraction. The angle between the crown and root structure is critical to correct buccal-lingual sectioning of the tooth. Note that most mandibular molars (including 1st and 2d) have a significant concavity in the distal root (yellow dotted line). This is important to remember when preparing boney access for deeply impacted mandibular 3d molars.

The red/black dashed line represents area prepared by the surgical handpiece. As the buccal trough progresses apically it is also expanded anteriorly as indicated by “A”. This is possible because of the normally distal concavity in the root structure of second molars. It is necessary in order to get a purchase point of the M-B line angle of the third molar. A distal trough is usually required to create space for the distally curved extraction path. Always preserve the alveolar bone on the distal CEJ of the second molar as this is critical to ensure support for the second molar and eventual bone fill into the extraction site.

A technique called troughing is frequently required to surgically extract impacted teeth. The surgeon must be very judicious to minimize vertical reduction of the alveolar bone. In general the axis of the handpiece should be parallel to the axis of the tooth. It may be helpful for the surgeon to visualize they are doing a crown preparation on the root rather than a reduction of the alveolar bone.

Fully erupted teeth can be extracted by using only a “sulcus flap”. Deep impactions require a more extensive flap. Isolated teeth, lingual version teeth, supernummary teeth, tori, alveoloplasty, may require adaptation of flap design. Pell and Gregory Class C normally require an anterior releasing (vertical) incision to obtain adequate access. Give careful consideration to adjacent critical soft tissue structures, e.g. nerves, blood vessels, saliva ducts/glands. Good surgical closure is necessary to minimize post-op discomfort and enhance hard tissue healing. Ensure all flap designs allows for adequate blood flow to the reflected flap. The base of the reflected flap should always be wider than the apex to promote collateral blood circulation through the entire flap.

Incision starts as an anterior releasing incision between papilla and the M-B line angle. An incision through the papilla may result in a slight loss of the interdental periodontium. An incision on the M-B line angle is subject to masticatory forces when healing which might result in a permanent cleft. The incision is made at a 45° bevel, or undercut, to facilitate primary closure. A beveled incision does not have to be lined up perfectly to achieve primary closure. As the incision is carried distally it follows the buccal and distal sulcus terminating on the distal-lingual/distal-palatal line angle. From this point it continues in a semi-lunar shape over the mesial-lingual cusp and distal buccal cusps of the submerged third molar. The incision continues as a distal releasing incision by continuing to curve buccally until adequate reflection is possible. Note: The Mandibular distal releasing incision only appears to be at a 90° angle because the cheek is being distorted buccally by retractors for access. When the cheek is released the distal releasing incision will return to its normal location immediately above the ascending ramus. If required, a distal wedge can easily be removed from the elevated flap with a scalpel or Dean’s scissors. Note the “No Cut” zones are neurovascular rich and are best avoided. Note: anatomical studies revealed approximately 5% of lingual nerves pass over the top of the mandible immediately posterior to the third molar. Do NOT make incisions distal to the mandibular third molar, lingual paresthesia is far worse than IAN paresthesia. Anterior releasing incisions (extended flaps) are required for mandibular and maxillary Pell & Gregory class C impactions to afford adequate access to submerged crown structure. Note: some authors refer to the anterior releasing incision as a vertical incision. Note: The distal-lingual/palatal tissue must be released in order to deliver the impacted molar. Use a blunt instrument such as the round end of a Molt #9 to release or gently push aside the overlying tissue from the fibrous tissue attached to the impacted molar.

The lingual nerve crosses the mandible in close proximity to the third molar. Some cadaver studies indicate that as many as 5% of lingual nerves pass along the top of the mandible immediately distal to the third molar. The surgeon must display careful consideration of lingual nerve anatomy when making incisions or flaps in this portion of the mandible.

This is perhaps the most frequently encountered impaction. The ability to efficiently extract these impactions will be a great service for your patient population.

You should perform a comprehensive survey of all available current radiographs to correctly plan the procedure. Observe the overall outline of the tooth; are the roots convergent or divergent. This may determine if the roots must be sectioned. Notice the tilt or curvature of the crown/roots. This will determine the curved path of extraction. Look for other critical anatomical structures; IAN, sinus, mental foramen, suspicious radiolucencies. Although radiographs provide a great deal of information they don’t tell us everything. Always make a clinical examination before making a final decision or commitment to your patient.

Notice that a midline section through the roots extends coronally through the mesial cusp of the crown due to the crown/root 15° angle. This is important if you have to make a “blind” section through the midline of the roots without visible access to the furcation.

Begin sectioning the mandibular molar anterior to the buccal groove. Ideally the section will engage the furca as it is carried apically. Because of the slight distal inclination of the roots to the crown it is normally necessary to incline the sectioning at approximately 15˚ distally as it progresses apically to align it with the furca and bisect the roots. Notice a small buccal trough and a distal trough (one bur width) which allows the tooth to be extracted in a slightly distal direction.

The initial step in extracting the mesio-angle impaction is to carefully section the tooth through the furcation as indicated by the purple line. Next separate the two halves of the tooth by inserting a wedge shape elevater, such as a Cogswell A, deep into the groove and gently twisting the instrument to expand the groove until the two halves are separated. Use an appropriate elevator the first remove the distal halve of the tooth. Next use an elevator to rotate the mesial portion into the distal half of the socket before trying to elevate it completely out of the socket.

The orange line represents the original bone height which remains unaltered. To gain buccal access place the bur in the boney buccal sulcus. As you reduce the height of the bone apically also enlarge the access anteriorly into the concavity distal to the roots of the second molar. This will allow greater access to the M-B line angle which is critical to elevation of the third molar. Also make a narrow trough distal to the third molar. This provides space to elevate the tooth as third molars have a 15° distal curvature which dictates a distally curved path of extraction. Always preserve the bone at the distal CEJ of the second molar to ensure proper hard tissue healing.

This is a Pell and Gregory Class C (occlusal table below CEJ of 2d molar) which usually requires and extended flap with an anterior releasing incision. The dotted white line represents the hinge axis of the flap which provides more than sufficient access while maintaining good collateral blood circulation to the flap.

The disto-angular impaction is a very common impaction that can easily be extracted by following technique guidelines.

Notice 15° relationship of crown to root structure typical of most third molars - The distally curved path of extraction is dictated by the anatomy of the tooth. This will cause the tooth to bind near the distal marginal ridge. The greatest width of root structure is less than the CEJ making the outline of roots is cone shaped. Cone shaped roots seldom require sectioning. Careful considerations to nearby anatomy

The overall distally curved outline will force the tooth distally when elevated. To acquire adequate space for elevation a distal trough should be prepared extending apically to the CEJ. Often additional space is required which can easily be obtained by sectioning off the distal half of the crown from the mesial cusps to the distal CEJ.

Dark area represents void created by distal trough and removal of occlusal-distal section of crown. This is the space through which the tooth will be elevated.

The orange line is the original bone level which remains unaltered. Create buccal access with a buccal trough by closely following the outline of the buccal surface of the 3d molar with the bur of the surgical handpiece. Judiciously carry the trough anteriorly to engage the M-B line angle for proper extraction leverage. A shallow distal trough extending no further than the CEJ is necessary to provide room to elevate the tooth distally. Preserve the bone on the distal CEJ of the second molar for proper tooth support and healing.

An envelope incision on the second molar with a distal releasing incision extending into the buccal vestibule provides adequate access to the tooth and boney structure. An anterior releasing incision is not required unless the tooth is a Pell and Gregory Class C. The dotted white line represents the axis of the flap. The dotted white line represents the base of the flap which is much wider than the apex of the flap. This provides excellent access to the surgical area while maintaining an adequate collateral blood supply to the elevated flap.

Mandibular horizontal impactions often present the most challenges to the general dentist. Careful adherence to technique guidelines will greatly enhance outcomes.

Notice the crown/root angle is approximately 15°. The distal surface is covered with alveolar bone blocking a clear extraction path. The crown is in the locked in the undercut of the concavity in the 2d molar. Look for proximity of anatomical structures; IAN bundle. Observe the radiolucency on mesial portion of impacted crown; probably a dental follicle. Consider submitting it for a biopsy depending on clinical findings.

The first step in sectioning the horizontal impaction is is to separate the mesial and distal halves of the tooth. Notice that a line bifurcating the two root halves intersects the mesial cusp of the crown (1st orange line). Section the two halves by cutting ¾ to 7/8 of the way through the tooth and then seperating them apart with an elevator like a Cogswell A. If you try to cut completely through the tooth you risk cutting through vital structures on the lingual aspect of the 3d molar. If you cut only ½ way through the tooth then the tooth may not fracture along the intended line. Next try to elevate the distal half of the tooth. If there is inadequate space to elevet then section the distal half of the tooth with a cut at approximately the level of the CEJ (2d yellow line). This cut should make the crown narrower at the base than at the exposed top of the distal crown. If the bottom is wider it creates an inverted wedge which will be mechanically locked in. Finally attempt to elevate the remaining mesial half of the tooth. If there is inadequate room to elevate or it is locked in place, then section off the crown ensuring that the bottom of the crown section is narrower that the top to prevent creating a locked in inverted wedge.

Start separating the mesial and distal roots by cutting through ¾ of the tooth diameter from buccal to lingual. Try to never penetrate the lingual surface of the molar with a surgical bur Then place a small elevator in the slot to fracture the mesial and distal roots. Continue to loosen each root in its socket by carefully rotating an elevator in the slot. After both roots have been loosened try to elevate the distal root first. If there is insufficient room to elevate the distal root in total then remove an adequate portion of the distal crown while leaving at least 2-3 mm of the crown exposed and attached to the remaining root to serve as a “handle” to remove the remaining distal fragment. Finally remove the mesial portion of the tooth. Again if there is insufficient space, remove a portion of the crown leaving 2-3 mm exposed and attached to the remaining mesial fragment as a “handle” for extraction.

This slide depicts the sequence for removing sections of the horizontal impaction utilizing the sectioning technique from the previous slide.

The orange lines represent the original unaltered bone level. Create the buccal trough by following the buccal tooth surface apically with the surgical bur while slightly advancing the access window anterioirly to engage the M-B line angle of the 3d molar. Create a shallow distal trough down to the CEJ to allow for room to elevate the tooth/fragments.

Horizontal impactions normally require the extended flap with an anterior releasing incision.

Tooth #32 presents as a Pell-Gregory Class C with widely spread roots. Mandibular molars with this root anatomy may be difficult to extract even if it is fully erupted. Notice proximity to IAN. Try to limit handpiece sectioning below the furca.

The width of the root structure is obviously wider than the diameter of the tooth at its CEJ. Attempting to extract this molar in one piece will almost certainly result in a fractured root (tip). Complicating this extraction is its Pell Gregory Class C classification and juxtaposition to the IAN. It is important to perform a careful survey of all radiographs before extraction to minimize complications and advise the patient of possible adverse outcomes.

The first step is to separate the mesial and distal halves of the tooth via the primary section line. Note that a line bisecting the roots intersects the mesial cusp of the crown. A line extending apically through the buccal groove risks cutting off a portion of the mesial root. After elevating the distal root out of the tooth socket evaluate the remaining mesial tooth half to determine if it can be elevated in toto from its position. Two factors preventing tooth elevation are its position in the distal concavity of #31 and the dilaceration of the root tip. At this point it may be necessary to separate the remaining crown structure from the root via the optional section line. The mesial root half will not immediately elevate coronally but elevate distally into the space created by removal of the distal half of #32 due to the distal curvature of the root.

The orange lines represent the unaltered bone level. Create the buccal trough by following the PDL down to the level of the mid crown. Try to expose the mesio-buccal line angle of the crown while preserving bone around the distal of #31. A slight distal groove will greatly facilitate the elevation of the tooth distally.

Tooth #32 will require an extended flap with releasing anterior incision (vertical incision) to adequately access the surgical area. The dotted white line represents the hinge axis of the flap which provides full access to the surgical area.

Pell and Gregory Class A,B,C can be used on maxillary teeth but Class I,II,III do not apply P & G class B will require an envelope releasing incision P & G class C will require an anterior releasing incision An occlusal approach is extremely difficult for impacted maxillary third molars. Normally impacted maxillary third molars are extracted via a buccal approach. Ensure there is adequate buccal space on clinical examination. Examine the patient for large buccinator muscle, limited opening, or large coronoid process that will impinge on buccal access. Also try to determine if Pell and Gregory class C impactions are palatally displaced. Pell and Gregory class C palatal impactions are best referred to oral surgeons because of extraction difficulties; vital anatomical and neurovascular structures.

The crow/root axis is approximately 15° dictating a distally curved path of extraction. The root outline is convergent which will negate the need to vertically section the roots. The crown is in the undercut of concavity in the roots of the second molar. There appears to be adequate bone between the roots and the maxillary sinus but always remember radiographs are two dimensional and human anatomy is three dimensional.

The orange and yellow lines represent the boney access. The path of extraction will proceed both distally and buccally.

The orange line is the original bone level which remains unaltered. The buccal trough is created by following the buccal surface with the surgical bur. As the trough proceeds apically, expand the trough anteriorly to engage the M-B line angle. A shallow distal trough will allow the distally curved third molar to be elevated distally as well as buccally.

Maxillary Pell and Gregory class C also require an extended flap with an anterior releasing incision in order to obtain adequate access. The dotted white line represents the hinge axis at the base of the flap which allows adequate surgical access.

“Be kind to soft tissue and soft tissue will be kind to you.” Soft tissue management is critical to hard tissue healing. This is a very important part of the overall surgical procedure. Resist the urge to “short change” closure procedures once you have just completed a difficult extraction. General dentists’ increased awareness of periodontal procedures gives them a slight advantage over most traditional oral surgeons in this area. Ensure there are no loose fragments or boney spicules underneath the flap area. Use bone file on any surfaces where the surgical bur has been utililzed. Replace the soft tissue flap over the hard tissue and palpate with your finger to detect small or sharp edges. Use copious amounts of irrigation after using bone file and curettage. Properly align tissues to ensure muco-gingival margin and sulcular margins are in correct anatomical positions. Utilize adequate sutures to stabilize tissues, i.e. stretch cheek and lips to see if incision opens under function. Surgical stents may be required especially for palatal surgeries to prevent excessive ecchymosis. Suture selection based on location and type of procedure. The time spent performing a proper surgical closure may save the patient considerable discomfort and save the dentist considerable POT appointment time.

Infection prevention in oral surgery is mostly “mechanical” not chemical (antibiotics). Utilize sterile technique; remove the infected tooth, roots sequestra; curette debris, fragments, granulomas; reduce bacterial count via copious irrigation. Make an effort to remove every part of the tooth as it is often the source of infection. Subjective clinical decisions must be made when adjacent vital structures are jeopardized by removal of small tooth fragments. Curette the socket for tooth fragments, fragments of broken restorations, large chunks of calculus, and soft tissue such as granulomas or follicles. Use caution when deeply curetting the apex of a root socket (IAN, max sinus). Use copious amounts of sterile irrigation to physically reduce the number of bacteria in the surgical site. Antibiotics only when clearly indicated Adherence to infection control techniques is not only a legal requirement but will also help to reduce and minimize post op infections.

Where there is a clearly defined swollen area, I & D is often the treatment of choice. If the infection and swelling are less than two days old, indurated, warm to the touch, and perhaps slightly red in color, then the infection is not yet well developed and will not be very productive, most likely only a thin bloody serous exudate. These patients are also very difficult to anesthetize. Consider placing the patient on analgesics and antibiotics then re-evaluate/treat in 24-48 hrs. Infected tooth or bone fragments, sequestra should be removed surgically with a flap, curettage, and copious irrigation. Antibiotics are not normally required except as an adjunct to surgical treatment and for febrile, medically compromised, or immunocompomised patients. Always follow up on infection patients within 48 hrs or less to ensure they are getting better. A simple telephone call may be adequate. However if they are getting worse they need to be seen as soon as possible; i.e.< 24hrs. Uncontrolled local infections that progress into spacial infections often require weeks of inpatient hospitalization sometimes with fatal outcomes. Do not hesitate to refer an infection to an oral surgeon or the hospital if you are not comfortable with your treatment success.

The best location for an I&D incision is at the muco-gingival junction. This provides a fixed attatchment (gingiva) to attach and stabilize the drain and a flexible area of tissue(mucosa) that can easily be manipulated to achieve drainage and place sutures. The resulting incision scar tissue is more easily hidden at the M-G junction than on an open area of gingiva or mucosa. Bluntly disect under the periostium and surrounding tissues to relieve infective exudate. Apply slight pressure, “milk”, the surrounding area to force the exudate out through the incision. Do not use excessive force as this may spread the infection beyond its current boundaries. Use copious irrigation to flush out and dilute exudate and reduce the bacterial count. Use a sterile penrose drain tailor cut to fit the incision. It should extend fully to the depth of your disection and extend approximately 10mm externally from the incision. Use at least two silk sutures to properly stabilize the drain. Do NOT use gut, chromic gut, vicryl, or other “dissolvable” sutures. If the sutures dissolve and the drain dissapears before the patient returns, then where is the drain? Did it fall out or did it submerge under the periostium only to re-emerge in 3-4 weeks as a subperiosteal infection? You should establish some type of follow up within 24 to 48 hours after draining the infection. This may be as simple as coordinating telephone call. The point is to ensure the patient is getting better, not worse. If the patient is getting worse then make arrangements to exam the patient soon as possible. Penrose drains should normally remain three days to allow ample time for drainage while the patient’s immune forces are mobilizing. If drains are left in more than five days the incision may start to epithelialize. Antibiotics are not normally required unless the infection is systemic or the patient is immunocompromsed.

Always give written and verbal post-op instructions and document in record. Post op bleeding is controlled by a gauze pressure dressing for at least one hour. Advise patient to expect a little “seepage” resulting in thin red spit for a day or two. However, provide extra gauze dressings for the patient to apply another pressure dressing prn if excess bleeding persists or begins spontaneously. Swelling can be controlled via the “RICE” formula. Restrict activity for at least one day (quarters), place Ice on the affected area, Compression(gauze dressing), Elevate, use extra pillows any time patient lies down. NSAIDS will also reduce swelling. Pain control is accomplished mostly through medication. A combination of ACAP, NSAIDS, and Schedule II or III drugs should be selected appropriate for the procedure. Application of ice for approximately 24 hours starting immediately after surgery will help reduce post op pain. Following other post op instructions will also minimize pain. Diet should avoid hard or crunchy foods, acidic foods, and carbonated beverages which might dislodge the blood clot. Brush remaining teeth normally but avoid surgical areas. Surgical areas may be cleaned with a cue tip or rolled up paper towel. Rinse mouth gently with Peridex or Listerine if possible. Avoid smoking and tobacco products. Patient is normally given one to three days quarters based on procedure followed by two to three days of restricted activity with out PT. You must provide instructions on who to contact or where to go in case of an emergency after hours. This is especially true in private practice. A telephone number and a location should always be provided.

A competent evaluation can not be made without a clinical examination. Always perform a clinical examination before you make a final diagnosis, treatment plan, or commitment to the patient. Resist the temptation to make a diagnosis, treatment plan, or an appointment strictly from a radiograph. A tooth in occlusion produces much denser alveolar bone and will require more effort to extract. Third molars in occlusion are more difficult than other molars because of their extreme posterior position. Note: third molar occlusion is difficult to predict from a PANX. Exostosis bone is thicker and usually denser. If a maxillary molar is surrounded by exostosis does not readily elevate then extract it surgically(flap, trough, and trifurcate). Forceful extraction may result in fracturing off a large piece of alveolar and maxillary bone along with the exostosis (sinus exposure risk). Exostosis often takes longer to adequately for anesthesia to infiltrate. A small opening to the mouth compromises access. Limited opening may make access difficult. Examine clinically for thick buccinator, large coronoid process, or shallow buccal vestibule. Patients with a strong gag reflex may require modifications to treatment style; place patient in upright position, shorter appointments, anesthetize only right or left side during one appointment. Nitrous oxide will suppress most gag reflexes. Exceptionally anxious patients usually have bad experiences in the dental operatory and so do their dentists. A “normally” anxious patient may be treated with oral sedation or nitrous oxide. However, a true dental phobic should be treated with IV sedation.

Clinical examination is essential for evaluation of maxillary impactions. Deep roof vault has easy buccal access to crown and roots, vestibule is above the surgical field, roots are anchored in alveolar bone vs. maxillary bone, and has less chance of sinus exposure. Shallow roof vault has limited access to crown and no access to roots, vestibule may below CEJ or the crown, roots may be anchored in maxillary bone, increased risk of sinus exposure.

Know your limits! Do not make your professional life and your patient’s life miserable by attempting cases that are beyond your limits. This is especially true if you are in an isolated area. You are not expected to be an expert in every discipline in dentistry. Establish good rapport with your referral network so that you will not hesitate to refer when indicated.

This is an obvious referral case to an oral surgeon! No matter how much experience or qualifications you might posses, a general dentist should not attempt this case. If the patient is in pain then administer vicodin, percocet, demerol, or morphine as appropriate and immediately refer or Medivac to an oral surgeon. A major contributor to success in oral surgery, as in most disciplines in dentistry, is case selection. Know your limits!

Teeth that were treated endodontically more than two years prior to extraction tend to become extemely brittle. Be prepared to extract the tooth surgically and advise the patient beforehand that extra procedures may be necessary. The tooth is weakened by the removal of external tooth structure for the restoration and internal tooth structure for the endodontic treatment. Limit the amount of force when using elevators and forceps to avoid root fracture. Frequently endodontically teeth will require surgical extraction. For surgical extraction of bicuspids or anterior teeth it is recommended the dentist utilize an Impact Air or Piezoelectric type handpiece. These handpieces typically preserve more alveolar bone which is advantageous to restoration of the extraction site.

Isolated molars are challenging because there is increased risk of sinus exposure. This is especially true in older patients who have experienced significant pneumatization of their maxillary sinus. Utilize minimal forces when attempting to extract the tooth conventionally. If the tooth does not extract easily with conventional techniques then immediately use a surgical approach. Sectioning or trifurcating the root structure minimizes the required extraction forces, reduces the chance of an O-A opening, and reduces the size of potential O-A openings that may occur.

This surgical technique is especially applicable to isolated maxillary molars. Section the crown to divide the palatal cusp and root from the buccal portion of the tooth. The cut should extend partially through the floor of the chamber but not all the way into the furca to prevent a possible oral-antral opening. Use an appropriate elevator to separate the palatal portion from the buccal portion of the molar and loosen the roots in the alveolus. Once separated and loosened the palatal portion may be extracted utilizing a forcep with narrow nibs, e.g., #65 or #69.

Section the buccal cusps through the buccal groove. Then separate and loosen the two cusp/roots with an appropriate elevator. The two individual cusp/roots can now be extracted with an elevator or narrow nibbed forcep, e.g. #65 or #69.

Whenever you must surgically extract a maxillary posterior tooth you should always check for an oral-antral opening. “Stop! Look! Listen!” Stop the suction or any other noisy equipment. Have the patient hold their nose and gently blow. If the patient blows vigorously they may blow out an otherwise intact Schneiderian sinus membrane. Place the mouth mirror directly under the socket. Look for misting or fogging on the mirror emitting from the socket. Listen for unusual sounds of air escaping from the socket. If there is an O-A opening, don’t panic! If you extract maxillary posterior teeth you will eventually experience an O-A opening. If there is an O-A opening, can you account for all of the tooth and its fragments? If not, then do a close clinical and radiographic examination to determine where the missing pieces are. If you are not able to retrieve them the immediately refer patient to an oral surgeon. If immediate referral is not possible then close O-A opening appropriately and make arrangements/appointment for patient to be seen as soon as possible by an oral surgeon. Fragments in the sinus must be removed. Three common surgical closure techniques: Buccal advancing flap, Palatal advancing flap, Buccal fat pad. Always close with sutures. Many experts advocate utilizing an “X” pattern over the socket and extra sutures to serve as a matrix for the clot. Gelfoam or Surgicel are also recommended. Although primary closure is difficult, try to cover as completely as possible. Both buccal and palatal flaps can be extended farther by scoring the underlying periosteum of the flap to achieve additional release. The Buccal advancing flap is best for general dentists. Unless you have extra experience or training the Palatal advancing flap and Buccal fat pad are probably best left to the Oral Maxillofacial surgeons. Prescribe analgesics as indicated. Antibiotics are indicated to prevent sinus infection. Pen VK or Amoxicillin are good choices . Augmentin® is probably the best but expensive. Also prescribe antihistamines to dry sinuses to prevent sneezing, coughing, or runninig noses. Sudafed® is a good choice. You may also prescribe a nose spray like Afrin® for the first 3 days only. Inform the patient about their condition. Instruct them to avoid blowing their nose, sneezing, or coughing as much as possible for 7-10 days. It is wise to generate a patient post-op instruction sheet for oral-antral openings if one is not already available. Also provide normal surgical post-op instructions. Follow up in 24-48 hours for normal post-op observation. Usually the socket appears closed and normal for the first 2 days due to post-op swelling and inflammation, but it may “open up” in a week or two. Therefore schedule post-op follow up appointments for 7 and 14 days. If the O-A opening re-appears then you may choose to refer the patient unless you have experience in closing established O-A openings.

Buccal flap advancement requires additional release of the flap. Extend the mesial and distal buccal incisions into the buccal vestibule. Score the underlying periosteum horizontally if necessary to gain additional extension.

The oral antral opening may be reduced by crushing the buccal plate inward (orange arrow) or by reducing the height of the alveolar crest which allows the flap to extend farther across the opening. However both of these techniques reduce the eventual height of the residual bone. This may compromise future implant or ridge lap pontic prosthodontic procedures.

Examine all teeth in the sextant for existing broken restorations, large carious lesions, crown and bridge restorations. Frequently the extraction of a third molar is requested in order to restore the adjacent defective restoration. Due to the slight flexure of the alveolus, a crown one or two teeth away from the extraction site may have its cement seal broken especially under excessive elevation forces. Always anticipate and advise the patient before surgery of any potential problems with restorations/crowns and document it in the informed consent section of the patient record. Use a controlled moderate force when elevating. Avoid placing the elevator on the adjacent tooth with a large carious lesion, defective restoration, or crown. In select cases a conservative surgical approach may be indicated to preclude the use of excessive force near risky teeth or restorations. If a tooth or restoration should break off smooth sharp edges and place a temporary such as Ketac® When crowns or bridges are loosened do not attempt to recement permanently at the time of surgery. There may another reason the crown/bridge came off; decayed margins or defective preparations. If the defective bridge was placed by another dentist and you recement it permanently then you just “bought it”.

Ensure you utilize a secure finger or hand rest on the patient. If the patient should suddenly move and your hand is not secured to their mouth or head the result could be traumatic to hard and soft tissues, including yours! Ensure the correct bur guard is utilized. If the bur shaft is not protected and watched carefully it may abrade against large areas of soft tissue. This is embarrassing to explain to the patient. The bur cuts most efficiently and less traumatically (less vibration) when run at nearly full speed. Use the “paint brush” technique to remove hard tissue. This prevents heat build up and allows debris to flushed away quickly before it clogs up in the flutes of the bur. Copious amounts of irrigation is essential. Irrigation keeps the bur and the hard tissues cool, it flushes away debris to prevent clogging the bur, and it lubricates the bur to further reduce heat buildup. Ensure your staff is following manufacturer’s maintenance guidelines. Surgical handpieces are expensive!

These handpieces were borrowed from orthopedic surgeons for use in oral surgery. They are bulky, heavy, difficult to manipulate , and have no feedback. They do have tremendous torque, indeed too much. These are best left in the hands of orthopedic surgeons, sheet metal workers, and woodshop carpenters.

Impact Air Surgical Handpieces are designed with a rear air exhaust to prevent surgically induced air emphysema. They are excellent handpieces for removing broken teeth, endodontically fractured teeth, or recalcitrant “routine” teeth. They incur minimal collateral damage to adjacent alveolar bone. However they lack the required torque to efficiently remove impacted third molars.

Piezosurgery utilizes piezoelectric vibrations to cut bone tissue. By utilizing the ultrasonic frequency of the device it is possible to cut hard tissue while leaving soft tissue untouched by the process. Piezosurgery is used for minor oral surgery procedures, to harvest bone, for sinus lifts, and for adjunctive implant surgery. They are also used in prosthodontics for crown lengthening, periodontics, and endodontics.

Questions and Comments ?/!

1/23/2012 1 ADMINISTRATIVE This power point presentation is designed to be utilized in the >Normal< mode under the View menu bar option. This allows the viewer to read the didactic notes at the bottom of the slide screen. ADMINISTRATIVE 3rd Edition August 2011

1/23/2012 2 Oral Surgery Tips for the General Dentist user

1/23/2012 3 MEDICAL EMERGENCIES Equipment, Supplies, Medications Emergency Protocol and Procedures Staff Training and Documentation

1/23/2012 4 Automated External Defibrillator

1/23/2012 5 Personal Protective Equipment Infection Control vs. OSHA

1/23/2012 6 Patient Management Style Based on Your Personality Be Positive and Confident Develop a Relaxed Comfortable Style Address the Dental Fear/Pain Complex

1/23/2012 7 Know Your Patient Interview the Patient Review Medical History Examine Dental Record and Radiographs Clinical Exam of Patient Confirm Diagnosis and Treatment Plan Use the 5 Minute Rule on New Patients

1/23/2012 8 RADIOGRAPHS CURRENT: No more than 6 to 12 months old DIAGNOSTIC: Clarity and Accuracy

1/23/2012 9 Evaluate and Plan the Procedure Assess/Anticipate difficulties: Refer PRN Advise Patient: Informed Consent: –Surgical Info and Risks –Alternative or No Treatment –Signed Consent Form Dental “Plan of Attack”

1/23/2012 10 Dental “Plan of Attack” Simple vs. Complex Sequence of procedures Plan Sectioning of Teeth Boney Access Opening Flap Design Closure, Sutures Prepare Appropriate Instrumentation

1/23/2012 11 Instrument Trays

1/23/2012 12 150 151 151S

1/23/2012 13 150 151 151S

1/23/2012 14 65 (Top) 69

1/23/2012 15 88L / 88R 23

1/23/2012 16 “Standard” Elevators 301 34 304

1/23/2012 17 COGSWELL A B

1/23/2012 18 Patient Protection 1 2 3

1/23/2012 19 Anesthetic Considerations Patient’s Medical History Type and Duration of Procedure Presence of Inflammation or Infection Pregnancy

1/23/2012 20 Needle Modifications Curved Surfaces (Needles) are Stiffer than Straight Surfaces Less Deflection Upon Insertion Better Access to Injection Sites

1/23/2012 21 Needle Modification Curved Needle vs. Bent Needle - YES NO

1/23/2012 22 Anesthesia Access Difficulties

1/23/2012 23 Needle Modification Better Access to Anesthetic Sites Curved Path of Insertion IAN – Buccally & Superiorly Max Mand

1/23/2012 24 Linguala/IAN Alignment

1/23/2012 25 Hard Tissue Considerations Tooth Anatomy Location and Angle Boney Access/Reduction

1/23/2012 26 Pell and Gregory Classification

1/23/2012 27 Mandibular Molar Anatomy Textbook Anatomy Real World Anatomy

1/23/2012 28 Mandibular Boney Access

1/23/2012 29 Troughing Impacted Teeth

1/23/2012 30 Flap Design Considerations Determined by Hard Tissues Location of Tooth, Tori, Other Degree of Impaction Soft Tissue Anatomy/Physiology Closure

1/23/2012 31 Flap Design, Extended (Anterior Releasing Incision) BUCCAL Undercut Incision Max Mand BUCCAL BUCCAL

1/23/2012 32 Lingual Nerve

1/23/2012 33 Mandibular Mesio-Angular

1/23/2012 34 Mand Mesio-Angular Survey Root Axis Crown Axis Convergent Tooth Outline 15° Ext Path

1/23/2012 35 Mandibular Mesio-angular Sectioning

1/23/2012 36 Sectioning Mandibular Molars

1/23/2012 37 Mandibular Mesio-angular Extraction Sequence 1st 2d

1/23/2012 38 Mandibular Boney Access Preserve M-B Root Access Distal Trough Buccal Trough

1/23/2012 39 Mandibular Mesio-angular Flap

1/23/2012 40 Mandibular Disto-Angular

1/23/2012 41 Pre-Op Survey of Tooth 15° Root axis Crown axis Ext Path Cone shaped root outline Bind

1/23/2012 42 Disto-Angular Sectioning Section Mesial Cusp to Distal CEJ Distal Trough 1st 2d

1/23/2012 43 Disto-Angular Extraction Path of Extraction

1/23/2012 44 Disto-angular Boney Access Distal Trough Buccal Trough Preserve Existing Boneline Access to M-B Line Angle

1/23/2012 45 Mand Disto-angular Flap

1/23/2012 46 Mandibular Horizontal Requires Multiple Sectioning

1/23/2012 47 Horizontal Impaction Survey Root Axis Undercut Crown Axis Bind

1/23/2012 48 Horizontal Sectioning Sequence 1st 2d 3d

1/23/2012 49 Seperate Mesial-Distal Roots

1/23/2012 50 Horizontal Extraction Sequence

1/23/2012 51 Horizontal Boney Access Preserve Distal Trough Buccal Trough M-B Access

1/23/2012 52 Mandibular Flap, Extended

1/23/2012 53 Mandibular-Wide Roots And Dilacerations

1/23/2012 54 Mandibular-Wide Roots & Dilacerations Survey CEJ Root Width

1/23/2012 55 Mandibular-Wide Roots & Dilacerations Sectioning OPTIONAL PRIMARY

1/23/2012 56 Mandibular - Wide Roots & Dilacerations Boney Access Existing Boneline Buccal Trough Distal Trough Preserve

1/23/2012 57 Mandibular-Wide Roots Flap

1/23/2012 58 Maxillary Impactions Pell and Gregory Class C Buccal Approach Normally

1/23/2012 59 Maxillary Survey Ext Path Convergent Root Outline Undercut Root Axis Crown Axis

1/23/2012 60 Maxillary Impaction Extraction Ext Path

1/23/2012 61 Boney Access Maxillary Distal Trough Preserve Access to M-B Line Angle Buccal Trough

1/23/2012 62 Flap Design Maxillary

1/23/2012 63 Surgical Closure Soft Tissue is Critical for Healing Prepare Boney Surfaces Align and Secure Tissues Surgical Stent prn Suture Selection

1/23/2012 64 Infection Prevention Sterile Technique Extract Entire Tooth, Roots Curettage; Fragments, Debris, Granulomas Irrigation, Irrigation, Irrigation Antibiotics NOT Normally Indicated

1/23/2012 65 Infection Treatment I & D Where Obvious Flap, Curettage, and Irrigation where Feasible Antibiotics as an Adjunct Only -Febrile Patient -Immunocompromised Patient F/U Appt< 48 hrs

1/23/2012 66 I&D Technique Location, Muco-Gingival Junction Blunt Disection Slight Compression Irrigation Penrose Drain 2 Silk Sutures F/U in 24-48 hrs Remove in 3-5 Days Antibiotics PRN

1/23/2012 67 Post Op Instructions WRITTEN & VERBAL Bleeding Swelling Pain Control Diet Oral Hygiene Limit Physical Activities Emergencies ( POCs )

1/23/2012 68 Evaluation Considerations Third Molar in Occlusion Exostosis Small Obicularis Oris Limited Opening Compromised Buccal Space Strong Gag Reflex Exceptionally Anxious Patient

1/23/2012 69 Evaluations (Cont) Maxillary Impactions Deep Vault vs. Shallow Vault

1/23/2012 70 Evaluations (Cont) Know Your Limits

1/23/2012 71 Evaluations (Cont) Know Your Limits ORAL SURGEON!!!

1/23/2012 72 Complications Endodontically Treated Teeth May be Extremely Brittle and Ankylosed >2 yrs Crown and Root Weakened by Tooth Reduction

1/23/2012 73 Complications (Cont) Isolated Maxillary Molars

1/23/2012 74 Maxillary Molar, Surgical (ISOLATED) SECTION SEPARATE EXTRACT

1/23/2012 75 Maxillary Molar, Surgical (ISOLATED) SECTION SEPARATE EXTRACT

1/23/2012 76 Complications (Cont.) Oral-Antral Opening Check for O-A Opening Check for Fragments in Sinus Surgical Closure Medications - Patient Instructions - Follow-up

1/23/2012 77 Oral Antral Management

1/23/2012 78 Oral Antral Management

1/23/2012 79 Complications Broken Restorations -Examine for Defective Restorations Crowns -Advise Patient before surgery -Use Caution When Elevating -Use a Surgical Approach -Replace Broken Restorations with Temps -Replace Loosened Crowns/Bridges with Temp Cement

1/23/2012 80 Using Surgical Handpieces

1/23/2012 81 Gas Driven Handpiece, Hall Drill Compressed Nitrogen

1/23/2012 82 Impact Air Surgical Handpiece

1/23/2012 83 Piezosurgery Handpiece

1/23/2012 84 Questions ?